Feb., 1886 ] PREVENTION AND TREATMENT OF SCURVY. 33

?rijjinal (|ommituinition!i. NOTES ON" THE PREVENTION AND TREAT- MENT OF SCURVY IN PEACE AND WAR.

By R. Temple Wright, M.D., F.R.C. S.,Eng.;

Surg eon-Major, Bengal Army ; Sujpdt., Prison, JYagpore, C. P.

Much useful information is printed in annual official reports and returns which is practically lobt., as statistics are so repulsive, that no one reads them but the unfortunate people who are obliged to compile them.

It may be interesting to the profession, if an abstract be given in a medical journal of pro- fessional matters, which are buried in the printed annual reports on the prisons of the Central Provinces of India, for the last five years, 1881 to 1885, both inclusive. The " Central Provinces" must not be confused Central Provinces vs. with "Central India,"

Central India. which is often done, the former consisting of some " non-regulation

"

pro- vinces, under the administration of a Chief Com- missioner, whose head-quarters are at Nagpore; while the latter term," Central India," is applied to a collection of feudatory States under the

political guidance of a diplomatic officer, called

the Governor-General's Agent, or briefly the Resident, at Indore. The Central Provinces include the four Com-

missionerships of Jubbulpore, Nerbudda, Nag- pore, and Chhattisgurh, with their head-quarters at Jubbulpore, Hoshungabad, Nagpore, and Raipore, respectively. (

^

There are three Central Prisons, at Raipore, Nagpore, and Jubbulpore; the latter receiving all the prisoners of the Central Provinces en

route to the Andaman Islands, who are consider- ed fit for transportation. The Central Prisons do not draw their pri-

soners entirely from the jails of the districts of

their respective divisions, but, for the sake of

convenience, they are received as follows:? In Raipore Prison, the convicts of the

C. P. districts and districtsin the Chhattisgurh languages. Division, viz., Raipore, Bi- laspore, Sumbulpore, and the feudatory States of Kalahandi, &c.

In Jubbulpore Prison, the convicts of districts in the Jubbulpore and Nerbudda Divi- sions, viz., Jubbulpore, Saugor,Damoh, Muudla, Nursingpore, Nimar, and Hoshungabad, with transportation prisoners from all districts in the Central Provinces.

In Nagpore Prison, the convicts of districts in the Nagpore and Nerbudda Divisions, viz., Nagpore, Balaghat, Bhandara, Betul, Chhind- wara, Seoni, Wardha, and Chanda, the last- named including Sironcha, or Upper Godavery. It is a depot for the temporary reception of

transportation prisoners for all districts in the

Nagpore and Chhattisgurh Divisions, and for t!je permanent lodgment of transportation pri- soners from Burmali.

It is, therefore, a Babel of languages?Hindi, Urdu, Uriya, Maratlii, Tamil, Telugu, Gondi, and Burmese being all spoken.^

I have had charge of the Nagpore Prison four years, except for four months in 1884 and 1885, when I had acting charge of the Jubbul- pore Prison ; and the following remarks refer to my own experience only, unless when I refer to that of the Civil Surgeon of Jubbulpore, and I am glad to find my views are corroborated by the opinions of Dr. W. R. Rice, an officer whose reputation is second to none in the service.

Experiments are tried unintentionally in pri- sons, owing to tlie varying notions of adminis- trators, so it is well for executive officers to observe their effects, and record them for the benefit of the medical profession and of the State.

In the Afghan War of 1878?81, I saw so

much suffering caused by scurvy, that, perhaps, I was more on the alert to recognize it than if I had not been on field service; and when I found the convicts of the Nagpore Prison were scorbutic at the end of November, 1881, I set

to work to remove the disease, with the results shown in the following table :? Table showing the number of Scorbutic Prisoners in the

Nagpore Jail in the last week of November.

Year.

1881

1882

1883

1884

1885

Total

Prisoners' actual numbers.

>? -a

W

452

685

566

642

656

3,001

Total.

ai

365

331

149

61

18

924 3,925

Number per cent.

M

70-78

67-90

90-82

91-89

97-33

m

29-22

32-10

9-18

8-11

2-67

Average No of months in J ail of the

>>

H

18

11

11

19

17

16

9

10

14

6

It is evident by this table that those who had been longest in jail were the healthiest. The Jail population amounts to about 2,000

prisoners every year, but the table includes only those who were present at the special inspection held every year at the end of November,?i. e.,

when the cold weather begins at Nagpore, and when scurvy is most marked. It is not often in

Scurvy every year in India that, in five succes- November. give Novembers, the same officer at the same place has the chance of

making similar observations under similar cir-

34 THE INDIAN MEDICAL GAZETTE. [Feb., 1886.

cumstances, so the experience gained from

nearly 4,000 prisoners is worth recording. In observing them, no prisoner was considered

scorbutic unless the gums were spongy, or the

Diagnosis of real legs were cedeinatous, the scurvy. latter sign being as frequent as the former, and the oedema very hard and

brawny. The gums were never rubbed, for rubbing

will cause many gums to bleed which are not scorbutic.

If gums were sivollen and tender, very light pressure was made on them with the tip of the little finger, and if this caused exudation of

blood or pus, the man was considered scorbutic, otherwise not. The gums of the lower jaw are always more affected than those of the upper jaw. Many dirty people, who do not clean their

teeth, have their mouths iu such a disgusting state, that this light pressure causes pus to

exude, but their gums are not swollen t and the fcetor of neglect is different from the foetor of

scurvy. This difference is indescribable, and is cognizable only by the nose, but such cases

were not registered as scorbutic. Occasionally, without any obvious cause,

gums are swollen, though not tender, and are

discoloured, the colour varying from brick-

red to purple or blue, but slight pressuie

produces no exudation whatever; so in these

cases the discolouration was recorded, but they were not registered as scorbutic.

In fact, among the Nagpore prisoners, the most conspicuous indication of scurvy was

great general debility, and after that, oedemsi of the legs, spongy gums being less frequent and less obvious. Ague is as common here as in other parts of India, but it is a noteworthy peculiarity of these prisoners that malarial

? , , , cachexiain them very rarely Enlarged spleen rare i i ,

J

at Nagpore. ' causes enlarged spleen as a

sequela, only one or two

cases occurring every year, while scurvy is so

common that nearly all those whose health on admission is recorded as " bad " or " indifferent "

are more or less scorbutic. Their occupations, before admission to prison,

are mostly agricultural or pastoral, and no par- ticular difference is observed in the inhabitants of different districts, except that the Chhind- tvara men are rather more robust than the rest, while the Kalahandi men were far the weakest. The latter are Khonds, who still practise

human sacrifice, if thev Khonds scabies. tl|ij|k |hey cau escaped*. tection, and on admission to prison, after their insurrection (in 1882-83), most of them were

found to be scorbutic, and suffering from scabies all over them, especially between the nates. In the more remote and jungly parts of

_A , the Central Provinces, in n on( s

many districts, Gonds also

are found, another aboriginal savage race, and prisoners from these tribes too are nearly as

much subject to scurvy and itch as the Khonds. The latter died in largo numbers in jail,

though they were not com-

vagcs!0?tatal to 6a-

pelleil to work, a?d the

greatest care was taken of them, the Superintendent giving them the sort

of food they preferred, and letting them cook it as they said they did at their own homes.

Tliey were far better fed, clothed, and lodged than they had ever been in their lives before, and had all sorts of medical treatment and hos-

pital comforts; but loss of liberty seemed to be fatal to these poor saviiges, and they seemed to enjoy nothing but sitting in the sunshine on the bathing platforms, alternately pouring water upon themselves, and scraping their bodies all

over with a piece of a broken chatty?reminding me of the patriarch Job and his potsherd. As a contrast, none of the Burmese prisoners,

fifty-five in number, were Burmese. found scorbutic 011 admis-

sion, and none of them had become scorbutic in jail. None of them have had enlarged spleen, though they constantly suffer from ague, diar- rhoea and dysentery, just like the rest of the

prisoners. The only predisposing cause common to all

scorbutic prisoners is pri-

thfSlrbu1ral3 ?> BUipri*- mg to find the worst and

the most numerous cases of scurvy among the habitual criminals, whose life, while they are at large, consists of an alternation of reckless self-indulgence and the most abject destitution. The inhabitants of a prison are the survival

of the unfittesr, so, instead Causes of sickness f exclaiming at the so-

and mortality m ]ails. ,, . . .

0

called high mortality in

Indian jails, the wonder is, that the mortality and sick-rates are so low, for many of the convicts are suffering from semi-starvation in various

forms, (complicated with venerea) diseases of all kinds,) from leprosy, from scurvy, and from intoxication owing to indulgence in country liquor, opium or bhang.

Their health improves and their weight increases in jail, but, in spite of this, loss of*

liberty must be always recognized as a depressing agent of tremendous force, and all convicts work so listlessly, that one free cooly must be always estimated as worth at least two prisoners, and often equal to three or four, so if a man has a tendency to scurvy, imprisonment will increase the tendency, unless measures are taken to prevent it. The next most powerful causes of scurvy are

cold and damp, and it was

damffCC^ C?^ UU<^

very remarkable to notice how very suddenly scurvy

Feb., 1886.] PREVENTION AND TREATMENT OF SCURVY. * 35

appeared in the Nagpore Jail every year at the beginning of the cold weather, a single night making the greatest difference. ?The cold was not great; it was an agreeable

change for people in ordinary health, but the effect on the weak was extraordinary, convales- cents from fever being unable to stand, and

some ordinary ulcers becoming gangrenous. Great improvements having been sanctioned

in the jail between 1881 and 1885, the number

of scorbutic cases fell from nearly 30 per cent, in the former, to less than 3 per cent, in the

latter year, and if we exclude those prisoners (twelve) who had been only just admitted, the scorbutic could be reduced to only 1 per cent, of strength.

There were 18 cases of scurvy altogether in

November, 1885, to be accounted for as fol- lows : ?

Twelve had been only just admitted, in poor health, and had not had time

Effects of depression. t() benefit by treilt?lellt. Of the other six, all had been subjected to

other depressing influences besides imprison- ment, viz., two had been tried on capital charges, and had just been sentenced to transportation for life; two were epileptics; and the other two had only recently recovered from other diseases, for which they had been some weeks in hospital.

It was an encouraging fact to find that sixty- four prisoners,who had been scorbutic in previous years, were found quite healthy in 1885, so that the treatment adopted was successful, in spite of their being mostly habitual criminals, and a year longer deprived of liberty. At the beginning of the cold weather of 1884

it was noticed that the pri- Scurvy ffc-acae. ^ ^

most severely, were also affected with acne on the face.' The same tiling was observed in

1883, when the coincidence was thought to be accidental, but as it occurred again in 1884, must we consider scurvy plus acne indicates a

worse cachexia than scurvy alone? In 1885, most of these prisoners had quite lost scurvy, but acne was still present, though to a less extent.

In 1885, only one woman had scurvy, and she had been sentenced to transportation ; so I told her this illness would prevent her from being fit to go to the Andaman Islands, which are much dreaded by natives, and this news cheered her so much, that she rapidly recovered.

It is evident that scurvy, a most debilitating ,. , disease, must make diar-

Scurvyplus diarrhoea , '

, , ,

..

or dysentery. and dysentery far more dangerous, and such

was found to be the case. Three scorbutic patients died in hospital while they were lying asleep at night, and were only discovered to be dead when their medicine was brought to them in the morning.

At a post-mortem examination on one of tliem, ,T the mucous membrane of Necropsy. the whole alimentary tract,

from mouth to anus, was found swollen and

spongy, of a soft, pulpy consistence, and a pur- plish crimson colour ; so that it was amazing the man could have lived so long in such a state before coining to hospital. The preventive treatment was as follows:?

t, Improved drainage of the Preventive treatment. ? ? i i w jail; improved shelter 111

the barracks ; improved clothing on the prison- ers?diet constructed scientifically to provide all the necessary chemical constituents of food, instead of so many ounces of solids ordered

haphazard by some one who was not a member of the medical profession. The curative treatment adopted was as fol-

lows:?Rest in bed : band- Ourative treatment. c , , ,

ages from toes to knees, but

latterly Dr. Rice's paint. Good nourishment, easily absorbed and assimilated, viz., soup, pish? pasli, arrowroot and milk, soft puddings of rice, tapioca, sago, &c. ; an ounce or two of rum

every day, with Tr. Ferri Perchloridi as a tonic. " Dr. Rice's paint

" is thus described in the

^ , annual reporton the Central

Dr. Rice s paint. -r> ? r m c t o o i Provinces Jails tor 1884,

page L8, para. 50, where the Inspector-General says, with reference to scurvy and its treatment, I reproduce the following interesting remarks by Dr. Rice [iu medical charge, Jubbulpore jail] :?" Scurvy was more than usually preva- lent during the year. Sixty cases with three deaths came under treatment, against eighteen cases with two deaths in 1883. I believe the

immediately exciting cause to have been the

excessively wet subsoil and humid atmosphere." [The rainfall at Jubbulpore in 1884 amount-

ed to nearly 100inches,or almost double the usual quantity.]

" These are always depressing, and in addi- Scurvy complicated tion causative of malaria,

with malaria. with the consequences of which the scorbutic symptoms intermixed,so much so, that, on occasions, I had to take time to make up my mind whether the case was one of scurvy or malarious cachexy. This latter is a condition of body more or less present in every prisoner coming into the jail, and leavens more or less

? i 11

every case of sickness with which we have to deal, always in the direction of debility. A curious feature in the nature of the scurvy was the fact, that, in nearly every case, the effusion into the cellular tissue of the lower extremities

(a common enough sign always) assumed this

year very grave propor- oedema.

tions, extending up to the knee, and in many cases quite up to the groin ; it even invaded the upper extremities, mak- ing the whole limb hard and swollen, and the skin brawny. This is the condition antecedent

36 xTHE INDIAN MEDICAL GAZETTE. [Feb., 1886.

to those gangrenous ulcers so often met with in the poorer classes of natives; it is not difficult to conceive how, with the soft structures of the

,. , leg in such a diseased state, Sloughing ulcers.

a ?0re which would other- wise be trifling*, may spread superficially, and in depth until half the flesh sloughs away."

[These frightful sores may be seen in time of famine, or after epidemics of fever, in the civil

population. Also, among native soldiers who have been stationed too long in notoriously un- healthy places, or who have had great privations on field service.]

Dr. Rice continues:?" Fortunately, we were ^ , saved from complications of Paint on limbs. *i ? i ? 1 i? ii *. ? this kind. Jb or the past two

years I have been painting the limbs with ordi- nary white lead paint: two or three coats are

put 011 as fast as they dry ; in a few days the limb begins to grow smaller, the skin becomes wrinkled, aud, finally, subsides to its natural

dimensions; for several days afterwards the pel- licle of paint has remained, giving the leg a shrivelled appearance, indicative of the extent to which swelling has been reduced. I do not

pretend to explain the rationale of this treat- ment: it may be due to the constrictive action of the dried paint, or to the deobstruent action of the lead, or perhaps to both combined. I should add, however, that the most careful

bandaging will not produce the same results in anything like so short a time. The fear of

lead-poisoning may be dis- Nofearof lead-poisou. ; d cllimerioa|. at all

ing. T '

events, I was very glad to have this treatment as a stand-by, and the

patients all liked it; they remarked that the skin of paint kept their legs warm; doubtless, the circulation was kept up, which in itself helps to remove effusion in the cellular tissue. There

were two or three cases where there was also

serous effusion into the knee-joints; in these

cases too, the paint application resulted in a

rapid absorption of the effusion, quite as effect- ively as if the joint had been strapped with

mercurial plasters spread on leather." As soon as I heard of Dr. llice's paint, I tried

it on my scorbutic patients, and the result is

so satisfactory, that I am glad to say my expe- rience confirms his in every particular. Of course, it cannot be applied if there is any

open sore. In such cases Solid India-rubber j dress the sore antisepti- bandages.

callj, and surround the limb with solid India-rubber bandages, the elastic pressure of which is agreeable to the patient, and causes absorption of the effusion

very rapidly. At night the India-rubber bandages are taken

off and washed. The patient's leg is also washed to remove the perspiration and par- ticles of skin which have accumulated during

the day, and flannel bandages are applied to bo worn on the leg all night. Next morning fresh dressing is put on the sore, and the India-rubber bandage is applied again, to be worn all day.

(To be continued.)