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conditions to disappear in comatose states and duringanaesthesia. But its disappearance should not cause thepractitioner to abandon a case or to hesitate to perform anoperation in extremis. With regard to diphtheria in

particular, the dictum of Archambault may be recalled : ’’ Donot hesitate to operate unless the child is positively dead."

RECENT STUDIES ON BERI-BERI.

IT is now quite generally accepted that beri-beri is usuallythe result of a too exclusive diet of polished rice or of otherfoods which are deficient in the neuritis-preventing substanceknown sometimes as " vitamine." " It has also been demon-strated that polyneuritis gallinarum is caused by a

similar diet; and although it cannot be asserted that thesetwo diseases are identical, it may nevertheless be assumedthat the symptoms in each are due to the same pathologicalprocess, and that their etiology is similar. If this be

conceded, it follows that probably any deductions, basedupon feeding experiments upon fowls, concerning the rela-tion of diet to beri-beri, may safely be accepted. For some

years careful investigations on this subject have been carriedout at Manila, among others, by two American experts,Captain Edward B. Vedder, of the Medical Corps of theUnited States Army, and Professor Elbert Clark, of

the University of the Philippines. The results obtained

by these observers have lately been published in

the Philippine Journal of Tropical Medicine (Vol. VII.,Section B, No. 5). Many feeding experiments were

made on fowls and very careful pathological examina-

tions were carried out. It is now stated that these inquiriesprove that there are three forms of polyneuritis gallinarum

I

-viz., (1) a form, that most commonly seen, in which thesymptoms of neuritis and those of general prostration arecombined ; (2) a form in which there is pronounced neuritis,but the animal remains otherwise in good health; and(3) a fulminating form in which the symptoms of neuritis areabsent, but great prostration occurs. It is inferred that

similarly there are three forms of beri-beri. After alludingto the researches of Funk, who found that chemical changestook place in the brains of fowls suffering from polyneuritisgallinarum, Vedder and dark contend that this diseaseis not a simple peripheral neuritis, as was formerlysupposed, but that on the contrary the entire nervous

system is affected. The symptoms are not chieflyreferable to degeneration of the peripheral nerves, since

degeneration occurs before the symptoms arise ; also

advanced degeneration may be present, but accompanied byno symptoms at all ; and, moreover, degeneration of thenerves remains after recovery has taken place. The feedingexperiments showed that meat and potatoes contain a

certain but relatively small amount of the neuritis-preventingsubstance, and this may afford an explanation of the

immunity from beri-beri of those races in which meat andpotatoes are main articles of diet. On the other hand, aman who eats a pound of rice daily with a small or occasionaladdition of meat will not receive complete protection fromberi-beri, though the onset of the disease may be delayed bythe meat that has been consumed. Potatoes, it appears,contain the neuritis-preventing substance, and those there-fore who live largely on them do not contract beri-beri.It is noteworthy that both meat and potatoes when cookedappear to afford more protection than when eaten raw,but no satisfactory explanation of this has as yet been found.The feeding experiments also revealed the very importantfact that white bread is lacking in the necessary vitaminewhich.prevents the development of neuritis. It is interestingin this connexion to note the statement that beri-beri beganto appear among the crews of Norwegian sailing ships in1894, the year in which white bread was substituted for the

rye bread consumed largely prior to this date by the sailors.Peas and peanuts (and probably most leguminous seeds)possess the same protective properties against beri-beri as dobeans and mongos (katjang idjo). This knowledge is ofsome practical importance, for the addition of peas to a ricediet will entirely prevent the development of beri-beri

among the consumers, whether they be native coolies onshore or sailors employed during long voyages on ships.Vedder and Clark regard vitamine as an organic base presentin varying amount in different foodstuffs, which pre-vents the appearance of polyneuritis gallinarum amongfowls, and presumably beri-beri in man ; it is an

essential element for normal metabolism of nerve tissue.These observers throw out the suggestion that there

may be two kinds of vitamine, one the neuritis-pre-venting substance and the other that which prevents generalprostration and cardiac failure. Such a hypothethis wouldaccount for the three forms of polyneuritis in fowls mentionedabove. It would also explain some of the apparent difficultieswhich have arisen in connexion with beri-beri in its "wet" "

and "dry" forms. It might be found that the so-calledepidemic dropsy which some regard as a manifestation ofberi-beri, is caused by the lack of the second vitamine andthat the various symptoms observed in "ship beri-be-fi

" are

due to the proportions in which the two essential vitaminesare wanting in the dietaries. At present, it is admitted that

there is no confirmation of this hypothesis by the experi-ments already made, but ,we are glad to learn that furtherinvestigations on the subject are now in process of beingcarried out in Manila by Captain Vedder with the assistanceof some of his colleagues.

MICROCOCCUS TETRAGENUS SEPTICÆMIA,

WE publish in this week’s issue of THE LANCET a recordof a case of chronic septicaemia due to the micrococcus

tetragenus observed by Sir John Byers and Dr. ThomasHouston, which is noteworthy, not only from its comparativerarity and its clinical interest, but also because of the

systematic and careful way in which it was dealt with, andbecause of the valuable comments made upon it by thesetwo observers. The patient was a boy between 10 and 11years of age, who for eight years had had recurrent attacksof acute illness, which had tended to become longer,more severe, and more intractable. The attacks usuallybegan as a " cold" in the head and naso-pharynx, spreadingto the ear, to the lungs as a broncho-pneumonia, and to theintestinal tract, causing diarrhoea. The attack which formsthe basis of the communication now published by Sir JohnByers and Dr. Houston commenced in December, 1912.When first seen the boy was suffering from catarrh of thenose and throat, which spread to the ears. At first he

improved, but early in January a fresh attack supervened.It soon spread to the ears and became complicated by abroncho-pneumonia. Bacteriological examination at this

stage revealed the presence of the micrococcus catarrhalis,the streptococcus, and a few diplococci. A mixed auto-

genous vaccine of the first two organisms was then

given without benefit ; indeed, the patient shortly after-wards became more acutely ill with broncho-pneumoniaand pleurisy. Further examination of the cultures showedthe presence of the micrococcus tetragenus, and the sameorganism was recovered by examination of blood culture.The fact that this organism was pathogenic in this case wasthen confirmed by opsonic index determinations. An ailto-

genous vaccine was at once made from it and used in the

treatment of the case with the best results. At a later stagea pseudo-diphtheritic organism was found in the dischargefrom the ears and a vaccine was made from this as well. In

commenting on this interesting case, Sir John Byers points