enough, there was found upon auscultation a change in the duration of the heart-sounds which Manson aptly likens to the swinging of a well-hung clock's pendulum, i. e., there was the same space of time between both sounds and between each succeeding heartbeat. There were also cases in which the patient was very much puffed up, and others in which the atrophy of the various muscles had almost reduced the man to a condition of skin and bones.

In all advanced cases there was impaired or difficult locomotion, which varied from a slight uncertainty of gait to an actual crawl, due to the general extension of the paralysis over the arms and legs. The patient may have had an ankle-drop, and in attempting to avoid dragging his toes along the ground, he lifted the front of the foot high before letting it fall, very much after the fashion of

a rooster.

As the disease advanced he found it impossible to stand or walk without the aid of a stick. A favorite position assumed was to place the supporting stick well out in front of himself and advance by a sort of "flop-step," the right foot first, then dragging or "flopping" the left foot after it. When he could no longer stand he , adopted the sitting posture, and with both hands at his sides or between his legs as a support, advanced his body, or he may have used his knees and bent-under legs as a prop, and thus advanced his body, placing his hands in front. When adopting this method his head was usually bent well over on his chest. One case found it easier to roll over and over in getting from place to place, and a few had to be carried.

A remarkable fact in many of these cases was the general absence of symptoms other than paraplegic and muscular. In the majority of them when under proper treatment there prevailed good spirits, and notwithstanding the helplessness of the patients, they laughed and joked, played cards, and those who were talented drew pictures or carved objects in wood.

Outside the edema or atrophy and the impaired locomotion, there seemed very few symptoms of importance at this stage. Fever was very rare.

I know of no other disease, except possibly syphilis or malaria, which is so amenable to proper treatment begun at the proper time as is epidemic beriberi. This statement will no doubt be challenged by many observers, but in an experience of several hundred cases I have been convinced that this conclusion is correct. I do not know that the disease is influenced by any single drug or combination of drugs. As a matter of fact, the treatment of beriberi by drugs is most unsatisfactory. Some of the symptoms may be relieved by them, but I doubt very much if, the disease once well on its course, it can be influenced by any medicinal treatment within our present knowledge.

In the two epidemics already mentioned, in which about 150 cases were handled, it was made quite clear that the very first step to be taken was the removal of the patient from the site occupied when attacked. If left in this place, he will very likely die. In

the kotta at Cebu, of the 100 natives stricken with the disease, 60 resulted fatally. The other 40 were removed in time and recovered. In the epidemic at Tuburan every case that developed was immediately removed, and 49 out of the 50 attacked fully recovered, the one fatal case not having been transferred until the disease had well developed.

If we are to accept the theory advanced by Manson, who is perhaps the greatest living authority, that beriberi is due to a germ which resides in the soil or in the houses and surroundings of beriberi spots, that it there distils a poison which, on being absorbed,

produces a neuritis, then we find a logical explanation for the appalling mortality in epidemics where those poisoned remain to absorb and reabsorb the ever-increasing toxin. We also thus find the cause for the great success experienced when patients are given an opportunity to throw off, as it were, the effects of the poison by removal to an uncontaminated spot.

In accordance with these facts, a course was adopted which gave to each patient the greatest possible amount of fresh air and sunshine. A camp was laid out on a dry and well-drained site, and tents put up which were supplied with floors made in two parts and of bamboo strips, to permit of easy removal and thorough ventila

tion. Each patient was given a thorough bath and a clean suit of pajamas. Those seriously affected were made comfortable on mattressed cots. Every morning all the patients were put out on slightly-raised platforms, and in good weather remained out most of the day. The tents were taken down daily as the weather permitted, and once a week they were pitched on a new site. Contact with the sun was encouraged, and to get the full benefit of its rays most of the patients rolled up the pajama trousers as high as possible and removed the shirt, thus exposing the greater part of the body. When the sun became too hot the patients were allowed the shelter of neighboring trees.

In this way the beriberics received the greatest possible amount of sunshine and fresh air. The siesta, or afternoon nap, so indispensable to every Filipino, was taken in the sun. The close proximity to the ground did not seem at all injurious—a result different from what is said generally to occur.

In rainy weather, of course, the patients were confined to the tents. When the rain lasted several days the cases did not seem to make any progress, although the only ill-effects noted was an increase in the rheumatic-like pains in the legs.

The diet was regulated. Following out the theory of the Japanese that rice was in some way a factor in producing the disease, this staple article of Filipino food was entirely interdicted, which was one of the greatest hardships the natives had to undergo. Bread and beans were liberally supplied instead, and fish in the form of canned salmon was furnished. Some meat was allowed, but was not relished. These articles, with some variation, formed the principal articles of diet. There seemed to exist what assumed the proportion of a craving for bananas among many of the patients, and these were allowed.

As regards medicinal treatment, it was practically all symptomatic. Where the heart needed steadying digitalis was administered. Strychnia was used to combat the atrophy. Iodide of potassium and the salicylates proved of little value. Liniments. were very popular with the patients, and proved soothing to the painful muscles, but as far as could be noted the effect of any medicinal treatment was not very marked. I might mention that the natives themselves frequently tied a piece of cord or strips of bamboo skin tightly about the limb, believing that in this way the spread or extension of the disease could be prevented.

It was truly remarkable to observe the influence this open-air treatment had on the beriberics. Patients who were almost helpless when taken out of the kotta were in a short while noticed to be able to sit up. Those who could only get about in a sitting posture gradually found themselves able to partly raise themselves, to be followed shortly by an attempt at standing. From being able to get up on his feet, one would soon be seen ambling along with the aid of a stick. In less than eight weeks the worst case could get about more or less comfortably. Patients who had only a slight impediment of locomotion soon were able to walk normally.

The edema gradually subsided in the edematous cases, and one of the last symptoms was usually the atrophy, which, although sometimes quite persistent, gradually went on to recovery.

Some of these cases extended over several months, and were finally lost track of. It can, however, be reasonably surmised that if a second exposure had not occurred the cases went on to recovery.

I cannot emphasize too strongly the value of pure air and sunshine. I believe that these were the greatest factors in their successful treatment. The marvelous improvement after a course in the open air assumed almost the proportion of a magical change, and leads one to wonder if this form of treatment, modified to suit our own climate, would not be applicable to the successful handling of other neuroses. Certainly this appears a fertile field for experiment.

THE OCCASION OF CANCER..

By A. K. Bond, M.D.,

Baltimore.

THE original cause of cancer, its infective organism if there be one, baffles investigation. We hear again and again that it has been discovered, and soon this is denied, while cancer marches on, gaining force with the growth of civilization and scattering death. and a terror worse than death throughout the community. Under these circumstances it seems wise for the practitioner to leave the investigation of its fundamental cause to the laboratory worker and to turn his attention more earnestly to the occasion of the disease.

For, whatever its original cause, its immediate onset in each case seems to be occasioned by a definite physical condition. There may be exceptions, there are apparent exceptions, but in most cases there is a physical something which is within our reach.

I think we may truthfully formulate it thus: The occasion of cancer is a long-continued local fret.

If this is so, the combating and the prevention of that fret is the plain duty of the practitioner, as well as the instruction of the public as to this prevention. That some cancers are due to local fret is already known among the laity. The wart that is "scratched into a cancer," the chronic sore that "breaks down into a cancer" are public property. Before the practitioner can rest content, however, this public fear must be pushed very much farther, and it is for the urging of this extension that I write this article.