A beriberi big problem

Beriberi—kakke in Japanese—affected all levels of Japanese society, but it became especially prevalent among the urban residents of Edo, the classic name for Tokyo. The disease became known as the “Edo sickness.” Art from the period shows men in wheelchairs afflicted with beriberi.

The malady completely immobilizes its victim, as discussed by English explorer Isabella Bird in her 1880 book Unbeaten Tracks in Japan. “Its first symptoms are a loss of strength in the legs, ‘looseness in the knees,’ cramps in the calves, swelling and numbness.”

“The chronic [form] is a slow, numbing and wasting malady,” Bird continued, “which, if unchecked, results in death from paralysis and exhaustion in from six months to three years.”

At the time, the causes of the disease were unknown. It became the subject of great debate among Western medical personnel in Japan. Basil Hall Chamberlain, a preeminent Japanologist, demonstrated the lack of understanding of the disease’s causes in his 1890 Things Japanese: Being Notes on Various Subjects Connected with Japan.

“The disease springs, in the opinion of some medical authorities, not from actual malaria, as was formerly imagined, but from a climatic influence resembling malaria,” Chamberlain wrote. “Others have sought its origin in the national diet—some in rice, some in fish.”

“In favor of this latter view is to be set the consideration that the peasantry, who often cannot afford either rice or fish, and have to eat barley or millet instead, suffer much less than the townsfolk,” Chamberlain continued.

But the disease wasn’t contagious. We now know that beriberi stems from a lack of vitamin B1, which the body requires for metabolizing carbohydrates and maintaining neurological functions. Without it, a person succumbs to nerve damage and eventually death.

The source of the deficiency was the urban diet. Much of the poor countryside ate a combination of millet and brown rice, which retained their protein-rich husks. However, in the cities, husked and polished white rice had taken over. Easier to store, cook and eat, white rice was a sign of affluence.

Traditional medicine already had remedies for the disease—buckwheat, barley rice, or azuki beans supplied inadvertent boosts of vitamin B1. But “modern” Japan increasingly saw traditional medicine as archaic.

Modern assumptions suggested a bacterial or viral cause. One man found challenging these assumptions an uphill battle.

Beriberi was endemic in the Imperial Japanese Navy. Between 1878 and 1883, the disease incapacitated a third of sailors, on average. Beriberi cases made up almost half of all recorded injuries and disease in the fleet. Yet by 1886, beriberi was gone from the navy.

All thanks to Kanehiro Takaki.

The son of a poor Satsuma samurai family, Takaki was inspired to study medicine by his village Chinese-medicine practitioner. Takaki studied medicine starting in 1866 and, in 1868, answered the call for medical officers to support the Boshin War.

It was a revolutionary period in Japanese history. The West’s opening of Japan’s ports in 1853 spurred Tokyo to modernize. Unhappy with the Shogunate government’s handling of foreign influences, the Satsuma and Choshu domains strove to restore the young Meiji Emperor. This led to a civil war between the allies of the imperial court and those of the Shogunate.

Britain had close ties to the pro-Emperor Satsuma domain. The Imperial forces needed Western medical expertise on the battlefield. William Willis, one of the two physicians at the Legation, found himself running a field hospital at Yogenin Temple in Kyoto.

The efficacy of Western doctors such as William Willis made an impression on the young Takaki. Willis treated hundreds of patients as the fighting spread north—all while revolutionizing wartime medicine. He introduced female nurses and emphasized the need to treat opposition casualties.

Willis’ abilities, knowledge and humanity secured him the post-war presidency of the leading medical institution in Japan, the Tokyo Medical School. But his tenure was short. The Japanese elites decided to follow German medical practices—an authoritative, empirical approach where the patient was more of a test subject than a human being.

Willis lost his job and moved to Satsuma territory in modern-day Kagoshima.

Their close ties with the British and their first-hand experience of Willis’ methods led the Satsuma to create their own school under Willis. Takaki was the school’s first student. He picked up English and acted as teaching assistant and translator during his studies.

Willis pushed Takaki to study abroad. There wasn’t enough money in Satsuma to fund the young doctor’s passage and board. There was just one way Takaki could afford to travel.

He joined the beriberi-riddled navy in April 1872.

Takaki immediately made note of the debilitating effects of beriberi on the fleet. Every few months, around a quarter of its sailors came down with the disease. But why didn’t the British, French and Americans suffer from beriberi?

Kanehiro Takaki through the years. Jikei University photos

Naval nutrition

The main reason that the Western navies didn’t have a problem with beriberi was that their sailors ate a balanced diet that included the bran from cereals. This supplied enough vitamin B1 to sustain them. But Western navies had suffered from their own nutritional problems for many years.

Until the 18th century, scurvy was a regular affliction for British crews. The disease causes lethargy and depression, along with seeping sores and partial immobility. Unknown to doctors at the time, scurvy also results from a lack of vitamins—primarily vitamin C, which the body needs to synthesize collagen.

Navies had experimented with the provision of citrus fruits. It was the experience of HMS Suffolk which turned the tide. In 1794, she embarked on a 23-week non-stop voyage to India … and returned with a healthy crew.

Her secret? Daily rations of lemon juice added to the men’s alcoholic grog. The Royal Navy began stockpiling lemons to keep its men healthy. Limes eventually replaced the lemons—the origin of the American slang term for a Brit, “Limey.”

In June 1875, 26-year old Takaki traveled to London to attend St. Thomas’s Hospital Medical School. Over the next five years, he learned medicine on a level that would have been impossible back in Japan. This included exposure to the Royal Navy’s battle with scurvy—a struggle that presaged Takaki’s own campaign against beriberi.

The key to addressing the beriberi problem was a change in thinking. Japan was firmly in the thralls of German laboratory-based empiricism, but Takaki had returned from Britain with a different method: epidemiology.

As a discipline, even as a concept, epidemiology—the medical study of patterns—didn’t yet exist in Japan. But it was the cornerstone of British medicine.

Takaki returned to Japan in November 1880, and soon became director of the Tokyo Naval Hospital. The navy was growing but the beriberi problem was as bad as ever. There were so many patients in the summer that they overflowed the hospitals and had to be carted into nearby temples.

“Such conditions used to strike my heart cold whenever I came to think of the future of our empire,” he wrote, “because if such a state of health went on without discovering the cause and treatment of beriberi, our navy would be of no use in time of need.”

Takaki resolved to end the crisis. “If the cause of this condition is discovered by someone outside of Japan, it would be dishonorable,” he told the emperor.

The Naval Medical Bureau had only collected the most basic of statistics between 1872 and 1877—treatment results, lists of known diseases and the names of hospitalized patients. From 1878, practitioners added facts about non-hospitalized patients and hygiene, but it wasn’t until 1884 that a truly holistic approach to record-keeping took hold.

There wasn’t enough data for Takaki to really investigate the disease, so he started from zero.

In February 1882, Takaki became vice-director of the Naval Medical Bureau. He was now in a position to investigate beriberi in the fleet. He compiled everything he knew about the disease.

Beriberi was more prevalent at the end of spring to summer, but occurred at some level throughout the year. It affected both ships and bases, skipping some units entirely. And the state of quarters and clothing seemed to have no impact on the disease.

Looking more broadly, Takaki noted that sailors from higher social classes rarely came down with beriberi. The disease mainly struck large cities … smaller towns sporadically.

Takaki rejected Western doctors’ hypothesis that beriberi resulted from “high temperature, moisture, marshy air, over-crowding, hard labors, nervous exhaustion, coarse food, etc.” All navies had to contend with these conditions, but the beriberi problem was seemingly unique to the Japanese.

Takaki began to suspect the navy diet. He petitioned the navy ministry to give him a broad remit to investigate the problem—but the navy was skeptical. The German-trained doctors at the elite Tokyo Imperial University all pointed to a microbiological cause.

Falling back on his Satsuma connections, Takaki finally managed to persuade the ministry to approve an investigation into the navy’s great shame.

Takaki surveyed living conditions, including the length of the workday, sanitation, clothing and diet. In the data he spotted a “great deal of difference” in sailors’ eating habits. Cross-referencing similar British studies, he finally pinpointed the culprit—protein deficiency.