THE FINAL REPORT OF THE ROYAL COMMISSION ON ARSENICAL POISONING.

1674 the origin of the considerable quantities of arsenic found in the beer was "brewing sugar," sold by the Garston firm of Bostock and Co., which had been prepared by the use THE annual lecture under the endowment of the Richard of an arsenical sulphuric acid manufactured by the firm of Nicholson and Sons of Leeds. Valuable reports on inquiries Middlemore Post-Graduate Lectures will be delivered at made in consequence of the epidemic were issued by medical the Birmingham and Midland Eye Hospital by Mr J. men and chemists, particularly Dr. J. Niven, Dr. E. W. Jameson Evans, surgeon to the hospital, on Friday, Dec. 18th, Hope, Mr. Tattersall, Dr. G. Reid, and Mr. E. Sergeant, by at 4.30 P.M. The subject chosen by the lecturer is a strong expert committeeappointed by the Manchester Bacterial Diseases of the Conjunctiva and there will be brewers, and by Dr. Buchanan on the result of inquiries made on behalf of the Local Government Board. These a clinical and microscopical demonstration after the lecture. inquiries brought into prominence a state of affairs which All members of the medical profession are invited to attend. on all hands was recognised as unsatisfactory : uncertainty, for example, regarding the extent of the epidemic, the share A PAPER is to be ’read to-night (Friday) at the meeting which malt and other ingredients of beer might have had in the recent poisoning by arsenic, the tests for of the Epidemiological Society at 11, Chandos-street, producing arsenic most suitable for use by public analysts and brewers’ London, W.C., by Dr. Louis Sambon on Sleeping Sick- chemists, and the risks of arsenical contamination in the case The paper of Dr. Sambon, who is a lecturer at of other articles of food or drink. Moreover, they showed ness. the London School of Tropical Medicine, may lead to an the necessity of thorough investigation of a number of im. questions which had arisen in consequence of the interesting debate if, as expected, Professor Ray Lankester, portant demonstration afforded by the epidemic of the defects in the Sir Patrick Manson, Lieutenant-Colonel David Bruce, present laws relating to food and in existing administration R.A.M.C., and Dr. Adolph Castellani are present. under the Sale of Food and Drugs Acts. The Royal Commission which was consequently appointed at the instance of THERE will be no measure introduced in Parliament next the President of the Local Government Board was given a session to provide for revaccination. The Government appear wide reference covering these and other matters. The Commission issued an interim report in July, 1901, on which we to have found out at the last meeting of the Cabinet that their commented at the time, setting out the results of its hands were too full to permit of the introduction of the inquiries up to that date and the directions in which it was Bill. Whether it will strengthen an administration whose ’, proposed to undertake further work, while making an best friends cannot describe as robust thus to shelve a interim recommendation for the exercise of control by the Board of Inland Revenue over arsenic in beer ingredients. necessary and promised piece of legislation is, to say the It is evident that the investigation which has followed during least, doubtful. the past two years has been thorough and comprehensive. The final report is divided into the following parts :THE announcement is made that His Majesty the King Further observations regarding the epidemic of arsenical poisoning has accepted an offer from Mr. John Brickwood to build a in1.1900 and as to the medical and public health aspects of the evidence church for the Royal Sanatorium at Midhurst. The cost is received regarding arsenic in beer and food. 2. The suggested relation between the disease "beri-heri" and estimated at £20,000. This may appear a late addition to arsenical poisoning. 3. Tests for arsenic in foods and substances used in the preparation the original scheme, but a place of worship was specifically or manufacture of food. omitted from the plans which obtained the first prize in the 4. Ways in which foods are liable to become contaminated by arsenic. reasons which Dr. A. the for winner, Latham, competition 5. Precautions which should be taken by manufacturers to exclude ’, arsenic from foods. gave. 6. Present means of official control over purity of food in relation to

Dec. 3rd there the disease.

were

60

cases

of

plague

and 41 deaths from

___

--

THE FINAL REPORT OF THE ROYAL COMMISSION ON ARSENICAL POISONING. I. THIS report has now been issued as a Parliamentary paper.i It is a document of 50 pages and is signed by all six Royal Commissioners, Lord Kelvin (chairman), Sir William Hart Dyke, M.P., Sir William S. Church, K.C.B., Dr. T. E. Thorpe, F.R.S., Mr. H. Cosmo Bonsor, and Dr. A. Whitelegge, C.B. Dr. G. S. Buchanan, of the Local Government Board, acted as secretary to the Commission. It is stated that two volumes will shortly be issued, comprising the evidence received by the Commission and also various supplementary papers and reports of scientific inquiries which have been undertaken. In the present article, and in another which will appear in a subsequent issue, we propose to give an account of some of the principal points dealt with in the report. The main circumstances which led to the appointment of the Commission in February, 1901, are sufficiently familiar. At the end of November, 1900, it became known that for several months large and continually increasing numbers of patients suffering from peripheral neuritis had been admitted to Manchester hospitals and Poor-law infirmaries and that Dr. E. S. Reynolds of Manchester had established that the cause of this occurrence and also of the prevalence of some other forms of illness was the presence of arsenic in beera fact which was confirmed by independent inquiries made by Mr. C. H. Tattersall, medical officer of health of Salford, and by several other investigators. Almost at once it was realised that this epidemic of arsenical poisoning was spread many parts of Lancashire, Staffordshire, and elsewhere in the north and midlands and it was shown that in all cases over

1

Cd. 1848,

Eyre and Spottiswoode, price 5½d.

arsenic. 7. Recommendations as to improvements in official control over the purity of tood. 8. Recommendations as to the proportions of arsenic in food which should now be held to constitute an offence under the Sale of Food and Drugs Acts. I he report has evidently been very carefully arranged and worded and its argument is so much condensed that it is by no means easy to abstract. In the present article we summarise some of the principal matters dealt with in Parts 1 to 3. After briefly recalling the circumstances of the BostockNicholson occurrence and the steps taken by public health authorities and by brewers to put an end to the outbreak of poisoning in 1900 the Commission reports the action which it took to secure that some 700 tons of arsenical glucose and " invert sugar" remaining at the works of Bostock and Co. after the company had gone into liquidation were disposed of for textile and other purposes unconnected with food. The danger of poisoning which arose through the use of arsenical sulphuric acid by this firm was not restricted to brewing sugars. In 1900 Messrs. Bostock and Co. had begun to manufacture preparations resembling treacle termed table syrups "-sugar which had been"inverted by Nicholson’s sulphuric acid, flavoured with various fruit essences, and put up in two-pound tins for sale. The contents of some of these tins, examined by Dr. G. McGowan, D.Sc., showed about one grain of arsenic per pound. Fortunately, at the date of the discovery of arsenic in the firm’s brewing sugars scarcely any of these syrups were on the market, as a trial series of tins sent out to retailers had not proved a success commercially on account of an accident in manufacture which led to the syrups crystallising. 14 tons of£ these tins were ultimately burnt by order of the liquidators.

Extent, Distribution, and Fatality of the Epidem’ic of 1900. Information on these points was obtained by the evidence of witnesses and by circular letter addressed to medical officers of health throughout the country. No cases were reported from the southern or eastern counties, from London,

1675 or

from 37

English county boroughs ;

the districts affected

every-day practice,

without

an

epidemic

or

other circum-

in the north-west and midlands. stances to suggest arsenic, the true nature of such cases (and Lancashire and Staffordshire suffered most severely. Medical especially of the slighter forms of poisoning) would very officers of health, in giving estimates of the number of cases seldom be capable of being satisfactorily established. which occurred in their districts, were in many instances Poisoning from Arsenic in Beer apart from the Epidemic careful to point out that there must have been others which of 1900. did not come to their notice, and the Commission concludes The report gives a good deal of space to the question of that the total of persons attackedwas certainly 6000 and probably the number was, in fact, very considerably greater." arsenic in its relation to "alcoholic neuritis." The ComIt was impossible to determine the fatal cases with any mission is satisfied that before 1900 medical men in approach to accuracy. A total of 70 deaths occurred in Manchester and other places were much more familiar with which arsenical poisoning was entered on the death certi- " alcoholicneuritis " than was the case in London, Scotland, ficate as one of the causes of death or was found to be the and large centres of population in the south of England, and this view is confirmed by the comparative data cause of death as the result of a coroner’s inquest, but the deaths so certified did "not represent the total number of obtained from hospitals. It is observed that in the former cases in which death resulted from, or was accelerated by, places the disease had been recognised (for some years before

were

in

nearly all

cases

poisoning due to arsenic in beer. the discovery of the cause of the

Deaths occurring before outbreak were frequently certified as due to ’chronic alcoholism’ andcirrhosis of the liver,’ and in some cases were attributed to Addison’s disease and locomotor ataxy. Other deaths were recorded as due to alcoholic,’ peripheral,’ ormultiple’ neuritis." Owing to the fact that the Registrar- General’s classification does not separately distinguish deaths from these diseases, no estimate of the fatal cases due to arsenic in the districts affected can be made by comparing the deaths in 1900 with those of previous years. Effect of the Epidemic on the Birth-rate Reference is made to statistics furnished by Dc. Niven, medical officer of health of Manchester, which suggest that a strongly marked fall in the birth-rate of Manchester, Salford, and Liverpool in the third quarter of 1901 was attributable to the epidemic. These statistics, which include comparison with other large towns unaffected by the epidemic, will be !’tudied with interest when the volumes of evidence* of the Commission appear. The fact, if established, would’ accord with observations made by Brouardel and others on anaphrodisia and impotence resulting from long-continued doses of arsenic.

Symptoms of Poisoning due to Arsenic in Epidemic of 1900. The report points out that-

Beer

1900 and the "Bostock-Nicholson"incident) as one which affected beer-drinkers far more than spirit-drinkers. Malt has now been shown to be liable to contain material quantities of arsenic, especially when dried by exposure to the products of combustion of gas coke. Manchester and Liverpool brewers who gave up the use of Bostock’s and other brewing sugars found, nevertheless, that they could not produce beer which could be regarded as practically free from arsenic until they had discontinued the use of malt which bad been dried over this fuel. Use of gas coke on the fire of the malt kiln has never been common in the southern and eastern counties, but at Manchester and Liverpool until the 1900 epidemic a large part of the malt used came from Yorkshire and had been dried over local gas coke. Some of these malts after the epidemic were found to contain onetwentieth of a grain and exceptionally even one-sixth of a grain of arsenic per pound, the quantity of malt used to the gallon of beer being usually between one and two pounds. From these considerations the Commission concludes thatThe fact of greater prevalence of alcoholic neuritis among beerdrinkers in Manchester and Liverpool before 1900, when compared, for example, with London and places in the southern counties, is consistent with the explanation that (whatever may have been the case with regard to brewing sugars) the degree to which beer was likely to become contaminated by arsenic was greater in these two cities owing to the larger proportion of arsenic contained in much of the malt there used.

during the

The report shows that this is confirmed by the evidence which the Commission has received of the marked diminution in " alcoholic neuritis " and in the condition locally known as "alcoholic heart"in Manchester during 1901 and 1902, when compared with other periods before the epidemic year of 1900. This diminution corresponds with stringent and effectual. precautions against arsenic which have been taken by Manchester brewers since the epidemic, including the disuse of arsenical malt.

great differences in individual cases as regards the arsenic in the beer consumed, the amount of beer taken, and the duration of the period over which arsenical beer was drunk; and there were also further differences between individual beerdrinkers—e.g, as to age, sex, health, conditions of nutrition, and habits as regards alcohol-which determined the extent of their susceptibility to arsenical poisoning at the time when they began to take beer containing arsenic....... Corresponding to these and other differences, the disease produced by the arsenical beer during the epidemic varied greatly in its manifestations. one On the hand, there occurred throughout the epidemic (and particularly, it would seem, towards its termination, when been had drinking arsenical beer for many weeks or people months and so had taken considerable quantities of the poison) an abundance of cases in which, once the possibility of arsenic was entertained, there was comparatively little difficulty in deciding on clinical grounds that the illness was consistent with arsenical poisoning. Such cases presented symptoms corresponding to those described as characteristic of subacute poisoning by arsenic, or which are met with in the poisoning which occasionally results from long-continued doses of arsenic taken medicinally. They showed, for example, infl tmmation of various mucous surfaces-leading to coryza. huskiness, lacrymation, and the like; gastro-intestinal disturbance and diarrhoea; peripheral neuritis affecting sensory and motor nerves, and in some cases associated with herpes or with well-marked erytbromelalgia, keratosis. or recent pigmentation corresponding to that which not infrequently occurs in persons taking arsenic for long There

were

quantity of

Arsenical

Poisoning in Halifax in

1902.

A small but instructive outbreak in Halifax, which was for the Commission by Mr. H. Hammond Smith, and also by Dr. J. T. Neech, medical officer of health of the borough, gives point to these conclusions. Some 15 cases (three of which were fatal) presenting symptoms pointing unmistakeably to arsenical poisoning were discovered in this town early in 1902, the circumstances being first brought to notice by Dr. J. F. Hodgson :-

investigated

All the persons attacked were beer-drinkers and in most instances was no reason to suspect that they had received arsenic otherwise than through beer, while there was strong evidence that the beer they had consumed had been arsenical. Samples of beer taken in January, 1902, from public houses frequented by certain periods. of these cases were found to contain between one-fortieth and oneOn the other hand, symptoms of the above kind were often slight sixteenth of a grain of arsenious oxide per gallon. Inquiry was made as or absent altogether and one of the most instructive points in conto the origin of the various beers which had come under suspicion. They nexion with the outbreak is the occurrence of cases in which the were traced back to particular breweries and the source of the materials symptoms, if taken by themselves and apart from the epidemic, would used in the brews which were specially implicated was ascertained. not have appeared to be readily or sufficiently explained by the sugIn some of these brews glucose or " invert" sugar had teen used, gestion that arsenic was the cause of illness. Thus in several com- but these had been supplied by different manufacturers, and the eviparatively mild cases the sufferers complained merely of burning hands dence gave no indication that the beers in question had obtained their and feet or they showed a variety of skin eruptions which are observed arsenic by way of brewing sugars. None of the breweries concerned in many conditions which have nothing to do with arsenical poisoning. had been customers of Bostock and Co. in 1900. In two beers conIn other ca,es, again, the main symptoms were those resulting from one-sixteenth of a grain and one-thirtieth of a respectively taining dilated heart; and special difficulty arose in cases showing evidence oi grain of arsenic per gallon no brewing sugar had been used. On well-marked peripheral neuritis not associated with symptoms point- the other hand, the facts pointed strongly to the conclusion that the ing clearly to arsenic and which appeared practically identical with implicated beers had been contaminated by arsenic derived from "alcoholic neuritis.’ a disease previously considered to be the result, malt used in their preparation. In nearly every instance there was alike in drinkers of beer and spirits, of the toxic action of alcohol or evidence that the malt concerned had been dried over local gas coke nerve tissue. and that the brewer, before using it, had taken no precautions to its condition as regards arsenic. In most cases the malt ir ascertain The latter considerations are of considerable which had been used in the implicated brews had been dried in the in tht previous malt.ing season, 1900-01, over gas coke; and at some maltings relation to the argument, of arsenic should bE} in the Halifax neighbourhood gas coke was still used in 1902. One report, that even minute malt, was using as much as 85 per cent. such as that ir large brewery, making its own In an excluded fiom food. of gas coke for malt drying: at another it was found that gas coke was Manchester when once the fact of arsenic in beer was knowr used when a sufficient supply of anthracite was not available. Certain But it1 samples of malt which appeared to correspond to those which had deal of anomalous illness was a

heavy beer-drinkers. There

.

’

importance subsequently developed quantities epidemic

great

explained.

.

1676 "been used in the beers under inquiry showed amounts of arsenic such .as one-sixtieth of a grain per pound. In one instance where the brewer had used malt in the proportion of two pounds to the gallon of beer, a in of the taken beer, January, 1902, was found to contain one’sample - sixteenth of a grain of arsenic to the gallon, and it was shown that on the single occasion on which the maltster bad sent a sample of his malt to be examined for arsenic the analyst had reported the presence of as much as one-thirtieth of a grain of arsenic to the pound.

The Commission points to the circumstances of this small ’outbreak as showing that poisoning by arsenic in beer may - even now easily pass undetected, notwithstanding that a umber of cases may be occurring in the same place at about the same time, and adds that the Halifax beers associated with the outbreak "must have been typical in respect of arsenic of a large class of beers prepared before the 1900 epidemic from arsenical malt."

Dr. McGowan on behalf of the Commission. In promising a detailed account of the information thus obtained the

report states

:-

In a few instances the results gave some ground for inference that the beri-beri cases inquired into had lately been taking arsenic along with their food. Thus the hair of one or two of the patients contained noteworthy amounts of arsenic, while small quantities of arsenic were found in several samples of dried fish-an important article in the diet of sailors on Scandinavian sailing ships. But when such clinical, etiological. and chemical data as we have been able to collect are considered as a whole, they cannot be said to support the view that cases of beri-beri met with on ships arriving at home ports are essentially attributable to poisoning by arsenic.

Tests for Arsenic in Food and Substances used in the Preparation and Manufacture of Food. All who have followed the "arsenic question"during the past two years will be aware of the great difficulties which Alcoholic Aeitritis apart from Arsenical Poisoning. arose, particularly at first, in obtaining satisfactory methods ’On this subject the Commission states :of estimating minute quantities of arsenic in organic subIn our view it is important that the question of arsenic should stances. The Commission has received a great deal of be fully cousidered in all cases of peripheral neuritis attributed to chemical evidence, especially from two strong committees, To what extent beer free from arsenic is of beer-drinking. capable a joint committee of the Societies of Public Analysts and one neuritis drinkers the data at our do among heavy producing disposal not suffice to permit an opinion to be given. We are unable to accept Chemical Industry, with Mr. Otto Hehner as chairman, and the thesis of some witnesses that there is, practically speaking, no the other, with Dr. Thorpe as chairman, appointed by "alcoholic neuritis" apart from arsenic. Inquiries which we have made as to the experience of London and provincial hospitals show the Board of Inland Revenue to advise as to arsenic in beer The report deals with the essential principles ’that cases of alcoholic neuritis are met with from time to time in ingredients. which the alcoholic liquor consumed has been exclusively spirits. All of what is now termed the "Marsh-Berzelius test’ applying the evidence adduced is to the effect that spirits are not liable to to various substances. In this test, as is well known, the ..contain arsenic. arsenic from the arseniuretted hydrogen is deposited, not on As regards arsenical beer, "it may be conjectured that a porcelain tile, as in the Marsh"t, st, but in a capillary when small doses of arsenic are taken for a long time, tube. Within a certain range "mirrors " of arsenic deposited together with considerable quantities of alcohol, the arsenical in these tubes show definite differences in intensity according poisoning liab’e to result will be manifested more frequently to the quantity of arsenic present and an estimation is made and more conspicuously by peripheral neuritis than if the the intensity of the mirror obtained from a arsenic had been taken without the alcohol." Although it is by comparing of substance with a set of standard mirrors. weight given possible that arsenic may enter into some combination with Attention to various points of detail is essential to accuracy. the organic matter of beer the chemical evidence is incon- In nearly all cases it is necessary in the first instance to clusive and the Commission sees no reason to assume from destroy completely any organic matter present. The merely clinical data that poisoning by arsenious oxide in presence of iron salts in the Marsh apparatus may seriously beer is itself insufficient to explain the morbid conditions vitiate the result. It is not only necessary to have zinc" observed. Professor Delépine and others have shown that which is free from arsenic but also zinc which is I I sensitive there is no evidence that cacodyl or substances akin to and does not retain the arsenic in the solution tested. The cacodyl are formed in arsenical beer. Commission finds that chemists are now agreed as to these The rest of Part I. deals with the evidence as to individual nd other sources of error which it is necessary to avoid and susceptibility to arsenic, accumulation of arsenic in human that if due regard is had to these points differences as small tissue, and ways in which arsenic is eliminated,’It is as 0 2 of arsenic 1,000,000 in the substance taken, or -obvious that the Commission has received a large amount 0.0014 part of arsenic per per grain pound, can be readily distinguished. of valuable information on these points and its evidence When various substances are taken for analysis in quantities when published should provide a store of useful material for which have been found of convenient the practically reference. An investigation into the elimination of arsenic arsenic will be detected when in amounts well presence below oneby the hair, which the Commission undertook with the thousandth of a grain per pound, or in the case of a liquid assistance of the medical registrars of certain London well below one three-hundredth of a grain per gallon. The hospitals and the medical superintendents of certain London departmental committee has found that in the case of beer infirmaries, is summarised in the final report, and the com- ingreoients many of the difficulties attending the Marshplete account of this inquiry, which appears to have shown Berzelius test are obviated by an electrolytic method of that the hair may give clear indications of arsenic when as arseniuretted hydrogen, which can be applied little as one twentieth or one-thirtieth of a grain has been evolving wherever a current of sufficient intensity is available. Wide taken daily for two months, will be awaited with interest. experience of the working of this method may soon be Importance of the Exclusion of Small Quantities of Arsenic looked for. from Food. Under this heading the report deals with the general trend THE LONDON SCHOOL OF TROPICAL of the evidence on the subject ; as to individual suscepthe of arsenic received at the same tibility, possibility being ITS ACHIEVEMENTS time from more than one source of food or drink, the diffiAND REQUIREMENTS. culty of ascertaining the true nature of milder forms of arsenical poisoni g occurring in isolated instances, and the toxic effect of small doses of arsenic administered over long Sir Patrick Manson, M.D., F.R.S., gave an excellent periods to rodents. address on Monday last, Dec. 7tb, atthe London School of The question has often arisen, with reference to particular foods Seamen’s Hospital, Royal Albert Dock, qiable to contain a relatively minute quantity of arsenic, whether such Tropical Medicine, o. quantity may not be regarded as unimportant and altogether E., on the Achievements and Requirements of the School. negligible and the Commission have, as it were, been challenged to say A distinguished company was present to hear the address that it can do no harm. and to wish Sir Francis Lovell, the dean of the school, But reasons are given for not accepting this position. godspeed in his self-imposed task of paying another visit We adhere to the view expressed in our first report that it would be unwise to express an opinion that any quantity of arsenic, to the East to collect funds to carry on the work. however small, is to he regarded as aamissible in any articles of food, At the commencement of his address Sir PATRICK MANSON and we think it should be the aim of the food manufacturer to exclude said that he wished to make public acknowledgment of arsenic altogether from his products. the obligations of the London School of Tropical Medioine to Relation between Beri-beri and Arsenical Poisoning. Mr. Chamberlain, the late Colonial Secretary, who had been This question has been investigated by Dr. Herbert the mainspring of the movement for education in tropical Williams, Mr. C. C. Bullmore, and other port medical officers medicine, and to the Seamen’s Hospital Society and its of health, who have ascertained particulars regarding cases governing body who supported Mr. Chamberlain’s scheme. of beri-beri on vessels arriving at London, Falmouth, and In a hundred ways it had been helping forward the elsewhere, and have collected specimens for analysis by good work. As regards the educational work of the school

MEDICINE;