lathyrism central ind shourie 1945b par miles

7/29/2019 Lathyrism Central IND Shourie 1945b Par Miles

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Ir.d. Jour. Med. Res... 33, 2, October,. 1945.AN OUTBREAK OF LATHYRISM I F CENTRAL INDIA.

BYK. L. SHOURIE, M . B . : M.SC.

(Nutrition Research Laboratories, Coonoor, South India.)[Received for publication, July 24, 1945.]

LATHYRISM is an ancient disease. According to Chopra (1935) ' in the old Hinduliterature, Bhavaprokasa, it is written that " the triputa pulse " causes a man to becomelame and crippled and it irritates the nerves '. Hippocrates observed that the prolongeduse of certain peas as food was liable to cause paralysis. In the seventeenth and eighteenthcenturies outbreaks of disease which were ascribed to the eating of lathyrus occurred in France,Germany, Italy and Algiers. The first account of lathyrism was written by a layman,General Sleeman, over 100 years ago. Sleeman (1844) encountered an outbreak in a numberof villages near Saugor in the Central Provinces in 1834-36 and described it in his ' Ramblesand Recollections of an Indian Official', published in 1844. His account, which is clear andvivid arid could scarcely be bettered to-day, may with advantage be quoted in full:' In 1820 the wheat and other spring crops in Saugor and surrounding villages were destroyed by severehailstorms and rains and in 1831 they were destroyed by blight. During these three years the " teori " or whatin other parts of India is called " kesari " (Lathyru3 sativus), a kind of wild vetch which, though not sown itself,is Jeft carelessly to grow among the wheat and other grains and given in the green and dry state to cattle,remained uninjured and thrived with great luxuriance. In 1831 they reaped a rich crop of it from the blightedwheat fields and subsisted upon its grain during that and the following years, giving the stalks and leavesonly to their cattle. In 1S33 the sad effects of this food began to manifest themselves. The younger part of thepopulation of this and the surrounding villages, from the age of thirty downwards, began to be deprived of theuse of their limbs below the waist by paralytic strokes, in all cases sndden, but in some cases more severe thanothers. About half the youth of this village of both sexes became affected during the year 1833-34 and many ofthem have lost the use of their lower limbs entirely and are unable to move. The youth of the surrounding


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T H E B A C K G R O UN D O F TH E E P I D E M I C .One of the conclusions reached in the investigation is that lathyrism, as its name impliesis due to eating la thyr us. There have been othe r theorie s of origin, which will be referred'to late r. As regards the imm ediate cause of the disease, nothing has been discoveredwhich does not conform to the. observat ions of Sleerrian and th e classical con ception ofaetiology. An attem pt has, however, been made to study the social, economic and agriculturalbackground of the outbreakto discover, in fact, wh y the vic tims of the disease were forced t orely on lathyrus as their staple food. Accordingly, before the clinical features of the epidemican; described, an account will be given of the environment in which it occurred.

. -B hopal St ate , which lias an area of 6,902 square miles and a populati on (3941) of785,000, is divided for administra tive purposes into two districts, eastern and western. Itwas in the eastern distric t tha t lathyrism m ade its appearance. This district is aD uplandarea, partially covered with forests, about 1,000 to 1,500 feet above sea-level, and less fertilethan the western district . The population is mainly Hindu. M alaria is prevalent and thespleen rate is high. " vExc ept in B hopal C ity and certain smaller towns, the entire population is engaged inagriculture and lives on food produced in the area. There are three types of workers inthe villages : v

(a) land-owning cult ivat ors;(6) sub-tena nts of the above ;(c) labourersthese do various kinds of work as well as cultivation. Labourersare usually paid in kind and very rarely in cash.

There are no modern means of irrigation. In bad seasons, rust, blight, hailstorms,excess of rain, etc. , may lead to danger of scarcity and food shortage. The diet changesto some extent with the season, following the succession of harvests.The prin cipa l food crops and seasons of sowing and harv esti ng are as follows :

C rop. T im e of sow ing. T i m e o f ha rv es tin g .

RiceM a i z e' J owar ' (Sorghum vulgare)' S a w a n ' (Panicum frumantaceum)' K o d o n ' (Paspalum stolonifcrvm) .. .B i a c k g r a m (Phaseolus mungo)Red gram (Oajaniis indicus)WheatB a r l e y (Bordeum vulgare)B engal gram (Cicer arictinum)L entil (Lens esculenta) ...' T eora ' (Lalhyrus salivus) . .. .

J u n e OctoberD e c e m b e r

October

O c t o b e r - N o v e m b e rOctober

M a r c h

F e b r u a r y -M a r c h

Lathyrus salivus is known as ' teora ' or ' teori ' in this part of India. Various names in-elu d in g ' ma tr a ' , ' ma tr i ' , ' b atr a . ' , ' k h esa r i ' , ' g ar asb ' , etc . , ar e u sed in o th er p ar ts of( 240 )

IIu

the co untry. How ard an d Kh an (1928) described in detail the Indian types of Laihyrsalivus. It is an impo rtant crop in the eastern district of-Bh opal for (lie followi:reasons : .1. It is used as a fodder crop.2. It gives a good yield with minimum labour. It is a hardy plant and thrives w


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result th at the puur consumed cheaper grains in increasing quan tity. The prices of foodgrains have risen to 2 to -i times the pre-war level. In T able II the market rates ofdifferent food grains for the period J939 to 1945 are shown:TABLE II .

Market rates at which different food grains were available in the period from 1939to 1945 (per 5 maunds).

Name of foodstuff. 1939. 1940. 1941. 1942. 1943.

W heat' Teora ' . . .Bengal grnmI.entU' B a t l a ' * . . .

R s.12

S1012

8

Ks .1612141812

R s. 1C12141913

Rs .2013IS2015

Rs .24 to 30

20252520

Rs .3020252520

R s3U20

' ' 252520

'B at la ' is a pulse which resembles a pea. Ite consumption is being encouraged ns an alternative to' teora '.In 1944 the state authorities introduced the rationing of w heat into the urban areas. Tomeot the demand of the towns the cultivators were asked to give on paym ent certainquantities of wheat per acre sown. In areas where the wheat crop wns poor, the cultivatorwas left with limited supplies of wheat. The position of agricultura l laboure rs was alsoaffeoted for the following reasons: (a) The labourers are paid in kind. C ultivators did nothave enough wheat and the labourers were given ' teora' (Lnthyrvs sativus) instead of wheat.(4) The landowning cu ltivat ors found a ready excuse for refusing deman ds for wh eat on thepart of their employees by saying that practically all their wheat had been taken by the stateand that nothing was left. The net result of the crop failure and the procurement operationsvrae th at the poorer section of comm unity was reduced to living a lmost en tirelv on ' teora '.Visits to houBes in villages at the time of preparing meals confirmed the above statement.It was found that poor villagers generally consumed ' chapntties ' made of ' teora '. In somecases ' toora ' was mixed with B engal gram, bnrley or wheat.State, of nutrition.One hundred children in a village were examined for the incidence ofclinical signs of deficiency diseases. The resu lts obtained are as follows :

- Number of children showing phrynoderma7 per cent.,, ,, ;, B itot 's spots Nil. ,,, ;.. ,, angular stomatitis2 per cent.Practica lly all the children showed discoloration of the conjunctives. The general impressiongained from this survey was that the sta te of nutrition was very similar to tha t of villagechildren in many other parts of the country. This is a point of importance, since suggestionshave been made that vitamin deficiency plays a. part in the causation of lathyrism.

THE OUTBREAK.Preliminary inquiries revealed th at at least 1.200 cases had occurred in the district.Fifteen villages in three tahsils in which a high incidence was reported were visited and about150 people showing eviden ce of the diseas e were exam ined. A full historyof 75 cases ofrecent onset during the second half of 1944 or early in 1945 was obtained. " It was felt thatcasos occurring earlier might not be able to recollect details about the onset of the disease andattention was focmsrd on more recent cases.

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The disease is liot a mysterious unfamiliar malady to th e inh abitants of this area.Eve n' year, or every second or third year, a few persons contract it. Villagers are familiarwith it and know that it is associated with famine and poverty, and that it is not aninfectious disease. It m ay be added that the present outbreak of lathyrism was not confinedto B hopal Sta te. There were reports of cases occurring in adjacent areas outside thestate boundaries.Age.T he villagers cannot give their age with any degree of exactness. Table IIIshows approximately the incidence of the disease by age groups: '

TABLE III .

Age group,yearB.

4-1011-2021-3031-4041-5051-60

Number ofcases.

13192111

71

P ercentage.

18-028-4,2 9 115-29-11-3

B uchanan (loo. cit.}, M cCombie Young {loc. oil.) and S hah (Joe. tit.) all observed thatthe majority of cases were in the age groups 11-20 and 21-30. This agrees with the observedage incidence in the present investigation. 'Season.Tab le IV gives the number of cases and the percentage of cases occurringin different mon ths: . . . 'TABLE IV.'xMonth of onset.

JanuaryFebruaryMarchApril . . . .May . . .JuneJuly .. .August .. .SeptemberOctoberNovemberDecember

' . T O T A L

Number ofcases.

21

112322

\ . ' 91

69

Percentage.

2-91-5

15-933-931"813-0

l-B

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The above figures show that most- uf the wises occurred in the months of August .September and October, the highest number being in the month of September, Shah (loc.cit.) recorded that most of his cases occurred in August and McCombie Young (loc. cit.)observed a peak in October. It is during or just after the rainy season tha t the paralysis oflathyrism tends to appear.Sex incidence.The percentage of cases occurring in the population of two villages andthe. sex incidence are shown in Table V :

TABLE V. -

Name of villa >z Totalpopulation.Number ofpersons.

Number ofpersons suffer-ing fromlnthvrism.Percentage.

Birpur

Uninrkhoh

940 13427

207

37

234

7-2 ' l - l

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The above shows th at males suffer more than females. Out of the 69 persons sufferingfrom the disease in these villages, only 9 were females; This is in conformity with the findingsof the earlier workers previously referred to.Economic status.The victims of lathyrism belonged to the poorest section of the

community, usually labourers in villages owning no land. Out of the 73 persons afflictedwhose history was taken only 4 were cultivators owning some small parcel of land, and therewas one ' Banis ' (grocer). The others were all labourers. ' Chamars' (shoe-makers) con-tributed the largest number of victims.Incidence of signs of dim-deficiency diseases,-All the cases were examined for clinicalsigns of dietarv-deficiency diseases. None showed angular stomat itis. There were 3 casesof phrynoderma among the 73 cases. A history of night-blindness was given by 2 cases.The general impression was gained that the affected persons were not badly nourished. [_Clinical findings, (a) Onset.In all the patien ts examined, no premonitory symptomssuch as an attac k of nausea, vomi ting after meals, or diarrhoea, were complained of.MoCarrison (1926) noted th at constipation tended to occur in his cases, but this was not aprom inen t feature in the presen t series. Of the 73 persons examined, only 10 gave a historyof mild or severe constipation . Inquirie s revealed tha t 15 cases suffered, previous to the on-set of the disease., from fever which was most probably malaria.In 33 patients the onset of the disease was sudden. Some gave a history of sleeping

normally and awakening with stiffness of the muscles and parti al loss of control of the lowerlimbs. Others fell down while working (ploughing, etc.), and found themselves unable to get-up and walk back to their houses'. In the remaining 40 cases the onset of the disease wasslower. In one case the patien t did not know tha t he was a sufferer until otherspointed it out to him after seeing him walking with bent knees. A few days laterhe found himself paralysed. In cases in which the onset was slow the patients first sufferedfrom backache and stiffness of the lower extremities with some difficulty in dorsiflexion of theknees. Severer signs and symptoms followed slowly. Some pat ient s reported tha t in theenrly stages contraction of the muscles of the calves had occurred. A ' lump would form : inthe morning when the pati ent was getting out of bed. These ' lumps : of contracted muscleswould prevent the straightening of the lower extremities. The patients would massage these 'out and for the rest of the day could walk withou t much difficulty. Then slowly severersymptoms would set in.

(b) Gait.In ii'ild cases there was only a little bending of the kntes a rd patie nts feltdifficulty only on runn ing or on going downhill. In rro re seveie cafes the patients walkedwith bent knees, the knees being approximated and the feet more widely sepaiated tha nnormal. IB this stage th e heels leave the ground earlier tha n the toes and there is someswaying of the hip s. In more advanced cases' the ' scissors ' ga it (crossing of the legs onwalking) developed, with a tendency on th e part of the pat ien t to walk on the toes andswaying of the hips was more marked. Such pati ents requ ired t he use of one or two sticks,according to th e severity of the paralysi s. Very severely affected pat ient s -were reduced tocrawling in a sitting position. Tn all the above stages insta bili ty was increased by running ,jumping , crossing a. small drain, going down a hill, etc. There was a frequent tendency oilthe part of patients to fall down.(c) Musculature. There wan no marked change in the appearance of th e muscles of thelower extremities. Muscular tone was, in most cases, in excess of normal! Spasm of thecalf and thigh muscles occurred on slight exertion or in the absence of exertion in some case.No case complained of any weakness in the upper extremities.(d) Reflexes.In G:j cases the epigastric and abdominal reflexes were exaggerated. Theplantar reflex was extensor in type in those in which it could be elicited. The knee-jerkswere exaggerated in all cases. Ankle-clonus was present in 62 cases. The sphincters ofthe rectum and the bladder were unaffected.(e) Sensation was normal in all cases. There was no change in the functioning of thecranial nerves. Speech, sight, smell, hearing, etc ., were- normal . Mental symptoms andpsychological disturbances were not observed.It is apparent th at the paralysis of lathyrism is an upper motor neuron lesion. Presum-ably the pyramidal trac ts are involved. No post-mortem histological examination of thespinal cord in cases of lathyrism appears to be on record in the literature.

iETIOLOGY.Villagers in the area affected by th e outb reak a nd th e v ictims of the disease have nodoubt that the paralysis is caused by consuming lathyrus seeds in large quantities for severalmonths. TM B is the tra ditional view of the cause of the disease ; hence, in fact, its name.The observations of Sleeman have already been quoted. A number of those who have studiedthe disease in India (Buchanan, loc. cit. ; McCarrison, 1928 ; McCombie Young , loc. cit., andothers) have adopted the traditional standpoint . Anderson, Howard and Simonsen (1925)and Shah (loc. cit.), however, consider that another pulse, Vicia saliva, mav be the cause ofthe disease.The feeding of Lathyrus sativvs or Vicia saliva to rats by McCarrison (1928) and to poniesby Stott (loc. cit.) did not result in the product ion of lathy rism or of any lesion? of thenervous system.During the present investigation it was found that those who developed latbyrism hadusually consumed Lathyrus sativus in large quant itie s, for six months or more". It wasimpossible to obtain exact information about the proportion of Lathyrus talivvs in their diet.It appears, however, that it formed the great bulk of the diet. The victims of the disease

were mostly labourers, and were paid in kind. They ate what they could get, and this wasmainly lathyrus seed6. It was said by the villagers tha t those who mixed Lathyrvs lalinixgrains with equal amounts of wheat did not contract lathyrism.Anderson etal. (loc. cit.) stated that samples of ' khesari dhal ' or lathyrus obtained fromlocalities in India in which outbreaks of lathyrism had occurred were contaminated with thevetch Vicia sativa, popularly known as ' akta '. They reported t ha t ' akta ' was poisonous toducks and monkeys whereas lathyrus was not. The toxic signs produced in thew species bythe feeding of diets containing ' akta ' did not, however, closely resemble human l athyrism. Inthe present inquiry the question whether the lath}Tus seeds which were being consumed in the

affected district were contaminated with ' ak ta ' was investigated. A pure sample of Viciasaliva was obtained from Dr. B. P. Pal of the Imperial Agricultu ral Research Inst itu te. New-Delhi,, and was shown to stockists in villages and towns, and to intelligent v l t i( 245 )


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in v arious villages. In not. a single case did the y recognize the Vicia saliva seeds and all weresure that such seeds were not to be found in Lathyrus salivus stocks. About 50 samples oiLathyrus salivus were collected from various families and in various villages. Some of thosewere from stocks actually consumed by people who developed lathyrism. C areful exam inationof these samples in the Imperial Agricultural Research Insti tute, New Delhi, failed to revealthe presence of Vicia saliva seeds.At three places about 200 lb. of Lathyrus salivus were sifted through a sieve with a meshsmaller than normal Lalhyrus sativue grain. Asearcli was mnde in the sieved material for' ak ta ' seeds, which are smaller than lathyrus seeds. No ' akta' could, however, be sievedoat in this way.It was thought that ' akta.' seeds, being lighter nnd smaller than Lathyrus sativus seeds,migh t be separate d with th e chaff in the process of winnowing. A sample waB taken from thelatent crop in the field which was ready for separation. 'Ihe husk was carefully removed.The resultant seeds were examined for ' akta ' seeds but none could be found. This showsthat Lathyrus saiivus stocks were not contaminated with Vicia sativa. ;M ellanby (1934) has put forward the theory tha t ' lathyrism is due to an active neuro-toxin in the food whose detrimental effects can be prevented by protective foods containingvitamin Annd carotene, such as milk, eggs and green vegetables, even when much of thetoxic agent in the lathyrus peas is consumed. It may therefore be classed among thedeficiency diseases'. M cCombie Young (loc. cit.) was also of the opinion th at vitamin Adeficiency was concerned in causation. Lesions of the nervous system have, however, beenmore frequently observed in experimental anim als as a result of deficiency of various membersof the vitamin B group than as a result of deficiency of vitamin A. The present investiga-tion has not thrown any further light on the problem whether lack of vitamins is associatedwith a toxic factor in producing the paralysis. Lathyrism is a famine disease and thecircumBtanr.es which lead to an increased intake of lnthyrus will at the same time lead to a

deoieased intake of other foods, including protective foods. None of the facts revealedis incompatible with M ellanby's hypothesis, but in view of the low incidence of vitamindeficiency states in the affected area, the author is of the opinion that lathyrisni should beregarded as a disease due to a toxin of unknown nature rather than as a deficiency disease.Until, however, lathyrism has been satisfactorily reproduced in experimental animals, thequention as to what part vitamin deficiency may play in causation cannot be finallyanswered.The higher incidence of the disease amongst men than women can probably be explainedby the greater intake of lathyr us on the part of the former. During the rainy season and justafter, agricultural labourers work hard at ploughing and other agricultural operations. Theircalorie requirements are correspondingly increased and when only Inthyrus is available tofulfil these they eat it in large quantities.

TBBATMENT AND PREVENTION.As far as at present known, the nervous lesions are permanent and the disease incurable.

No social study has been made of the fate of the victims of lathyrism ; niBny no doubt remainin their villages and contribute to the work of the village as far as their crippled state permits ;ethers swell the ranks of beggars in cities. It has been stated that many of the paralysed 1||]i beggars who obstruct the pavements of C alcutta and other large cities are| | lathyrism. victims" ofPrevention is a social, economic, administrative and agricultural problem. Lathy ruscan apparently be safely consumed in small quantities, but when they form the bulk ofthe diet the disease makes its appearance. The circumstances in which this tends to occurhave been described in this paper. S atisfactory preventive measures include encouraging theproduction of suitable alternative crops to lathyrus. the improvement of the economic statusof agricultural labourers, and the importation of other foods such as wheat into endemic areaswhen an outbreak threatens. Awatch should be kept by public health authorities for (heappearance of the disease in such areas in C entral India and elsewhere in the country.

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Procurement operations to supply wheat to towns under rationing schemes should not beallowed to deprive rural areas, in which lathyrus is a stand-by, of excessive amountsof wheat.S U M M A R Y.

1. An outbreak of lathyrism in C entral India has been investigated._ This wasassociated with the consumption of Lathyrus sativus in large quantities for a period of sixmonths or more. Some 1,200 cases occurred in the district. Of these, 150 were seen, and fullnotes of 73 cases were taken.2. Villagers in the area in question and patients who contracted the disease realized thatit was due to the consumption of this pulse. They also realized that it is not an infectious

disease and understood its association with poverty. " ' '3. The chief sufferers from lathyrism were young adult males belonging to the poorestclasses. September and October were the months of greatest prevalence.4. C linically the disease manifests itself as a spaBtic paralysis of the lower limbs. Thespiiincters of the bladder and the rectum are not affected. No mental or sensory disturbanc eswere observed. .5. No Vicia saliva seeds were found in the stocks of lathyruB seeds consumed in th evillages in which the outbreak occurred. The investigation points to the existence in Lathyrussalivus of a toxin affecting the pyramidal tracts. \6. Preventive measures are discussed. : .

ACKNOW LEDGMENTS.Grateful thanks are due to Sir Colin Garbett, E.C.I.E., C.S.I., C.M.G:, Revenue M inister,Bhopal State, and to Lieut.-Colonel M . L. R. Siddiqui, F.R.C.S., Chief Medical Officer, B hopa lState, for assistance in the investigation.

ACTON, H. W (1922)A H D E B S O N , L A P. , H OW A R DJ. L. (1925).ISuCHAKAN (1904)CHOPRA, E. N. (193C)H O W A B D , A, and K H A N , A R. (1928)MCCABJUSON, It. (1920) - ...Idem (1928)MAC KEKTIE, L. H. L. (1927)M C C O M B I B Y O O K O , T. C. (1927)M S O A W , J. W D., and GUP T A , J. C. (1927)MB LLAJTBT, E. (1934)SIiNcmu, R. L. H. (1940)SHAH, S. R. A. (1939)SI-EBMAH, W H. (1844) ...STOTT, H. (1930)

R E F E R E N C E S ... . Ind. Med. Qaz., 57, p . 241.A., and SIMOKSEH, Ind. Jour. Med. Ret., 12, p. 613.

.. . Nagpur Civil Administration Report.'T he B ritish encyclopaedia of medicalpractice ' , Lond. , 7, p. 651... . Memoirs o f the Department of Agricul-ture in India, 15 , p. 51 .Ind. Jmir.. Med. lies., 14, p . 379.Ibid., 15, p . 797.Ind. Med. Qaz., 62, p. 201.Ind. Jour. Med. Sec, 15, p . 453.Ind. Med. Qaz., 62, p. 299.' Nutrition and disease.' Oliver &B o y d , L o n d .Brit. Med. Jour., 1, p. 253.Ind. Med. Qaz., 74, p . 385.' Rambles and recollections of anIndian official', 1, E a t c h a r d andSons, L o n d .Ind. Jour. Med. Res., I B , p . 5 1 .

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lathyrism central ind shourie 1945b par miles

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