lathyrism india hendley 1903

7/29/2019 Lathyrism India Hendley 1903

1/6

-carch revealed malignant tertian parasites and quinine treat-s resumed ; and, with the exception of a slight rise on the,1 ague on May 4th anod adhesi ons ar oun d t he gauze packing an d no trace of leak-; charge into th e peritoneal cavity. The liver was removedstomach and duode num and rig-lit lung a ltoge ther. Only oneU stone in the depth of the liver in the right hepatic duct wasInch was much smaller than some of those removed at then. so would easily have escaped through the opening made in;. and would doubtless have escaped through the wound,1 too deep in the liver to b


2/6

'70S **-~j THYRISM.native States, gone on spreading ever since, helped by thesecond severe famine of 1899-1900; until at the present timeMajor Buchanan writes to me that he has an incompletecensus of 2,700 cases in one district and 1,400cases in another ;and in a recent letter says, " I have seen 190 cases thismorning." Symptoms.I will now pass on to a description of the sym ptoms andmode of onset of the disease. For reasons, given above, itwill be seen that only the poorest classes are liable to thisdisease ; those who are forced to subsist on th e grain un-mixed or diluted only slightly with other grain. All theaffected will be found to belong to this class. They eat iteith er ground into flour as bread, cooked as porridge orboiled with or without oil as lentils, much as we eat haricotbeanp . Prac tically all are field labourers, and the wonderfulunanimity with which all agree as to the onset of the diseaseis most striking. A man will say, ' I went to sleep perfectlywell and very tired after a day's ploughing or other field workin the rain (it is always in t he rain y season) and awoke inthe morning to find my legs stiff, weak, trembling, and veryheavy to lift when I rose to walk." L have never been ableto-elicit any histo ry of prem onitory symptom s.) This weak-ness and trembling, you will be told,.increased so rapidlythat within ten days progression became difficult, even withth e aid of sticks . Still the patients have no sense of illnessand no pain; they have good appetites, sound digestions. and n atur al sleep at nig ht. Both legs are usually affectedsimultaneously, first the calves, then the thighs, and soonafter this all sexual app etite an d power was lost. All com-plain bitterly of this. On examination of any typical case, of some six weeks'dur ation , you will find that the gait is very peculiar. Aided with a long two-handed staff walking is possible, the rate ofprogression being under two miles an hour. The body abovethe liips sways from.side to side, whilst the feet, which seemclogged with invisible weights, are lifted with.evident diffi-culty and dragged forward, the toes scratching along or barelyclearing the ground. The leg bearing the weight of the bodyis bent at the knee and trembles, whilst the advancing leg,dragged wearily forward strongly adducted, is planted un-steadily directly in front of its fellow, the toes reaching theground first. In short a kind of paralytic goosestep. Thegeneral effect is one of laboured unsteadiness, due to greatweakness . The evident spasm of t he thigh adductors ceasesto be very apparent when the patient reclines on his back,when the thighs can be separated, usually without resistance,to a norm al extent. There is no wasting, no loss of mus culartone, no true tremors, only tremblings of th e entire limbswhen weight is put.oD them . Sensation seems quite un-affected. The tendon reflexes are much exaggerated, bo thknee-jerk and ankle-clonus ; the slightest stimulus startingthe latte r phenomenon going for a long time . There is noloss of power or undue excitab ility in bladder or rectum.The arms, trun k, head and neck muscles are unaffected. Themind is clear, speech natural, pupils normal and reactingnaturally to light and accommodation. The u rine is often ofrath er high specific gravity (1030), acid, and contains abundan turates. ouch are the symptoms as I have found them. I amaware that some writers state that digestive disturbances,colicky pain s, and diarrhoea are usually precursors of theparalytic state ; and that sensory disturbances such as hyper-aesthesia, anaesthesia, and formication, with bladder troubles,such as inco ntinence and retentio n of urine, are common. Ihave never met with a case in my experience of manyhund reds where the slightest history or evidence of any suchcomplications could be traced.

Etiology.As regards th e etiology of th e disease, it is, I think ,generally conceded now that the paralysis is in some way dueto lathyrus poisoning.. Other mam theories of causation are :1. That latbyrus eating has nothing to do with it.' 2. Tha t if i t has , it is only diseased grain which is capable ofpoisonous effects.- -: 3. That exposure to sun or some local hot wind is the true cause.4. That the paralysis is due entirely to cold and damp.5. One em inent authorit y on tropica l medicine (Manson') ha s thrownout the suggestion that, like alcoholism and probably bert-bcri, thedisease m ay be due to the en trance into the body of a toxin'gen orated bygerms-whose habitat is outside the body.' 6. Lastly, I am quite prepared to h ear some champion of parasitismarise and suggest tha t some organism, so minu te as to have hithe rtoescaped observation, is really the author of all the mischief... In the time at my disposal I cannot fully discuss these and

other theories, and can only say that the oecurrenppdisease in epidemic form among lathyrus eaters andno others, seenis to me very strong evidence that a ITdie t is prim arily respo nsible. The idea that diseasedonly is injurio us is an argum ent probably borrowed froanalogy of ergotism. I know of no facts to support thThat exposure to sun or some local hot wind can h ' i respo nsible is at one disproved by the undou bted fact tli 11disease has occurred (amongst lathyrus eaters) equally ri ife(g y s) equally ]t rous ly in India , I ta ly , France, Algiers , and Wurt^ml Zcountries with vastly dissimilar meteorological condiii 'nAlso, if exposure to cold and wet alone could induce lE l d l h l d b f l l f hy y , , g , d W u r t^ m l Zcountries with vastly dissimilar meteorological condiii'nAlso, if exposure to cold and w et alon e could induce latln-riamEng land surely should b e full of such cases. As n'tmrd'

Man son's suggestion that th e affection, like beri-beri mavSa "p lac e disease," one has only to remember that thparalysis is incurable, and that removal from the localltwhere the person was attacked is in no sense beneficial J Jto what the actual poison is, and how it acts, that is a matterstill left for our eminent physiologists and chemists to decid?Church has stated the chemical composition of the grain atwater, 10.1; albuminoids, 31.9; starch and fibre, 53.9; on*0.9 ; ash, 3.2 ; and has further observed tha t " the oOexpressed is a powerful and dangerous cathar tic." -,Astier says " there is present in the grain a volatile liqnifl "alkaloid, probably produced by some proteid ferment, whichexhibits the toxic action of the seeds, and the action of Jwhich is destroyed by heat." On this volatility and destred/Htion by heat notion has been based much speculation as i&';"Spossible variations in methods of cooking, explaining flit"?eaprieiousness of the effects of a diet of this grain on difieren t"1individuals. Scheube says, "Several poisonous alkalokihave been extracted but further investigations are necessaryâlso, " that by the administration of preparations made frwthe grain, a disease giving rise to symptoms similarlathyrism has been produced in anim als."Professor Dunstan, of the Indian Institute, is now working?at th is subject. So far his investigations and experiments oaanim als are inconclusive, but go to show (1) Tha t only certala.*samples of lathyrus are poisonous ; (2) there are some reason!to think the poison is contained in the skin or husk of thseed, bu t no fungus has been discovered ; (3) that poultry ax*Jimmune, but that rabbits and guinea-pigs are sometime-*!affected. Professor Duns tan also tells m e tha t in Canadlathyrus is largely grown and freely used as poultry food,prob ably bird s are imm une. My own pigeon feedingexperim ents in India were all negative and so support thisview. 4There remain two points of interest in connexion withcausation of lathyrism, namely, its marked preference / ;males and its seasonal incidence, that is, during the rainyseason. Dr. Irvin g found th at the proportion of females to:males a ttacked was about 1 in 12. Major A. Buchanaa^jI.M.S., with a recent very large experience, tells me he findit 1 in 10. I personally have only seen 3 female cases against vmany hun dre ds of ma les. Major Bucha nan accepts the con****-parative immunity of females as an unexplainable fact,says tha t the reason for the seasonal incidence of t h diseis very simple, namely, th at "h e finds that thegrain pits or granaries are closed in June, andgrain is only issued to labourers in the rains." . i*1The difficulty in th e way of accepting this explanation 1;that (1) I do not believe the custom he alludes to is genetU'jthat of only eating lathyrus during the rainsit certainlyjwas not during the recent famines ; and (2) the fact l**according to this idea cases occurring quite early in hiem ust have been caused by a very few days' dietary of tn jpoison ; and this is opposed to all my experience of his ton ej|given me by pat ients . I prefer an even simpler solutionboth difficulties. As long ago as 1858 Dr. Irvine quoted*prevalent opinion amongst intelligent educated nativesbeing, tha t "t he lameness produced by eating latb yju sreally a mixtu re of palsy and rheumatism," and added 1seem to think th at living on this particular grain is thedisposing cause, and exposure to cold, rain, and dam pê atthe exciting cause." Tvw rI believe the native idea is t he correct one. I Denevelathyrus, whilst it may possibly cause paralysis by iordinarily only predisposes to it, that it makes the anr.?ady or ripe for the attack of paralysis, but that ezto severe wet and cold is required actually to exea tesudden seizure. This seems to me to explain th e unving history of the sudden unexpected attack during wseason only ; for nearly always the attack oc^^Jrûsually thorough w etting w hilst ploughing, watching c

thai


3/6

te.

i* . h , o r other field work that ordinarily falls to man's lotL dnot to woman's. To Lheir greater protection from severend prolonged exposure alone, I believe, women owe theiriomDarative immunity. I have suggested to Major Buchananthat the respective shares which exposure and a lathyrusdietary have in producing the paralysis might well be testeddurinethe extensive animal-feeding experiments which are tobe carried out at the Bombay Research Laboratory.Morbid Anatomy and Pathology.Satisfactory observations on the morbid anatomy and path-ology of the disease are wanting. From the clinical sym-ntoms one would be justified in assuming it to be a form oflateral sclerosis, but in "Watts's Dictionary I find a statementthnt ' Cantarri of Naples has published a number of cases inwhich he has carefully observed the conditions after death.Jio nllection of the spinal cord was discovered. The musclesof the lower extremities, especially the abductors, were foundto have undergon e a fatty degeneration, etc." Scheube men-tions one published necropsy (where death resulted frommalarial cachexia) where ' ' a softening of the spinal cord abovethe lumbar enlargement was found." Allbutt refers to twoexaminations of horses which had died of lathyrus poison-ing. In these the symptoms were apparently mainly those ofenrdiac and respiratory oppression, and after death "the mis-chief was found ma inly;in the cells of the anterior horns ofthe cord, which were diminished in number and atrophied.There was also thrombosis of small arteries, which were alsothickened. There was, too, fatty degeneration of the h ear t andintrinsic muscles of the larynx." From this he suggests tha tthe nerve mischief may be secondary to the vascular lesions,which would suggest a similarity to ergotism. The prognosis

of this disease as regards life is favourable. It does not seemto cause death directly, but the paralysis is incurable. Treat-ment, I believe, is quite futile.A PLEA FOR THE PROPER MEDICAL SUPER-VISION OF " R E F R E S H M E N T S " P U R V E Y E DON RAILWAYS IN THE TROPICS :WITH SPECIAL REFE RENCE TO INDIA, AND FORBETTER LATRINEAND LAVATORY ACCOMMODATION FOR THETRAVELLING INDIAN PUBLIC.

By H. D. M C C U L L O C H , M.B.,Chief Medical Offleer, N.G.S. Railways, In dia.OUR vast Imperial commerce and the foreign enterpriseswhich have come into being since the introduction of steamas a m otive power, our great mercantile marine and extensiverailway communications, extending in India alone to over26,000 miles, has resulted, among other things, in rapid in-tercourse between E ast and West., which in its turn has goneto bring into prominence certain disadvantages, having re-gard to the public health of the communities concerned,hitherto remote from one anoth er. Contingencies havearisen necessitating the adoption of special precautionarymeasures to preve nt th e conveyance of infection from already"ected areas to uninfected areas.Owing partly to the infection being undetectable during thelatent period in man and the vitality of the virus undervarying conditions, climatic and otherwise, the difficultiesexperienced by medical authorities in the framing and adop-A ruBaXL}^SLry preventive regulations have been very great,an a the inconvenience to the general public extremely'Kaome, at these times of panic, the consequence being theaDandonment of such regulations or their irregular adoptionm certain area "pro forma," and the adoption of serumJjjoculations of Haffkine's antitoxin systematically and on aarge scale, by the temporary employment of a large sup eriornueal aud sanitary staff, with the greatest benefit, where5a* iterateded'6 necess ary last year for the Home Government tondia a special railway expert in administrativeand Mr. Thomas Robertson, C.V.O., was selected asZ ^ ^ i ^ D a n i i s s i o n e r to inspect and to report on the ad-"iwwations of railways in In dia from the commercial and^nonucaspectB, though the administrations of the variousie marine companies in which our Government is ? c l y interested was not included." ***t Mr. Robertson's report was, I believe,m india last May, but the Blue Book to be issuedr * ? m ^01*1' 8t !n ** * the hands of the King's printers .irom an Indian newspaper article on " Indian Rail-

way D efects," referring to th e very candid report of the SpecialCommissioner, he is represented as having stated that, speak-ing generally, he thought the present administration andworking of the Indian railways cannot be regarded as satis-factory, etc . He advocates the provision of dining cars on allfast through-service tra ins to economize time, and thinks thatrailways in In dia are not sufficiently appreciative of the valueof th eir third-class passenger traffic, drawing special attention'to certain gross abuses to WhicK these are subjected. Hefurther suggests the introduction of electric fans, which hethinks should be made compulsory within five years ; theuse of oil sprinklers to llay-dust, a nd lavatory accommoda-tion in all third-class carriages, which should be widened.Beyond these important sanitary recommendations noreference is made to the medical departments ofTfcailways,this being, perhaps, a matter beyond the; province of hisreport. . ' '"."' " : V v ' :\"j J'"The Government of India, however, in the PubH'c W orksDepartment addressed the different railway administrationsthrough the local governments last year desiring tha certainrules should be formally agreed to between the.m edica l andsanitary authorities of local governments and th'ose of rail-ways within their areas, for the purpose1 of affording suchmutual advice, support, and intimation of outbreaks- ofepidemics, etc., as may be for the general benefit of the'public health and for the prevention of much, sikness andmortality. ,'.'' .. \ ,"While these rules are having the consideration of ourGovernment the proposition that I would venture ro advanceis the necessity for adequate medical and sanitary staffs riotonly on our great Indian railways, but also on our mercantilemarine, to enable them to cope with modern sanitary andmedical requirements, the urgent need for which the dia-f ram matic represe ntations belowwill,I think,make obvious; andtrust tha t the time has now come for our medical membersof Parliament, aided by the General Medical Council, to urgethe Government to send out a Special Commissioner andmedical expert to inspect and report upon the medicaladministrations of our mercantile marine and great railwaysin the interests of public health

Diagrams representing inequali ty andinadequacy of Sup.Medl. Staf fs on Rys.Miles3000-2 5 0 0 -2000-1500-1000 -5 O 0 -

n

IIPR EIR MR BNR SIR EBR NGSR

I* Excessive expenditure on superior medical staff. .'...

Great Indian Peninsular Railway,East Indian Railway ...Madras Railway...Bengal Najpur RailwaySouth Indian Railway-Eastern Bengal RailwayNizam's State Railway...

Miles.

',6743,3381,6001.5571,35099745

Employs .

0,50030,30013.5008,9008,000

MedicalAdministration,Cost Per Mile.Rs .31.4030.0.: 6.5035-378.9450.18

The democratic idea that every citizen is entitled to thebenefit of everything that will add to human-health andhappiness is growing fast. Hea lth and sanitation Acts by theLegislature, medical officers of health, sanitary inspectora,inspections of workshops, etc., have all, in addition to pro-longing life and diminishing death, done incalculable serviceby rousing in the public mind the vague beginnings of atremen dously imp orta nt -mental "procesB of a dissipation" of


4/6

2 6 , '9O3-J SECTION OF T R O P I C A L M E D I C I N E . TIB BUI 70 7search revealed mnlignsr.t tertian parasites nnd quinine treat-s resumed; and, with tue exception of a slight rise on the l ague on May 4th an;! 7th, no m'"o fever occurred : theimproved, and he left h as pi tal on May 18th, the case at thistving been one of biliary colic complicated by malarial fever,ouiher 18th. 1902. he returned to hospital , and came under n:yI since 7th in bed. Has passed severa! gall stones since theich lie brought with him. the largest being about in. inThe liver dullness extended from the fourth space to 3 in.c costal margin. Spleen not enlarged, well-marked jaundiceh pain of a colicky nature requiring morphine . Temperature0 to 10 20, with profuse perspiration.,c r continued, and on December 22nd he coughed up a quan-scid frothy mucus. Tempera ture , of a hectic type, continued103e and 104e in the evening. The vocal fremitus was slightly

cd . but there was only partial loss of resonance at the rightdiagnosed suppuration in the bile ducts in the liver, andiperation for the purpose of draining the ducts and removingstones. After a consultation>this was agTeed to. On the morn-e 2sf.l1 he coughed up a small quantity o pus, butin viewof thentioncd above, in which a fatal termination ensued in anof this kind, in spite of the opening through the lung, andcrtain knowledge of gall stones having been passed, it wasto proceed with the operation as previously arranged. Captainin, I.M.S.. kindly helping me.ion.An incision was made in the right linea semilunaris with1; over the lower edge of the liver. Thegall bladder was com-liddcn beneath the edge of the liver, but its fundus was reachedled, and a number of small gall stones were extracted. On-ing the finger along the bile ducts beneath the liver, a largegall stones were felt deep under the liver, which could onlycached. The wound was now enlarged upwards and downwards,transverse incision made across to the middle l ine, so asle the lower edge of the greatly enlarged liver to beup . The mass of stones in the right hepatic ductsy be reached and opened, and with very considerable a mass of large gall s tones , some 3 in. in length and over andiameter in places, were removed, some of which were wellK: liver substance. As it was quite impossible at such a depth to opening in the duetto the surface, andas the patient was in a, a gluss drainage tube was inserted and gauze carefully packed: and the- wound united around the tube. The patient sufferedirom shock, but rallied somewhat in the afternoon, but wa sublcd by coughing up mucus. At 10 in the evening he wasnd coughing up mucus more easiiy. However, he never fully:om the shock of the prolonged operation and died at 5.30 a.m..'/.The same morning the body was examined. There were"Od adhesions around the gauze packing and no trace of leak-: charge into the peritoneal cavity. The liver was removedstomach and duodenum and right lung altogether. Only one!1 stone in the depth of the liver in the right hepatic duct wasliich was much smaller than some of those removed at the1. so would easily have escaped through the opening made in.. and would doubtless have escaped through the wound,. too deep in the liver tobpeuing into the duodenum was large and free.is case a correct diagnosis of suppura t ion in the intra-bile ducts was made very shortly after admission, andra t ion under taken wi thout any unnecessary de lay .ea t en la rgement of the l iver and depth of thein its hilum caused unusually great difficulty, yet i.'ts were completely cleared with the exceptionsmal l s tone ment io ned, and but for the unfor-"pening of the tracking abscess into a bronchus on thei arranged for the operation leading to a serious extrathe pa t ien t 's s t rength in coughing up the muco-pus, I} favourable result might reasonably have been hopedle the conditions revealed post mortem clearly showedthing short of r e m o v a l of the stones impacted in the duets , and free drainage of the pus-d istended in t ra - ducts, could have relieved the sy m b to m s and averted11 te rmina t ion of this very deadly affection. In short,case ha d come under my care a week earlier his lifelave.been saved by a sti l l earlier op eration, which empha -se importance of early diagnosis with a view to verypera t ion .ve not had t im e to search the l i te ra ture of thew years for cases of th is na ture , but I t h in k th a t: ate cases in which suppura t ion in the in t rahepa t icave been diagnosed and an opera t ion under taken wi thet object of dra in ing the abscess through opening th e-t s are sufficiently rare to be worth placing on record, cases are quite , disti nct from, and require to ta l lyL opera t ive- t rea tment to , the ord inary amoebic t ropica l

LATHYEISM.By Major A. G. H EN D LEY , I.M.S.TH E best definition of this aflection is Scheube's, which notonly sums up in a few words prevalent opinions as to itscausa t ion , but at once recalls the n a tu re of a too narrowly-known disease of importance . He says : " Lathyrism is adisease of the n a tu re of an intoxication with a spast ic sp ina lpara ly t ic course , which is a t t r ibutable to poisoning withvar ious k inds of the family of Papilionaceae lathyrus (chick-pea or common pulse) .D r . W a t t s , in his Dictionary of tiie Economic Products ofIndia, sa y s : " La th y ru s , a geniis of a n n u a l or perennia l p lantof th e n a tu ra l o rd e r Leguminosae, which comprises some 170species, seven of which a re na t ives of India ." The spec imensI have here are of the commonest cu l t iva ted Indian var ie ty ,la thyrus sa t ivus, known in different parts of India undervar ious vernacu la r names, as khesri dll, tera, lkh. orlkhri. To q u o te Dr. Wa t t s a g a in : "La th y r u s sa t iv u s(jaros8e or gesse) is indigenous from the Southern Caucasus toN o r th e rn In d i a ; it has spread as a weed of cultivation fromits or ig ina l home, and is now cultivated all over India." Inthe Central Provinces some 358,000 acres are under la thyrusc u l t i v a t i o n ; a nd it is in these provinces that the disease hasof late years become so increasingly preva lent as to call forGovernment inquiry , which inquiry his been ent rusted toMajor Andrew Buchanan, I .M.S. , who has for the past sixm o n t h s or more been devoting his ent i re a t ten t ion to th issubjec t . History.L a t h y r i s m is no newly-discovered affection. Its historydates from very early t imes, being, according to Huber ,a l luded to in the Hippocra t ic wri t ings, where ment ion ism a d e of the fact that " At Ainos those me n and women whoc o n t in u a l ly fed on pulse were attacked by a weakness in thelegs which remained permanent ." In Don's System ofGardening, aga in , it is recorded, in descr ib ing la thyruss a t i v u s , t h a t : "In several parts of the Cont inent a whitep l e a sa n t b re a d is made from the flour of th is pulse , but itprod uced such dreadful effects in the seventeenth centuryt h a t th e use of it was forbidden by an edict of George, Dukeo f Wu r t e m b e rg , in 1671, wh ich was enforced by two othere d i c t s u n d e r hi s successor Leopold in 1705 and 1714." InI t a ly and Fra n c e the disease was also observed durin g th ese v e n te e n th and eighteenth centuries, and in the earlier halfof th e nine teenth century , la rge numbers of persons becomingaffected in France , Bri t i sh India , and Algiers, attractedappa rent ly some considerable a t ten t ion . From th e years1857-68, when Dr. James Irvingthen Civil Surgeon ofAllahabadcontr ibuted f ive very in te rest ing and exhaust ivep a p e r s to the Indian Annals of Medical Science on the subjec tof an e p id e m ic of la thy r ism ' then preva i l ing in the North-

West Provinces, down to 1893, when I described in theIndian Medical Gazette a localized outbreak I had met wi thin th e Centra l Provinces, th e disease seems to have a t t rac tedno notice, save at the h a n d s of a few vete r inary surgeons,w h o n o te d it s effects on ca t t le , and m ay in consequence beassumed, as prac t ica l ly non-existen t . The c i rcumstancesu n d e r w h ic h I first made acquaintance with the affectionwere as follows :To w a rd s th e end of July, 1893, I came across a village wherequi te sudd enly some 10 per cent, of the male popula t ion ha dd u r in g th e previous five or six weeks (that is, since th e com-m e n c e m e n t of the rainy season) become paralysed, more orless severely, in the lower limbs. At tha t t ime I had neverh e a rd of su c h an affection as la thyr ism, but careful investiga-tion and inquiry in to th e c i rcumstances of the outbreak soonc o n v in c e d me that they owed their condition to poisoningw i th l a th y ru s sa t i v u s , a pulse on which all the affected, poorh a n d - to -m o u th l a b o u re r s ha d largely subsisted for somee ig h te e n m o n th s on account of the failure of the i r moreregular c rops, in consequence of which the village lan dlordh a d p a id hi s labourers in kind wi th th e cheapest grain avail-ab lenamely , la thyrus sa t ivus. For some years I saw nofur ther case of this disease ; but with years of scarcity-c u l m i n a t i n g in the terrible famine of 1896-7, th e local condi-t ions a r t i f ic ia l ly produced by the vi l lage- landlord in 1893became general-, the poorer agricultural labourers were drivento resor t ex tensive ly to the cheapest foodstuff procurable( l a th y ru s ) , and with most d isast rous consequences. In theaverage - vi l lage a dozen or more v ic t ims would be found,w h i l s t in a famine relief camp of some 4,000 persons itbecame easy to pick out one or two hund red such cases. ;Th e d i se a se has, in th e Central Provinces and adjoining


5/6

LATHYEISM.native States, cone on spreading ever since, helped by thesecond severe foraine of 1S99-1900 ; until at the present timeMajor Buchanan writes to me that he has an incompletecensus of 2,700 cases in one district and 1,400cases in another ;and in a recent letter says, "I have seen 190 cases thismorning." Symptoms.I will now pass on to a description of the symptoms andmode of onset of the disease. For reasons, given above, itwill be seen that only w poorest classes are liable to thisdisease; those who are forced to subsist on the grain un-mixed or diluted only slightly with other grain. All theaffected will be found to belong to this class. They eat iteither ground into flour as bread, cooked as porridge, orboiled with or without oil as lentils, much as we eat haricotbean?. Practically all arefield abourers, and the wonderfulunan imity with which all agree as to the onset of the diseaseis mos t striking . A man will say, " I went to sleep perfectlywell and very tired after a day's ploughing or other field workin the rain (it is always in the rainy season) and awoke inthe morning to find my legs stiff, weak, trembling, andveryheavy to lift when I rose to walk."' 1 have never been ableto elicit any history of prem onitory symptoms.) This weak-ness and trembling, you will be told,.increased so rapidlythat within ten days progression became difficult, even withthe aid of sticks. Still the patie nts have no sense of illnessand no pain; they have good appetites, sound digestions.and natural sleep at night. Both legs are usually affectedsimultaneously, first the calves, then the thighs, and soonafter this all sexual appetite and power was lost. All com-plain bitterly of this.On examination of any typical case, of some six weeks'duration, you will find that the gait is very peculiar. Aidedwith a long two-handed staff walking is possible, the rate ofprogression being under two miles an hour. The body abovethe hips sways from.side to side, whilst the feet, which seemclogged with invisible weights, are lifted with.evident diffi-culty and dragged forward, the toes scratching along or barelyclearing the ground. The leg bearing the weight of the bodyis bent at the knee and trembles, whilst the advancing leg,dragged wearily forward strongly adducted, is planted un-steadily directly in front of its fellow, the toes reaching theground first. In short a kind of paralytic goosestep. Thegeneral effect is one of laboured unsteadiness, due to greatweakn ess. The evident spasm of the thigh adductors ceasesto be very apparent when the patient reclines on his back,when the thighs can be separated, usually without resistance,to a normal exte nt. There is no wasting, no loss of musculartone, no true tremors, only tremblings of the entire limbswhen weight is put on them . Sensation seems quite un-affected. The tendon reflexes are much exaggerated, bothknee-jerk and ankle-clonus ; the slightest stimulus startingthe latter phenomenon going for a long time . There is noloss of power or undue excitability in bladder or rectum.The arms, trunk, head and neck muscles are unaffected. Themind is clear, speech natural, pupils normal and reactingnatu rally to light and accomm odation. The urine is often ofrat he r high specific gravity (1030), acid, and contains abu ndan turates. 8uch are the symptoms as I have found them. I amaware that some writers state that digestive disturbances,colicky pains, and diarrhoea are usually precursors of theparalytic state ; and that sensory disturbances such as hyper-aesthesia, anaesthesia, and formication, with bladder troubles,such as incontinence and retention of urine, are common. Ihave never met with a case in my expei'ience of manyhundreds where the slightest history or evidence of any suchcomplications could be traced.

Etiology.As regards the etiology of the disease, it is, I think,geaerally conceded now that the paralysis is in some way dueto lathyrus poisoning.. Other main theories of causation are :1. Tltat lathyrus eating has nothing to do with it . j . T h at if i t h as, it is only diseased grain which is capable ofpoisonous effects.- \ 3. That exposure to sun or some local hot wind is the true cause.4. That the paralysis is due entirely to cold and damp.5. One emin ent authority on tropical medicine (Mansoni has thrownou t th e suggestion that, like alcoholism and probably bert-beri, thedisease m ay be due to th e entran ce in to th e body of a toxin generated bygerms-whose habitat is outside the body.6. Lastly, I am quite prepared to hear some champion of parasitismarise and suggest that some organism, so minute as to have hithertoescaped observation, is really the author of all the mischief... In the tim e at my disposal I cannot fully discuss these and

othe r theories, nnd can only say tha t the occurrence m idisease in epidemic form among lathyrus eaters a n d i -no others seem^ ^~ r vt-\r ctmnr vi/irti-. * J _ * 4 * W yto me very strong evidence that a htresponsible. The idea that diseasedi t probably b o d 1 *diet is primariJ ^aonly is injurious is an argument probably borrowed^ ,analogy of ergotism . I know of no facts to support"h'tP*That exposure to sun or some local hot wind can }>'*\ i"responsible is at one disproved by the undoubted fact th' indisease has occurred (amongst lathyrus eaters) equally


6/6

rom severe** "prolonged exposure alone, l believe, women owe theirmJirative immunity. I have suggested to Major Bu chananthat the respective shares which exposure and a iathyrusdietary have inproducing the paralysis might well be testedduring the extensive animal-feeding experiments which are tohe carried out at the Bombay Research Laboratory.Morbid Anatomy and Pathology.Satisfactory observations on the morbid anatomy and path-ology of the disease are wanting. From the clinical sym-ptoms one would be justified in assuming it to be a form oflateral sclerosis, but in "Watts's Dictionary I un d a statementtlmt " Cantarri of Naples has published a number of cases inwhich he has carefully observed the conditions after death.jo nllVction of the spinal cord was discovered. The musclesof the lower extremities, especially the abductors, were foundto have undergone a fatty degeneration, etc.'1 Scheube men-tions one published necropsy (where death resulted frommalarial cachexia) where "a softening of the spinal cord abovethe lumbar enlargement was found.1' Allb utt refers to twoexaminations of horses which had died of lathyrus poison-ing. Inthese the symptoms were apparently mainly those ofenrdiac and respiratory oppression, and after death "the mis-chief was found ma inly ,in the cells of the anterior horns ofthe cord, which were diminished in number and atrophied.There was also thrombosis of small arteries, which were alsothickened. There was, too, fatty degeneration of the heart andintrinsic muscles of the larynx." From this he suggests thatthe nerve mischief may be secondary to the vascular lesions,which would suggest a similarity to ergotism. The prognosisof this disease as regards life is favourable. It does not seemto cause death directly, but the paralysis is incurable. Treat-ment, I believe, is quite futile.A PLEA FOR THE PROPER MEDICAL SUPER-VISION OF " REFRESHMENTS " PURVEYEDON RAILWAYS IN THE TROPICS :

man's lot { way Defects," referring to the very candid report of the SpecialCommissioner, he is represented as having stated th at, speak-ing generally, he thought the present administration andworking of the Indian railways cannot be regarded as satis-factory, etc. He advocates th e provision of dining cars on allfast through-service train s toeconomize time, and think s tha trailways in India are not sufficiently appreciative of the valueof their third-class passenger traffic, drawing special attention'to certain gross abuses to which" these are subjected. Hefurther suggests the introduction of electric fans, which hethinks should be made compulsory within five years ; theuse of oil sprinklers to allay du st, and lavatory accommoda-tion in all third-class carnages, which should be widened.Beyond these important sanitary recommendations noreference is made to the medical departments ofjrailways,this being, perhaps, a matter beyond the; province of hisreport. ' . ' ' ' ~\ '"The Government of India, however, in th e PUDKC WorksDepartment addressed the different railway administrationsthrough the local governments last year desiring that certainrules should be formally agreed to between the mdicalandsanitary authorities of local governments and tHose of rail-ways within their areas, for the purpose of affording suchmutual advice, support, and intimation of otbreaks- ofepidemics, etc., as may be for the general benefit of the'public health and for the prevention of much siekness andmortality. ' '."While these rules are having the consideration of ourGovernment the proposition that I would venture' "to advanceis the necessity for adequa te medical and sa nitary -staffs notonly on our great Indian railways, butalso on our mercantilemarine, to enable them to cope with modern sanitary andmedical requirements, the urgent need for which the dia-grammaticrepresentationsbelowwilljlthinkjmakeobvious-and1 trust tha t the time has now come for our medical membersof Parliament, aided by the General Medical Council, tourgethe Government to send out a Special Commissioner andmedical expert to inspect and report upon the medicaladministrations of our mercantile marine and great railwaysin the interests of public health

WITH SPECIAL REFERENCE TO INDIA, AND FOE BETTER LATRINEAND LAVATORY ACCOMMODATION FOR THETRAVELLING INDIAN PUBLIC.By H. D. M C C U L L O C H , M.B.,Chief Medical Officer, N.G.S. Railways, India.OUR vast Imperial commerce and the foreign enterpriseswhich have come into being since the introduction of steamas a m otive power, our great mercantile marine and extensiverailway communications, extending in India alone to over26,000 miles, has resulted, among other things, in rapid in-tercourse between East and West, which in its turn has goneto bring into prominence certain disadvantages, having re-gard to the public health of the communities con-cerned,hitherto remote from one another. Contingencies havearisen necessitating the adoption of special precautionarymeasures toprevent the conveyance of infection from alreadyinfected areas to uninfected areas.Owing partly to the infection being undetectable during thelatent period in man and the vitality of the virus undervarying conditions, climatic and otherwise, the difficultiesp en enc ed by medical authorities in the framing and adop-tion of sanitary preventive regulations have been very great,*o a the inconvenience to the general public extremelyc? 0*? ^ a t these times of panic, the consequence being theabandonment of such regulations or their irregular adoptionin certain, areas "pro forma," and the adoption of serumjnocalations of Haffkine's antitoxin systematically and on auu^e scale, by the temporary employment of a large superiorical and sanitary staff, with the greatest benefit, where

was tolerated.T6 necessary last year for the Home Government toI n , d i a a special railway expert in administrative, and Mr. Thomas Robertson, C.V.O., was selected asi n in i^ J i9 m m i 8 8 i o n e r to inspect and to report on the ad-"*ustrations of railways in Ind ia from the commercial anda n tna s p e c B ) t n o u g the administrations of the variousi r 1 ? - ^ 3 " 1 1 companies in which our Government isS ? c . t l y C r e s t e d w a s not included.e-?* of Mr- Robertson's report was, I believe,India last May, but the Blue Book to be issued^ 1 1 ' 8t!U in th e h a n d s of the King's printers. n d i a n n e w s p a p e r a r t i c le on " Indian Rail-

Diagrams representing inequality andinadequacy of Sup.Medl. Staffs on Rys.Miles3000-2500 -2000 -1500 -!000 -5OO _ u 1

IPR EIR MR BNR SIR EBRi* Excessive expenditure on superior medical staff. NGSR

reat Indian Peninsular RailwayEast Indian RailwayMadras Railway ...Bengal Najpur RailwaySouth. Indian RailwayKastern Bengal RailwayNizam's State Railway

Mes. Employs. MedicalAdministration,Cost Per Mile.3,6743,358i,6oo1.5571.359 974 5

20,50030,300i*,ooo15,50013,5008,9008,000

Rs .31.4030.0a6.5035-378.9450.1812.03The democratic idea that every citizen is entitled to thebenefit of everything that will' add to human health andhappiness is growing fast. Health and sanitation Acts by theLegislature, medical officers of health, sanitary inspectors,inspections of workshops, etc., have all, in addition to pro-longing life and diminishing death, done incalculable serviceby rousing in the public xnind the vague beginnings of atremendously important mental "process of a dissipation of

lathyrism india hendley 1903

Documents