lathyrism field study mccombie young 1928 par miles

7/29/2019 Lathyrism Field Study McCombie Young 1928 Par Miles

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452 A Study of Renal CEdema.2. In two cases primary retention of water seems to have been thecause ofthe oedema.3. In the remaining- cases it is probable that the dropsy wasof pre-renal

or igin, due to abnormal capillary permeability to wa te r and salt.4. Of the latter, one patient exhibited the features of pure lipoid nephrosis,and three those of nephrosis complicated by inflammatory renal changes. Incom-plete investigations on another case pointed to a condition of pure nephrosisIn the r e m a inde r t'he findings indicated degene rative and inflammatorychanges but the cholestrol content of the blood was not raised.5. In a case of pure nephrosis and in one of nephrosis with very earlynephritic changes considerable improvement was effected by a high protein diet andlarge doses of thyroid extract.Our thanks are due to Major V. R. Mirajkar, F.R.C.S., I.M.S., Professorof Physiology, King Edward Medical College, Lahore, for allowing us tomake use of his laboratory, to Dr, Raghbir Singh, Clinical Pathologist to theMayo Hospita l , formaking theblood urea estimations, and to Drs. Mohammad

Yusaf andFakharud Din for assistance during the investigation.REFERENCES.

BENNET, I., DAVTES., D. T. and Lancet, I, p. 3.DODDS, E. C. (1927).

DVKE, S. C. (1924)ELWYN, H. (1926)EPPENGER, H. and STEINER(1917).EPSTEIN, A. A. (1926)

Quart. Jour. Med., XVIII, p. 77.Arch. Int. Med., XXXVIII, p. 346.Wein Klin. Woch., XXX, p 7"Wesselow (1925).Jour. Amer. Med. Assoc, LXXXVII-, p.913 (containsavioiiq wnrl-1!

77. Quoted by de

K E N D A L L , E. C. (.1919)LEIBOFK, S. L. (1924)L O E B. L. (1923) . .M A C L E A N , H. (1924)M C N E E , J. W . (1922)MA-YRS, E. B. (1926)S T K A U S S and G R U N W A I . D

( 1 9 2 7 ) .V O L H A R D and F A H K (1914) : .DE W E S S E I O W , O. L. V. (1925)

V V H I T E H O R N , J. C. (1921) . .W I D A L , Am BARD and W E I I . L(1912) .

references to previous work)Endocrinology, HI, P- 156.Jour. Bio/. Chem., LXVI, p. 177.Medicine, II, p. 171.Modern Methods in the Diagnosis and Treatment of

Renal Disease, London.Jour. Path, andBad., XXV, p. 425.Quart. Jour. Med.. XIX. n. 273.

ie linghtioche Niererd e W e s s e lo w ( 1 9 2 5 ) .Quart. Jour. Med., XI X , p. 53.Jour. Biol. Chem., XLV, p. 449.Sem. Med., X X X I I , p. 361. Quoted by de Wesselow( 1 9 2 4 ) ! The C h e m is t r y of the M o o d in Clinical,Medicine, London.

A FIELD STUDY OF LATHYEISM.BY

LIEUT.-COLONEL T. C. McCOMBIE YOUNG, M.D., D.P.H. , I .M.S.[Received for publication, May 26, 1927.]

' Karya matra, pir pisanUsk'fi kltae, gor nisanHale chandi, matke kidYe delcho matra ke shul.'

Translation:' The black pea, with its yellow flourFrom eating it comes trouble in the legs,Flapping topknot and swaying hips ;Behold, the ill effects of eating matra. 'I N T R O D U C T O R Y .

TH E writer was deputed under the Indian Research Fund Association inN'vember, 1926, to examine in the field the epidemiological and clinical aspectsUundelkhand and Baghelkand in Central India, being areas in which aW e number of cases had been located, were selected as the venue of the investi-gation, with Rewa, and later, Sutna, as its headquarters. The investigation waspursued by daily visits to all likely villages within five to ten miles of a motoringroad.

. REW A, Genera l.Rewa State, the scene of the greater part of these observations, is a treatyState in the Baghelkand Political Charge of the Central India Agency, of which*arge it is (lie largest and most westerly State. It has an area of alxwt 13,00(5* 'quare miles, about the size of Bulgaria. A range of hills divides it into two'M "atural areas. One, the northern area, consists for the most part of an upland-|alluvial plain, the ' Uparihar,' about 1,000 feet above sea-level, which is continuousr^fcith the main Central Indian plateau; it is open cultivated country, with a^Population of 176per square mile. .


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454 A Field Study of Lathyrism.72 per square mile, and is less fertile than the northern area, cultivation ],ejI1=,for themost part confined to the valleys of streams.

In the plateau, 85 per cent of the population are HindusBaghels, Rajptu,and lower castes, while in the hills the population are chiefly animist hillnienthe Gonds.The average rainfall in the ' U pa r iha r ' is 42-2 inches: a maximum of64 inches was recorded in 1894, and a minimum of 2634 inches in 1905, whichwas a year of shortage of crops and of famine.

With the exception of coal mines at Umaria and Burhan in the hill countryand of the lime kilns at Sutna, the sole occupation of the State is agriculture.In theyears of normal rainfall it is self-supporting as to cereals, and exportgrain in considerable quantities, and only in a year following a failure of tliemonsoon rains is the normal outflow of grain exports replaced by an inflow of'imported cereals. Sutna, on the G. I. P. Railway, is the distributing centre andcommercial emporium of the State. A metalled road, 31 miles long, connects itwith Rewa, the capital, from which radiate other metalled -roads whose mileageaggregates 100 miles only. A par t' from these, unmetalled roads and villa?'cart tracks are conspicuously lacking, and owing to this lack of communication?the villagers of the interior live in the circumstances and under the economicconditions which have prevailed since time immemo rial. They are dependant}for their food supply on their own resources, and the shortage of food-grainj,;which follows a failure of the monsoon rains in a country depending for rainfall!on its crops, is not capable of relief by imported grain, and is a vital feature in:the subject under consideration. ':\

T h e l a n d o w n e r s ar e B r a h m i n s , B a g h e l s , R a j p u t s and o th ers . The field!w o r k is d o n e by l a b o u r e r s , the harwahas, who b e lo n g to the l o wer castes, KoJvj!C h a m a r s , etc. W i t h the field labour is as so c ia t ed a f o r m of economic bondage^th e ' harwoha' or 'lugwa' sy s tem , wh ich is re l ev an t to o u r - s u b j e c t . J

A 'lugwa' is a low cas te l ab o u re r who h av in g in cu rred a d eb t of some!R s . 60 to Rs. 80 by e x t r a v a g a n t e x p e n d i t u r e on a m a r r i a g e c e r e m o n y , or suchijlike, h as p led g ed the se rv ices of h im se l f and his fam i ly to a landowner unti l suchjt ime as h e h as p a id offh i s d eb t . Hi s m as te r , in r e t u r n for these services .guarantees|hi s b o n d m an ' s fo o d and c lo th in g . The food is a ' kliawai'a p ay m en t in kind ol ja daily rat ion of such foodstuffs as are available from the ' k h a r i f ' and ' raW.^c rops and as may be ex p ec ted u n d er th ese c i rcu m s tan ces , the ' l u g wa ' s ' rat ioajconsists of the c h e a p e s t g r a i n s . It is u n v a r i e d and m o n o t o n o u s and they arefirst to fee ! the s t r e s s of s c a r c i t y . ;

G r a z i n g g r o u n d s are a b u n d a n t in area , a l th o u g h p o o r in q u a l i ty , and the cat :!ar e sm al l and d e g e n e r a t e . In a H i n d u S t a t e n o ne ar e kil led for food, and nt^effort is m a d e to c o n t r o l t h e ir r e p r o d u c t i o n or to e l im in a te the unfi t . The a v e r a g e |vi l lage co w y ie ld s o n ly ab o u t $ seer of m ilk per d ay . On ly the b e t t e r c l as ses d r iw |milk or co n su m e d a i ry p ro d u c t s ' , and l i t t le enough at t h a t ; and such of the poorer^classes as have cat t le collect their milk for the p r e p a r a t i o n of ghee, which, l^ 1 * !easily p o r t a b l e , is sold to o b ta in the m o n ey wh ich p ay s the l an d rev en u e of tM|St a t e . T h e . on l y m i l k p r o d u c t w h i c h is co n su m ed by t h em is ' matha 'burl

T. C. McCombie, Young. 455

v n g m :ir.'u'l.-.vci;i' i:an y a|i> unk

l t i v a te d and used in other parts of India, and only the better das vj agel l l i n i ,i s at rare intervals and on feast days some green vegetables, wl chand hawked hv i t ine rant 'Kachhis ' or vegetable-sellers. Mango : , , and the mango in its season as the green or ripe f ru,t, as a dec -

, ed -p nna/ or a dried and powdered condiment- amchur, , la gel>hua flowers arealso used to a small extent in the Upanhar , bu he r_ f r e ,h , fomented, or sun-dried,-is greater among the Gond, o f h eh H' J o", i .e on a variety of other jungle products which mclude the lea, , ; The r.ond, unlike the orthodox Hindu of ' Upanhar, ' does no grow;!;!::c, a M,quanuty of Lathyrus (K, Slate Gacetler. 1907), and lathynsmnown among these hillmen. jAgriculture in Rewa.As has been noted, the Rewan crops are entirely dependant on rainfall.There are no irrigation canals. A primitive water lift, the ' Dhenkuri, ' isused to irrigate from small kutcha wells the exiguous patches of green vegetables,

loliaccn, or sugar-cane, raised by the ' Kachhis,' but of the agricultural irrigationof the cereal crops from wells, as practised elsewhere, there isnone. To conservethe rainfall and keep the fields moist enough to yield a ' rabi ' crop, earthen banksstyled ' bandhs ' are thrown across the lower ends of sloping fields to retain inthem asmuch moisture as possible. The Rewan farmer recognises several kindsof soil, to which frequent references were met in one's wanderings. Thu s, thereis the ' Mair,' a rich dark loamy soil, retentive of moisture and fertile in theautumn. ' Sigma ' is a lighter soil more suitable for the ' kharif ' crops and forrice. ' Dumat ' soil contains the properties of both and may be ' Dufasli 'suit-able forboth ' rabi ' and ' kharif ' crops, while there are other poorer soils, suitableonly for 'kharif' crops and after years of rest. There are two harvests, in thespring and summer, the ' kharif,' watered by the monsoon rains, and the autumn-winter crops, the ' rabi,' dependant on the residual moisture in the soil. The cereal 'kharif ' crops are as follows:Rice . . .. . . Oryza sativa.Saman . . .. . . Panicum frumentacewn.Jowar . . .. . . Jorghum vulgare.Kakun . . .. . . Sitaria italica.Bajra .. . . . . Pencillaria spicata.Kodon . . .. . . Paspalum stoloniferum.I Urad . . . . . . . Pltascohis radiialus.he pulses j Mung .. .. .. Phaseolus wungo.\ Arhar . . . , . . Cajanus indicus.

non-cereals, such as cotton and oil-seeds. Of the above list, the pooreruse Jowar, Bajra, Kodon, Saman and Kakun, and the rice is for the mostappropriated for the use of the well-to-do.Ihese crops are sown during the rains; much ploughing is done while rain-. "a .6> an


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456 A Field Study of Lathyrism.The pulses ripen in August and September, and the cereals, Kakim andSaman, ripen first about September or October, followed by Kodon, Bajra, ricand last of all, Jow ar in Novemb er. The method of preparation of these cerealsfor food is relevant to this enquiry.Kodon is husked with the ' chakar a '. a soft g rind stone made of sun-driedclay held together by rice husks. It is then cleaned in the ' sup a' or winnc ^basket and pounded with the Musal (the pestle) in the ' ka ri ' or mortar, anhusk ' kanna 'is given to an imal s or may be eaten by poorer classes,resulting gram is known as ' Kod ai.' This is washed and boiled, like riceeating as ' Kodo ka bh at' and the thick rice-water in which it is boiled, is fcattle.Saman and Kakun are similarly treated, Jowar and Bajra, aftertrodden by oxen, and winnowed, are ground in a hard stone Chakki amresulting w hole meal is cooked over a gird le (' Taw a ') into a girdle cal'ro ti. ' Rice is reaped in Octob er, trodden in the 'Ka li ha n' and winnowtthe ' supa.' Th e gram is husked in the ' chak ara,' shaken in the ' supaseparate the outer husk, which is used to consolidate clay for bricks. Th eat this stage is known as ' Ba gri.' It is now pounded in the ' mu sal''k ar i' to remove part of the pericarp . It is now ' Chawal,' and the' kann a,' is given to anim als. It is not polished or parboiled. It isboiled, in the usual ma nner. It will be seen that a very varied selectkcereals is available from the ' khari f ' crop for the use of the lower classesthat its method of preparation is not such as seriously to lower its vitamin coiAt th is time of year, the po orer classes use small quantities of green 1of a wild plant, ' Chakaora/ which grows in the rains and is gathered and usAug ust and Septemb er while still soft. It is eaten with salt, condimentsvegetable oils.No other green vegetable food is available until ' Chu na ki bhaji ' come:general, use in December. This consists of the green shoots of the young C

plant, gathered when it is big enough to admit of the young shoots being ' pr;by being nipped off by the finger and thum b. This prevents the plant gistalky and induces a branching w hich improves its yield. These pruningeaten raw with salt, or cooked, or dried for storage, and appear to be a vasource of vitamin A, see later.Common salt is used by all, as required. The vegetable oil, mustarand linseed, are used occasionally in small quantities by the poorer classes,these vegetable dishes, on the rare occasions when they are available,inability to supply fat soluble A is the reflection with which one regardsas a dietary ingredient.

The ' rabi ' cereal crops consist of the following:W heat . . . . . . Triticum aestivum.Barley . . . . .. Hordum vulgare.Matra . . . . . . Lathynis sativus.Chuna . . . . . . Cicer arietinum.

T. C. McCombie Young. 45 7

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These are sown in September and October and ripen in March and April.Double or treble sowing is practised, thus wheat is sown with gram and with' matra,' in drills, the seed being fed throu gh a tube (' nali ') attached to theplough, through which the seed is dropp ed into the furrow . It is thus easy todistinguish what is sown intentionally and what is self-sown (' la m er a' ). M atra(lolhxnts salivus) is sown with the wheat, as a precaution against the wheatfailing to germinate in a dry year, in which case only the matra comes u p. It isalso very largely self-sown. Th e resultin g crop of such an yield of mixed sowin gis known as ' berra ' and consists of a mixture of barley and matra(jao berra)or wheat and matra, or wheat, gram and m atra. Th e wheat and barley havingixen trodden and winnowed at the 'Kalihan,' is'ground in the hard stoneCbiKki. The coarser parts of the pericarp are removed by sieving through aClihaiini,' the bran being known as ' Ch okar,' but much of the pericarp remainsin the flour which is eaten as a 'roti,' and the vitamin value of the seed doesnot ippear to have been much impaired in the process of preparation of the flour.Lathvrus salivusstyled matra and batra in Rewa, and variously known inlndn as ' kesari/ ' teora/ etc., has now to be considered.The ' karya matr a,' or black pea , which is' the only variety of L. salivusgrown in Rewa, is the large-seeded dark-coloured variety which grows on uplandlicit land. If the seeds are small, the diminu tive ' niatri ' is applied to themvuu tion in colour yields another distinction, ' Bhu ra matra 'w hich.is of slightlypaler hue, and if the seeds are much flatten ed, it is called ' chipta m atra .' Allp|tir to be substantially the same stuff. ' Goliya matra ' is the seed of anotherlegi me which 1 have not been able to id entify but it is a close relative of ourgarden pea. It is grown in the Central Prov inces in Damoh and S augor, wh eren !. called ' batr a.' and there is used as a ' dhal ' but not as a ' roti. ' ' Bagalpu rimatra ' is the name given in Re wa to the small-seeded pale-coloured Lathynissoli us grown on rice lands of the Gangetic plain, which is imported duringfamine years. It is not grow n in Rew a, and is not seen there in normal ye ars.Matra is in Rewa the staff of life of the working classes at all times, and,owing to its ability to grow in a soil which is too dry for the other 'r a b i 'cereals,of the general population in years of scarcity. Th e labourin g manlike it; he considers ' matra roti ' to be ' filling at the price ' and think s its energ y-)ielding value to be considerable. An Abair (Re wa) kahawat exemplifies thisview :

Matra ,ki dhal men dal de king,To reng chale Sambhar ke sing.Translation: ' Only put a dash of asafostida in the dhal of matra, and even adried sarnbhar's horn will (come to life and) walk.'It is considered to be ' humble fairin ' and a Brahmin patient will not readily

o*". 'coram pub lico,'.to its extensive use in his own household. W hen ques-tioned as to his diet preceding an attack of lathyrism, he will commonly give""aginary accounts of a sumptuous and varied fare whose accuracy one learnedto discount by observing the grin s on the faces of the listening audien ce, and from


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45 8 A Field Study of Lathyrism. '. C. McC'owbie Young. 45 9a knowledge of the paucity of such fare in the famine year in which, perchancrthe case had developed.Tho se who can. afford to be more fastidio us in their feeding con sider tlu-' matra roti ' to be hard, difficult to m asticate, and indigestible, w hile they knowits proneness to produce lathyrism. O rdinarily the better class household usesit as a 'dhal,' taken with'rice in the evening meal, and under such circumstance^it never reaches one-third to one-half proportion of the diet, which Buchanan andother observers agree to be dangerou s. There are areas, however, where it?predom inance in the crops entail;; its being eaten in large quan tities mixedwith wh eat or b arley as a ' roti ' {see notes on K otar, where the amount ofmatra eaten is large, and the number of cases is considerable). Fo r eating, ">matra is ground, unhu sked, in the ' Chakki,' to form a yellow flour which isbaked into a ' roti,' eaten w ithout sieving by the lower classes. Better classpeople may remove the husk from the flour before preparing the ' roti. ' As a' dhal ' it is like the other pulses, husked in the ' Chakra,' which breaks the shell ""'and turns out the yellow hemispherical endosperm, which is separated from the *husk by shaking in the ' supa,' and boiled and eaten with rice. . ^Th us ma tra, and now for its ill effects. . ; l

CLINICAL. i^-The clinical manifestations of the disease have been recorded in great detail ^by earlier observers, who had, moreover, the opportunity in famine years, of'. ^seeing large nu mbe rs of cases, of recent orig in. Contin ued search has, in the*course of this inv estigation , revealed only 13 cases which occurred in 1926.' _.Examination of old cases might have been multiplied ad lib, but it was found .that info rmatio n as to diet and history of o nset could not be obtained from ths"' ""old outstanding cases and it seemed useless to cover ground already traversed'by earlier observers. $ """Brief notes, taken in the field, have been recorded as to 56 cases, old ana! ;?new, from which the following observations may be deduced. :T 1

Age of Onset.In the old standing cases, it is not possible to ascertain with any accuthe age of the patient at the time of onset. O ut of 23 cases that occurrt'1924, 1925 and 1926, the following was the incidence by decennial age groiif

5 to 10 years .. . . 4 cases.11 to 20 - ... .. 9 21 to 30 7 3 1 to 40 . . . . . . 3 Buchanan (1904) who saw a large number of cases, places the onset inmajority of cases in the groups 10 to 20 and 21 to 30. The villagers remanthat it is always the strongest and physically active who is struck down.

Sex.Few female cases were brought for exhibition, but the figures given for

KotarAIKIII"Kuan

Male.11 0

7153

Female.26712

TOTA L 23 4 45

Z -*

The proportion in my cases was, therefore, about 5 males to 1 female.Iliicliauan gave a proportion of 10 to 1 and whichever figure app roaches morenearly 1 accuracy, there is no doubt that th e sex incidence is very d ifferent, andlh.it females are less liable to the disease., Month of Onset.

Of 50 cases from whom reasonably reliable information could be obtainedas to the month of onset, the following was the distribution by the months of theSanibat year:(M ay) Baisakh . . . . ' . . 1(Jun e) Jeth . . . . . . 2(July) As ar . . " . . . . 12( A u gu st ) S aw a n . . . . . . 9(Septemb er) Bhadon . . . . . . 9(O ctober) Ku ar . . . . . . 16(Novem ber) Kart ik . . . . . . 1AgahanPottsMagh . . nil/ - Pha ga nChait

Among these crises, it was noticeable that of the 16 cases who assigned the"_i Onset in Kuar ( O cto be r), n early all w ere recent cases who connected the on set**' Fof their lameness with a preceding attack of fever (malaria ?) which prevails in" ^t h t autumn. Famine year cases usually selected Asar (Ju ly) as the time of^.caiiet. Diet in Period Preceding Onset.

T I" all recent cases, and in most of the old cases, with the exception of thosewhom, as might be exp ected, the lap se of years had effaced th e memory ofthey had been eating, a history of an exclusively lathyrus diet, or"tine in,*?c'1 lathyrus predom inated, was elicited. A strikin g feature of such 'dietary-calor ies was its monotony. . A typical diet of a ' lugwa ' suffering from lathyrismlie that during the three months preceding the onset of the disease, he hadj . W ing twice a day. a ' rod ' made from a flour of lathyrus, containingw |>ericarp ;md endosperm, taken with salt. This w ould be washed down


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460 A Field Study of Lathyrism.relieved the monotony , such being beyond their means. Occasionally the ' nichthmatra ' or unmixed la thyrus, migh t be varied with a ' berr a/ a m ixture of wheatand la thyrus , or ' jao b erra,' barley and lathyrus , in which lathyrus would pre-dominate. An other mix ture, that of two.legum es, gram and matra, seemed particularly noxious, and the ' jao berra ' seemed more dangerous than the wheat berra.A fifty-fifty mixture seemed to be the dangerous proportion, which agrees witliBu chanan's observations (B uchan an, 1 904). It was interesting to contrast thi .pre-lathyrism diet of the poorer class patients with that of the household of their *employers, the Brahm ins. Th us, in a Brahm in landowner's household of 6 personi \4 adults and 2 children, with tw o lathyrism-lame ' lugwas,' all eating the?same matra , about S seers of grain would be used daily. The basis of the^mornin g meal would be a ' roti ' of wheat and of the evening meal ' dh al' andrice, the ' dhals ' being of various pu lses, among them lath yrus, which would \sdused in April, May and June, at other times ' arhar,' ' mung,' etc., would take itiplace. This household had 7 buffaloes and 12 kine. ' About \\ seers of milkand 1 chhatak of ghee was used daily, the rest of the ghee being kept forThe bu ttermilk w as used in the household and issued to the ' lugwas.' No fruit %was consumed except mangoes in their season, and green vegetables would occasion-ally be purchased from a Kachhi. Th e wild vegetable ' chorai ' would begathered and used in its season. Pum pkins , rhuiya, etc., ' chuna ki bhaji ' in itsseason, salt, and other condiments, vegetable oils, and mahua flowers, fresh anddried. Con trasting the diet of a family of a caste and station of life whichordinarily escapes lathyrism excep t in a famine year, with that.of the low castelathyrism patient, one is struck by the absence from the diet of the lathyrism in-cases of the substances known to be rich in fat soluble A, viz., milk, butter andthe fresh green leafy vegetables. *j *

Mode of Onset.It is known that an attack of fever may precede the appearance of the syuip-"i

toms of lath yrism. 14 out of 51 cases gave a history of an attack of "" "'intermittent fever, with rigors and sweating, lasting for 5 to 6 days to ain the autumn, after recovering from which they found themselves lame,time of year, the type of fever, and the treatment, ' up as ' (ten day s' starvan'iwhich is ordinarily the village treatment of malaria), are suggestive ofhaving been the cause of the fever. Th ree cases gave a history of an attack",dysentery having been an immediate antecedent of their lameness, one offattack of smallpox, while in another, a medical man gave me a definite diaof pneumonia havin g been an antecedent. In ten cases, in whom no feveroccurred, an exposure to cold or wetting, or unusual exertion had been an immedantecedent. Th us one man had been on ' begar ' (forced labo ur) on a 'sarisbund with short rations, for eight days, with rain falling. Another hadweeding a rice field in two feet of wa ter or planting ' singhara n ut ' in aroofing a house, chasing run-away ca ttle and so on. Th e onset is alwaystically sudden and unusually unheralded by prodrom ata. A typical historybe that-the patient had had a heavy day's ploughing in heavy rain and had

T. C. McCombie Young. 46 1shelter and sat down under a tree. On getting up he found himself un able towalk and had to be carried home, or case 44, who got lame in Bhadon 1925. Hewas at work in the fields when a rigor of fever, w ith cold and shivering seizedhim H e went home and lay up for four d ays. He go t up and went outside toobev a call of nature and tried to jum p a gap in a bund . He fell down, could notnse' again and was brought home by his mother. In a very few cases prodromalsymptoms of tingling and numbness, pins-and-needles feeling in the legs, or painin (lie back, may have been noticed, but it seems clear that such are rare, or slight,prior to the development of the syndrome.

In the 51 cases of which records were kept there-was little variation in theigns and symptoms of a spastic diplegia.In none of the cases were there any sym ptoms of mental im pairment. . Speechas normal, and the cranial nerves unaffected, except in one case, that of Chida,No. 27. in which there was nystagmus, in whom also an exceptional choreicmovement of the upper limbs was noticeable. Imp airmen t of the tactile andpiinful sensation in the lower limbs was always absent and so also was cedema

or wasting of the muscles of the lower limbs. Th e superficial reflexes, cremasteric,abdominal, and epigastric, were often hard to elicit, and in some cases seemedabsent. The knee jerks were always present and exagge rated, and som etimesa tap on the ligamentum patella; would set up clonic spasms of the lower limbs.\ tendon jerk could usually be elicited by tapping the adductor tendons, thetcncio achilles, and the hamstring ten dons. T he pla ntar reflex, often hard toelicit in the horny soles of those who wear no shoes, was, when elicited, extensorin type in all but two cases with otherwise typical symptoms, in whom if wasflexor in type. Ankle clonus was present in nearly all cases. In extrem e casesthe sphincter control may be lost at the o nset but is regained later. . Sexualpotency is retained. Romberg's sign was always negative.Electrical Reactions.

In such cases as ail opportunity of testing the response of the leg muscles tothe Faradia current was obtained, all the muscles responded to a fairly briskstimulation at the motor points, the flexors more actively than the extensors.Arrangements for applying a galvanic current of sufficient voltage could not beextemporised under field conditions.Gait.

The gait is very characteristic and has been very fully described by earlierobservers.' The writer found it most easily understood on the hypothesis thathe disease is a lesion of the upper motor neurons, whereby the influence of thecerebral cortex in correlating th e actions of different muscle groups has beendisturbed, and the control of the postu ral reflex removed. Th is, which isnormally a continuous act of extension of the lower limbs and spine, is dis-ordered, the flexors overact and overcome the extensors, and the adductors.overpower the abductors of the thigh..


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462 A Field Study of Lathyrism. T. G. McGombie Young. 46 3The . latter disorder furnishes the earliest sign of the disease, which can I*detected in very slight cases showing an almost imperceptible impairment of loco-motion.A normal gait is on a fairly wide ' wheel base,' to speak in motoring terms

whereas the lathyrism case, owing to adductor overaction, walks on a linear foottrack, as if he were walking on a rail. He has no difficulty in heeling and toeinea line, unless rigidity and weakness interfere (Plate X LVI, fig. 7).

The next thing that at tracts attention is the progression with slightly bentknees, owing to overaction of the hamstrings.Overaction of the gastronemius and soleus leaves the toes on the ground

when the heels have left it and leads to a dragging of the toes as the foot isadvanced. In the effort to achieve this movement, the pelvis is tilted, while to maintain the balance disturbed by the linear foot track., the head sways from sideto side. Though a slight case may walk unaided, one stick or two sticks may be "required, according to the degree of disability. In more marked cases adductor 'spasm leads to a cross legged ' scissors gait' (Plate XLV, figs. 5 and 6) and thecalf muscles draw the feet into the position of spastic equinus, in which the :patient walks like a ballet girl on tip toe (Plate X ZLIII , fig. 2 and Plate XL1V,figs. 3 and 4) . In the last and extreme stage of the disease the postural reflex isentirely disorganised, the quadriceps extensor is overcome by the flexors, thelegs give way at the knee joints and the patient is reduced to crawling in a .sitting position with wooden hand supports (.Plate XLI II, fig, 1). i

Except in these crawling cases of many years' duration in whom contrac-tures from disuse prevented extension of the knee joints, it could be seen that thisdisorder of function is postural.. A spastic equinus case can get down on thesole of his foot when standing at rest, and the spastic muscles can all be coaxedinto relaxation by the pressure of the hand when the patient is in the recumbent .position.

The degree of disability varies from the slightest possible malfunction indi-cated by ai bent knee and a linear foot track, to one in which the patient istotally unable to walk. Notes on cases illustrating these different degrees ofdisability are sub-joined ;

Crawlers.Two such cases were seen. Stockman (1917) remarks that the clinical ci'iuli-

tion of such cases has not been recorded and the field notes may therefore be ;given in full. . ;;

Notes on Cases. ' .'Case. No. 46.Ram Das, male, age 30, caste Gosain, village Kotar. A professional-,beggar and lives on the alms of food grains which he collects. His mother is also a lalhyrisocase of old standing. He got lame 7 years ago (in ,1920a famine year) in the month oiSawan (July-A ugust). After an attack of fever which lasted some days he felt some pat" ,

in the back and the legs. He awoke one morning to find himself totally unable to walk, and .has remained so. No history of incontinence of urine or fa;ces could be elicited from him.;Before he fell ill, he was eating a mixture of matra and barley got as alms in the village. .:.Present condition: He is totally unable to walk and crawls in the seated position wiin ,

hamstrings of both legs. There ismuch spasm of the adductors, thethighs cannot IK separated,nor can the knee joints be extended much beyond a right angle. There is much wasting ofthe thigh and calf muscles. No analgesia or anssthesia of lower limbs. Cremasteric reflexnot elicited, abdominal and epigastric reflex not obtainable as contractures of the abdominalmuscles keep the trunk in partial flexion, on account of which patient cannot lie on his back.There is no nystagmus, the tongue is protruded straight, and the facial movements arecomplete.So tremors or ataxia of the upper extremities.

Case No. 22. Sepaiya. male, age 45, caste Chumar, pensioner at Sutna Lime W orks,here IK- was a coal breaker. Has been lame for 15 years or so, being first attacked in themonth oi Asar. The history is that he first got a pain in the lumbar region and found thathe was unable to walk over uneven ground. Th is gradually increased and by October he foundthai be needed two sticks to walk, when he came to the Lime Works as a coal breaker. Thennins-aiul-nccdles sensations began in his' legs and he found himself unable to stand uprightor t" walk without tailing, so he took to crawling. These feelings disappeared, but theinability to walk has remained. When at his worst, he had some trouble in retaining fascesnd urine./)iV/.For three months before getting ill, he was eating a bread of lathyrus and barley,the if.rnicr predominating. The bread was prepared by making a flour of the pea and eatingii without separating the husk. Buttermilk was drunk with it, but no ghee, milk or greenvegetables were obtainable. He continued on the diet for six months after first getting lame.Present condition:He crawls in seated position, with feet, buttocks and hands on theground. His general health is fairly good, bowels regular, and no incontinence of urine andf;cccs. His lower limbs are wasted, the range of passive movements at the knee joints is to a

the sreat toe was elicited in the right foot. Superficial reflexes, epigastric, abdom inal,crcniasu-ric and gluteal not elicited. The scapular reflex was obtained. There is no anesthesiaor analgesia ot the lower extremities. No tremors, .no impairment of the movements ofthe hands and arms; nystagmus absent; facial and lingual movements unimpaired.Electrical Reactions:Wi t h the Faradic current, in both legs some contraction wasobtained by stimulation of themotor points of the Tibialis anticus, Peroneus Longus. Adductors,Jml Quadriceps Extensor, Semimembranosus, Semitcndenosus and Biceps.No reaction in the Gastrocnemius and Soleus over the motor points but some movementwas observed with the electrode over the Sciatic nerve below the gluteal fold.This case illustrates the complete crippling produced by continuing with a lathyrns dietafter the first symptoms have appeared. The electrical reactions indicate an upper motorwuron lesion even in an extreme case such as this (Plate XLIII, fig. 1).Case No. 27, is an example of an extreme case, just short of the crawling stage.: Chida, male, age 30. ca-ste Kol. occupation, was a hurwaha. He got lame in a year ofUmuii:. about 12year* ago when the crops failed and no grain was obtainable locally. W heat*> then 4 seers to the rupee and matra was 16 seers to the rupee and he had to eat this.Ht obtained it from Sutna Bazar and it was Bagalpuri matra, imported grain. He couldoo4 then obtain any buttermilk, as he had no cows of his own and those who had buttermilkKrV^ it for themselves. Nogreen vegetable food was within hismeans and the only flavourin g|iR ^1 lms ' r o i i ' was common salt. This matra diet was continued till Kuar (Octob er-g November) when he got Kodon, and Dhan and other food. After a day at earth-work5p | a bandh in Sawan (August-September) be was sleeping on a charpoy outside. A 'bad'j| S w uid struck him and when he woke, he found himself unable to walk. He had no feverH | w no pain anywhere.i | | | : j ^ ,ou- "Uses two sticks as he drags his trembling legs along, with feet turned in and toesS r ' J 8 " 1 8 along the ground. The knee jerks are much exaggerated and a tap on the patellarn j S C t 5 u


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464 A Field Study of Lathyrism.Ankle clonus is mark ed and continues after the examining hand is withdraw n. The plantsreflex is very active and extensor in type. Much adductor spasm and limitation of abductioiwith adductor tendon jerk, ditto in hamst ring muscles, which are thrown into a clon'contraction by a tap on their tendons. No marked muscular wasting or trophic changeslegs. No anaesthesia or analgesia of lower extremitie s. Th ere is no appreciable impairmof the functions of the hands and arm s. He can grind the family grain, but a slight chorcicmovement of the arms w as noticeable. Nystagm us was present, and the pupillary reactionto light was doubtful. He has a little difficulty in retaining urine when the bladder is fullbut no incontinence of faeces. He claim s sexual potency and has one child 3 or 4 years oldThe nystagmus and slight choreic uncertainty of the arm movements are unusual featurain this case.The history of his diet illustrates the state of affairs in a famine year (Plate XLIVfig. 2 ).Case No. 25.L all M un, male, age 30, Chatri, c ultivator, he got ill 18 years ago in Oxfamine year of ' Chhappan ' in the month of A sar. He got fever, then the eruption of smallpox came out. Some 15 days after that, he fell down when at stool and got up to find himsclllame. He recovered somewhat and was able to walk with a stick.Diet.At that time, in a famine year as he was a poor man, he had to eat what he couldget, chiefly natra, which w as 12 seers per rupee and wheat 5 seers. Ma tha was obtainablefrom others but he had no cows of his own.Present condition:A well nourished stalwart man, who walks with a marked equimuposition of the feet. On the m orning he was seen, he had walked five miles to attend the courtat Sutna. W hen at rest, he stands on the flat of his feet. The toes drag as he walks, the foolis neither inverted nor everted. Knee jerks -\|- . Much spasticity of calf muscles and sonwspasm of adductor muscles. The plantar reflex is extensor, there is marked ankle clonus andthe tendo achilles tendon reflex is very active . An adduc tor tendon je rk is elicited by tappingthe cremasteric, abdominal and epigastric reflexes present; no impairment of movement]of upper extremities or cranial nerve functions. No Romberg sign, no anaesthesia or analgesiaor lower limbs.Reactions to Farudic current.A ll muscles respon d; the response of the Tibia lis Anticuiis very slight, and the response of all flexor muscles is strong (Plate XLIV, fig. 3).

At the other end of the scale of disablement are mild cases, of recent yeaisin whom the degree of disability is so slight as almost to escape detection.Case No. 47.B., female, age 14, caste Brahmani, daughter of C. B. of Kotar villageShe got lame inBhadon (A ugust- Sep temb er) of 1926. No fever or illness preceded itiappearance, and she had been going daily to weed the ' kharif' crops during the rainy season,when a slight uncerta inty of her gait w as noticed by others. At this time she was eaiinjthe matra-barley berra of K otar, in which lathyrus predominates, as a ' rot i' in the morning,and in the evening, Bhat (boiled rice) with a ' dhal' of matra (lathyru s). W ith the 'rot i'she was getting1 'm at ha ' (butterm ilk), and mango ' panna ' during the mango season, but nowhole milk or ghee, and no ' cho rai' or other green vegetable food.Present condition:A comely well nourished adolescent girl who has not yet gone to hcthusband's house; menses normal.Gait.A little jer ky, with a linear foot track. She can heel and toe a line withoolany difficulty and can walk on her heels with the toes raised. The re is no ataxia. Tbnich is also grown by itself or mixed with the p ea called ' goliya ma tra, ' whichi. * more common here than what one sees elsewhere.I" the low-lying fields in which ' kharif ' crops of rice are raised, there is anOnusual amount of Akri (Vicia saliva).,' As is the custom elsewhere, this-gro wth is assiduously weeded out and fed


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466 A Field Study of Lathyrism. T. G. McCombie Young. 467In the neighbourhood of the village, in the fields which are irrigated by thinundation from the north, the crops chiefly of barley and lathyrus arc rich amiplentiful. A novel mode of ma nur ing these fields prevails. The sweepmusfrom the west end of the village are dumped on the lee side of a culvert and

causeway which traver ses the main line of drainag e. Wh en the floods come, au-Jthe water pou rs over this cause way the refuse is carried away and spread l>vthese waters over the fields which they flood, and thus their fertility is effectivelymaintained. An inspection of th e fields suggested a predominance of legumesespecially lathyr us, in the crop s that they yield. An examination of the foodgrains used in the village and the accounts given by the villagers as to their dietconfirm this. Th e heaps of ' rabi ' grai n crops given in barter in the bazar andin the bania's shops show a large and predominant proportion of lathyrus, whichis of the large-seeded v ariety, t he ' kary a mat ra ' of the w heat uplands of Rewa,with a small admixture of ' goliya m atra,' another legume.Th e commonest mixt ure is the ' jao berra,' of barley and lathyrus, theproportions varying, but in all cases lathyrus forms the larger portion. The

mixture of lathyrus and wheat is less commonly seen, as the amount of wheatgrown locally is small. As it is a valuable g rain, for which there is a demandelsewhere, it is sifted out from the m ixed crop and sold to raise money andthe lathyrus is retained for consumption and for the wages of the field labourers.In both wheat and barley berra, there is a certain amount of gram.In none of the numerous samples examined by me could the seeds of Akri(Vicia sativa) be detected, despite the plentitude of this weed in some of the fields.Mango trees are num erous, and mango ' panna ' is much d runk during themango season, in May and Ju ne . Usu ally even the poorest obtain it,- and it isused to wash down the dry and unpalatable ' roti ' of matra, when no ' matha' urbuttermilk is obtainable by them . Mahu a trees are likewise abundant. Theflowers are sun-dried and stored and parched for immediate'consumption, form-ing a sweetmeat which is not unpalatable to European taste.A wild plant yields a leafy v egetable known as ' Chorai,' which is gatheredin Chait-Baisakh (A pril-M ay-Ju ne) by the Kachhis and is bartered in thevillage by them. It is general ly eaten durin g these months, at ten or twelvedays ' interval, but the poorer classes who have little food grain to spare for barter,cannot get it, and in a year of grain shortag e, no one can afford to obtain it.The staple diet of a better class Brahmin household, while the ' kharif'crop lasts, is, in the morning, a ' roti ' made of barley and matra, the latter [ire-dominating, washed down with panna (mango decoction) or matha (buttermilk)according to the time of the year; and in the evening, rice, with a dhal of matra,cooked whole.On this diet four mild cases of lathyrism o ccurred in 1926. Th e proportionof lathyrus in the diet varies in inverse ratio to the affluence of the family, a'1"

the poorer classes live for eigh t m onths of the yea r on an exclusive diet oflathyrus (nichela matra) and four months on Kodon, with a little dhan andsome matra.Families in comfortable circumstances can supplement this diet with sonic

rone of the fo rmer, and little , of the latter , except for such small amo unt ofcluiiia shoots, ' chuna ki bhaji ' which they obtain in the cold weath er. Fleshnieat is hardly ever eaten, even by those castes who indulge in it, except on thernre events on which it is obtainable as game.According to the village school master, malarial fever is very prevalent inOctober, as might be expected from the amount of the low-lying land whichMirrtnmds the village.The population of the village in the last census was 1,774, all Hindus exceptthree, who were Mohammedans,. The re were 369 houses, 856 Hindu males and918 Hindu females.A rough census of the number of cases of lathyrism in the village wasobtained by summoning a prominent man from each Moholla and getting him ioname those in his quarte r afflicted with lamen ess. Th e figures thus obtained were)1C males and 26 females, total 136.. On these figures it would appe ar that 7-6 per cent of the total pop ulation,or 12-S per cent of the male population, and 2-8 per cent of the female populationare affected with lathyrism , and it is probable that these numb ers are an u nder-estimate.It appears, therefore, that the description ' lame Kot ar ' currently applied tothis village, is justified by the condition of a population, 12-8 per cent of whoseadult males are crippled by lathyrism.Or. the supposition that lathyrus diet is the primary cause of this calamity,the state of affairs in this village is readily explainab le. Fro m t he foregoing notesas to crops and diet, it will be seen that the population lives very largely on a.lathyrus diet, which is the predo min ating food grain in this area. A local kahawalexpresses this depenclance on lathyrus in rhyme:i ' Matra ki roti, viatra ki dhal,

Matra hi pati rakhan har.', which may be translated as follo ws:' Bread of matra and matra as dhalI Matra indeed is the guardian of all. 'i Possibly the barley-lathyrus ' berra ' which they use is a more dangerousdiet than the wheat-lathyrus more common in other Mouzas of the Rewan^ ' Uparihar ' and the lack of variety an d the comp arative sho rtage of the ' kharif 'S trops of Kotar may also be an unfavou rable factor.; The villagers say that in former years they grew much more matra thanhey do now, and that this was the cause of the excessive lameness and of the*pithet' lame Kotar,' and they recall that in the famine years, to which all the oldertod more seriously affected cases refer the onset of their complaint, nothing butMra grew.f. ,. Under present-day con ditions, a small annual crop of mild cases is occurri ng.nine cases were reported to have occurred in 1926, of these 6 cases were seen andas lathyrism. One was absent from the village, one was not a case


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468 . A Field Study of Lathyrism.Owing to the discouragement by the State of the growth if lathyrus, and th-fact that the last few years have had good monsoon rains, and good grain isajpresent fairly plentiful, the 1925 and 1926 cases were comparatively few, aarftheir symptoms light. Nevertheless the amount of lathyrus in the diet of uu,community is unusually large and to this fact coupled with the poverty and

primitive mode of life, and the lack of the protective foodstuff in their diet ]would ascribe the unusually large number of cases of lathyrism in this villageABA1R VILLAGE. i

Abair is a village some three miles east of Kotar . Its fields show the samt'2predominance of legumes in their crops, particularly of lathyrus, and the villaeelldiet shows the same features, namely, a large proportion of la thyrus. TlieSvillage population consists of 1,480 persons, 715 males and 765 females, and|||Lthere are 71 males and 7 females affected with lathyrism, i.e., about 10 per cent;^3of themale population and about 10 per cent of the female p opulatio n" . "^^

T. C. McCombie Young. 469

K U A N V I L L A G E . Kuan village, in this neighbourhood has a population of 393 males and

The re are 53 males showing symptoms of lathyrism, and12 females, i.e., 13-5 per cent of males and 3 per cent of females. All399 females.

AMIRITI VILLAGE.Having noted the prevalence of lathyrism in Hindu communities who ._.on a diet in which lathyrus predominates and the protective food substances __.lacking, it was now thought desirable to investigate, as a control, the preva!encS!l|or otherwise of lathyrism in a community using lathyrus in the diet and liviflgiunder similar conditions, but with the addition to their diet of the ' protectn


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470 A Field Study of Lathyrism.a nd t h e p o p u la t io n , e sp ec ia l ly th e p o o r e r c las ses , w h o suffer most f rom lathvr"-h as b een ex p o sed t o p r i v a t i o n , m a l n u t r i t i o n , a n d v i tamin d ep le t io n , and arc ; co n d i t io n of g r av e n u t r i t io n a l in s tab i l i ty , cau sed b y a diet def icient in fat-so luhi A

S o m e e v i d e n c e in r e g a r d t o t h e e x i s t e n c e o f an a v i t a m i n o s i s of A is affordedb y ce r ta in f a c t s th a t came to l ig h t r eg ar d in g n ig h t b l in d n ess in association witht h e p r e v a l e n c e of l a t h y r i s m .

M c C o l l u m ( 1 9 2 5 ) s t a t es t h a t ' t h i s is a co n d i t io n w h ich seems r e la ted to def iciency of f a t - so lu b le A in th e d ie t o f m a n . ' H e r e g a r d s it a s ' a specifics y n d r o m e of d i e t a r y o r i g i n ' a n d su g g es ts th a t ' a d ie t d e r iv ed to o largely froaj 'c e r e a l p r o d u c t s , t u b e r s , a n d other foods having similar def iciencies, induced-lo w er ed v i ta l i ty w h ich b eco mes man i f es ted , amo n g o th er w ay s , in" faulty v ision/

M y o b ser v a t io n s in d ica te th a t th i s co n d i t io n is v er y co mmo n in R e w a . ; j |M a j o r C . H . S m i t h , I . M . S . . S u p e r i n t e n d e n t of the" med ica l d ep ar tmen t o f

R e w a S t a t e t e l l s m e th a t it is c o m m o n i n th e j a i l , mo s t ly i n th e h o t w eath ermo n th s w h en v eg e tab les f r o m th e j a i l g a r d en a r e l a c k i n g an d in th is connection 'it is n o t e w o r t h y t h a t t h e fa t e l e m e n t o f th e j a i l is der ived f rom vegetableoils , n o t g h e e .

T h e S u b - A s s i s t a n t S u r g e o n in c h a r g e o f th e N ag o d S ta te D is p en sar y tel lme th a t h e sees a n u m b e r of cases i n th e h o t w e a t h e r m o n t h s a n d t h a t h e connects 'i t s o ccu r r en ce w i th a l ack o f fa t i n th e d ie t . . J,

M r . J a r d i n e , t h e M a n a g e r o f th e S u t n a L i m e W o r k s , s ee s c a s e s of this'd i s o r d e r of v i s i o n a m o n g hi s l ab o u r f o r ce a n d h e first drew m y a t t e n t i o n to the 'belief i n th e efficacy of ch u n a leav es ' ch u n a ki b h a j i , ' a s a r e m e d y . .:>;

F o r th i s co mp la in t , k n o w n a s R a t a o n d h i , t h e t r ad i t io n a l I n d ian r emed y of a'd ie t of g o a t ' s l i v e r ( a so u r ce of f a t - so lu b le A ) , w i t h a p o u l t ice of goat 's l iver to ,th e ey es , is w e l l - k n o w n . 5

G h e e is a lso es teemed a s a r e m e d y an d i s u sed a s such by t h o s e wh o can :o b ta in i t . *A B r a h m i n c u l t i v a t o r e x p r e s s e d t o m e t h e u n p r o mp ted o p in io n th a t th o se who"ea t g h ee d o n o t g e t R a t a o n d h i a n d t h a t th e first milk of a n ew ly ca lv ed cow isalso eff icacious a s a c u r e . \

' C h u n a k i b h a j i , ' th e g r e e n p r u n i n g s o f th e y o u n g ch u n a p lan t is , h o w ev er /t h e m o s t u n i v e r s a l r e m e d y a m o n g t h e v e g e t a r i a n p o o r e r c l a s se s . T h u s in the 'f ami ly of a l a t h y r i s m c a s e N o . 5 1 , th e s to r y w a s to ld m e th a t th e y o u n g w if e of 't h e p a t i e n t h a d , i n A u g u s t o f th e y e a r in w h i c h t h e h u sb an d d ev e lo p ed la th y r i sm, 'su f f e r ed fo r s ix d ay s f r o m n ig h t b l in d n ess . H e r o l d mo th er - in - law p r o d u ced iso me d r ied ' c h u n a k i b h a j i ' w h i c h w a s k ep t i n th e h o u se , so ak ed it in w a t e r , put; . _it u p o n th e r o o f o f th e h o u se o v er n ig h t , an d fed th e p a t ien t on th i s , w h o found; " -^h er se l f cu r ed i n t w o d a y s . . }i

It is s ig n i f ican t th a t i n o n e f a m i l y t h e m a n d ev e lo p ed la th y r i sm an d th e wif*.j"n ig h t b l in d n ess i n t h e s a m e m o n t h a n d o n t h e same d ie t . 5 - cT h a t t h e a s s o c i a t i o n is not f o r t u i t o u s is s u g g e s t e d b y th e o b ser v a t io n th a t inj - * K o t a r v i l l a g e w h e r e , as we h av e seen , 1 2 p e r cen t o f th e male p o p u la t io n are-;

*

T. C. McCombie Young. ' 47 1This is embodied in a local kahawat, a jibe against Kotar, which runs as

: ' Ekai andliar, ekai lul,Ekai chale matkawat kid,Ye dekho Kotar ke shul.'

One is blind, another halt, and another lame with swaying hips; behold thetroubles of Kotar! 'Inquiries showed that the particular form of ' An dhar ' wa s night blindness,while 1 lie tilting and wriggling movement of the pelvis in lathyrism' matkawatk,,] ' js considered a diagnostic featu re of that disease.Mv case notes show that in the diet of lathyrism cases in particular, as ir.'& the diet of the population in general, there is a conspicuous absence of the leafyJ* \eqetaliles, and of whole milk, ghee or dairy prod ucts contain ing but ter f at, which^ are believed to be the most plentiful sources in a well balanced v egetarian diet of*? 1 .r. soluble A, while in regard to Ko tar it is seen that this com munity whichsuffers severely from lathyrism, also suffers from night blindness, an evidence ofthe lack of fat-soluble A in its diet. W ith this may be contras ted the state ofaffairs in .the ' control ' village of A mir iti, who se inh abitan ts gro w and eat asmucli matra as the average Hindu villagers do, but being Mohammedans theysupplement their cereal ration with fish and flesh meat and substances containinga modicum of fat-soluble A. Th is village has no lathy rism cases.

In Sind, which the writer subsequently visited on another inquiry, it appearsthat Lalhyrus satizms is grown and eaten, but cases of lathyrismknown as' matar niandai ' are very rare, and occur un der ex ceptional conditio ns of scarcity .The Sind villager grows and eats Lathyrus sativus, but he also keeps herds offine upstanding cattle and buffaloes, which give a plentifu l yield of m ilk, which isconsumed by the owners, and they also grow and eat green vegetables in con-siderable quantities. The conditions which, with a lathyrus diet, are in Rewaassociated with the occurrence of lathy rism are absent in Sind. I am indebtedtu Dr. Shiveshwarkar. Assistant Director of Public Health , Sind RegistrationDistrict, for the oppo rtunity of p erusi ng his repor t on an outbreak of scu rvyi" a Sind jail where, in addition to the lack of vitamin C in the diet, thesubstitution of lathyrus dhal for the other more expensive legumes from whichit had been previously prepared, was associated with the appearance of symptomsof lathyrism. Th is observation would also appear to mark an association pfUlhyrism with nutritional instability and avitaminosis, in this case of C.A C T O N ' S A M I N E T H E O R Y .

It is now for consideration what bearing the observations have on the twotheories of causation which it has been the work of the writer to investigate inthe field.In regard to Acton's theory of the formation of a poisonous amine bygermination, it may be noted that his investigations (Acton, 1922) were made in

tf

I?


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474 A F ield Study of Lathyrism.seeds of Akri may be found in a handful of wheat from the bottom of a htayThe large-grained ' Karya niatra,' the cheap grain which is fed to ' lugwas ' andwhose consumption causes lathyrism, ordinarily contains no Akri.

The "only crop in which a very small percentage of Akri may be found is a' berra ' produced in a somewhat moist field which in the previous year had beensown with wheat and matra, etc., and for some reason is being allowed to litfallow under a self-sown, unweeded crop, consisting chiefly of matra and alittle wheat, with some wild vetch in places.

Such a crop is given to the ' lugwas ' and may admittedly contain ' one pice inthe rupee ' of Akri, but such slovenly methods of farming, are very rare, I onlysaw one such field in four months' wanderings. . ;

None of the many samples of matra in current use which I collectedcontained any Akri seeds, which are easily distinguished from the large andcharacteristic seeds of .the upland wheat lands, although it may be more difficultto distinguish them from the smaller seeds of the grain grown on rice lands.Six specimens of grain which had been eaten by lathyrism cases were sent to

BarleyWheatRiceLinseedGram lentils,etc.

KesariAktaEar th

Weevils * ..

SAMPLS I.

25028139

22

48954

A greatdeal.Weevilledbut no liveweevils.

SAMPLE II.

.18 .891

1

4

9

6570

Very little.

Many liveweevils.

SAMPLE III.

29 3

36

?>

0

7

30 315

None.

Fewweevils.

SAMPLE IV.3

807

16

4970

None.

Veryweevilled,. many liveweevils.

SAMPLE V.2

32

-

60

657

0

None.

Very fewweevils.

SAMPLE VI.28

64

1

7

864

0A gTealdeal.

No weevils.

Mr. Bainbrigge Fletcher, ImperialT he weevils which infest matra were sentEntomologist, Pusa, for favour of examination.He reported 'that they are not real weevils, but are a species of Bruchus (Bruchidx) ofwhich several species attack pulses in India.' He advises that they occur practically throughoutthe world in various species of peas and beans and that it is therefore unlikely that they artconcerned in cases of lathyrism.' . . ' ,

T. C. McCombie Young. 475r |i,m-ard for examination as to the presence in them of Akri contamination.

I specimen No. 1, which was the leavings at the bottom of a grain bin, to' uV bottom of which the small seeds of Akta and grains of earth, and other' debris bad found their way, 54 seeds suspected to be those of Akri were( bfparated from a total of 489 of Kesari, not including seeds of other food* Th v Ak d i b 55 t 1 d*

d from a total of 489 of Kesa , n t gn< The average weight of Kesari seeds to Akta seeds is about 5-5 to 1 andJLJ proportions by weight of Kesari and Akta were therefore about 50 to 1,

while the percentage by weight of Akta in the mixture, which also containedbarley and other food grains, was still lower. In specimen No. 3, also one ofleavings, the proportion by weight of Akta to Kesari was about 111 to 1 and^as considerably less in the total mixture.

It has been remarked that the weed is more abundant in ' dumat' fieldswhich grow rice in the ' kharif ' and are more moist than the wheat lands. Werethis contamination the cause of lathyrism, one would expect the disease, withibe weed, to be more common in rice lands than in wheat lands. In RewaI could find no evidence that this is the case, nor does it appear that the diseaseis more prevalent in the rice lands of the Gangetic plain than it is in the uplandwheat lands of Rewa, where the weed is rare and the disease is common.The villagers are emphatic in rejecting the suggestion that Akri is evermixed with matra or that it is eaten in any appreciable quantity, and the opinionof those who sow, grow, weed, reap, harvest, grind, bake, and eat their own{ran is worthy of credence.

They clench the matter by pointing out that ' Akri grows only in moistfield and that in a famine year when lathyrism cases occur in great number;,tiic fields are all dry and no Akri g rows: how then can it produce lathyrism1?

Taking everything into consideration, therefore, I can find no confirmationoi the theory that lathyrism is caused by a contamination of Lathyms sativus bv.ihe weed of Vicia sativa.

DISCUSSION.Having failed to find evidence that lathyrism is due to an amine formed by

germination or to contamination of the grain by a poisonous weed, it remains todiscuss what other possibilities of causation are suggested by this investigation.

Lathyrism is pre-eminently a famine year phenomenon, it is one of thepain; and penalties of poverty and malnutrition, and the mechanism of itsproduction is as follows:

In a year when monsoon rains fail, the ' kharif ' crops on which the poorercla e? depend for a varied and cheap variety of cereals are in defect, and thepeopc are now ill-fed and half- starved. The wheat and barley of the ' rabi 'crop (ail to germinate in the dry soil, only the lathyrus grows, which is harvested" \pril , and the bulk of the population has to live chiefly on that and onuch imported grains as they can obtain, of which lathyrus, being the cheapest the most used. .. . ' .

Three months of such a diet brings on an abundant crop of lathyrism cases,i nni ng in July and continuing until the resumption of a better balanced diet01 September and October when the 'kharif' crops become available if. the'occceding monsoon rains have been more bountiful. In a year of normal rainfall


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472 A Field Study of Lathyrism. T. C. McCombie Young. 473privati on, on the inadequa te ' ra bi ' crop of 1920-21 , supplemented by cheia^im p o r ted g ra in s . -^

It has been shown that ' in a normal year, no importat ion of grain occurs tithat the ' Bag alpuri matr a ' whose germina tion h e suggests to be the causethe -disease, is never used. He suggests that the indigenous vetch is perhata-non- pois onou s, but of the 13 recen t cases, seen by me all had been eati ng localjyigrown matra and of the eight samples of such grain that were obtainable :" wer e of the large-seede d var iety , the ' kary a ma tra ' of th e wheat uplands*!Re wa. ~ *rt

From this i t would appear that the locally grown matra is as potent to pnlathyrism as is the imported ' Bag alpuri ma tr a ' w hose consumption in a famine"year has earned i t an undeservedly evil reputat ion in Rewa,a disrepute probaUjdue to the circumstances of i ts use rather than to any inherent and special toxidtKHe noted that the majori ty of cases seen by him gave the month of July

the time of onset, and he suggested that this indicated the possibility that germi:t ion of the grain occurs during the rains , which produces the poisonousto the ingest ion of which he considers the symptoms of lathyrism are due.Buc hanan (19 04) pa ras 52 and 64 to 67 of h is repor t , has shown that _

mon ths of lat hyru s diet at a ny t ime of the year w il l determin e the onset of>,lathyrism , and i t w ould appea r that th e ' facts which he ci tes afford a credible 'explanation of the appearance of the cases in July when three months of.pre-vponde rat ing l athyr us diet s ince the harv est ing of the ' rabi ' crops in A pri l , hadbeen accomplished, without as suming ge rminatio n and a poisonous amine to bethe explanation.The possibi l i ty of the occurrence of such germination was, however, .- . .

fu l ly invest igated . In none of the specimens of Lathyrus sativus which hadformed the s taple d iet of eight cases before the onset of their d isease, was anysign of germi nation detectable, and th is was confirmed by the D irector of the.Inst i tu te of Plan t Indu stry , In dore, A . Ho wa rd, Esq. , c .i .E., to whom sampleswere sent for exam inatio n. . ''",[

It does not appea r l ikely that such can occur. T he grain is harvested \&the hot dry mon th of A pri l . It is s tored in the houses in a large sun-baked | | pearthen jar cal led the Kut uli . -SUl

Grain which is to be used for seed is mixed with wood ashes to prevent t M j | | |inroads of weevils , while that required for use is kept in the Kutuli and ^ " V J U Lout and spread in the sun at frequ ent i nterv als to keep off weev ils. It is unhusked,,'sjfflLand. the perica rp is th ick and resis tant and unlikely to perm it of the germ ^ 6 " ^ ? ^ ^ ^activated by an increas e of atmosph eric humi dity . . ' ips&SH

I was informed by al l whom I quest ioned, that only such grain as has been ' jgsoaked in water wil l germinate, and that i f i t does, i t is rejected as unfi t iotjgjifood. ,tS -,No field evidence can therefore be discovered which suggests that an imported;*grain is the offender or that germination of the grain occurs , while the July

AKTA CONTAMINATION THEORY,jailed that Anderson, Howard and Simonsen (1925) observedof Kesari obtained from different parts of India, the only;uueni Lommon to all was the narrow leaved vetch, Vicia saliva var.known in the vernacular as ' Akt'a.'Their chemical investigations showed that the seeds of L. sativus containedd but the seeds of V. saliva var. angustifolia, were found to containand divicine, and alkaloic . .of two bases showing alkaloidal properties, viz., vicineucoside, vicianin: ..Divicine produced by inoculation of guinea-pigs' ' dicated thatetic characteristic fatal disease, and a series of animal expe rime nts indicated th asfa ducks and monkeys fed on Akta the majority showed a definite syndromiSMHiewhat resembling human lathyrism, although by no means entirely similar tosvniptoms which were absent in ' con trols '' fed only on Ke sar i.The possibility that lathyrism is due to the presence in commercial Kesari offlbc seeds of this contaminating weed was, therefore, examined in great detail in

fthe course of this investigation.This weed which is known in Rewa as ' Ak ri ' is a wild vetch which grow sVia moist soils. It is to be found in most fields which surro und a tank. Someay be found in a moist corner of a wheat field at its lower end where a bandh'ha been thrown up to retain in it the monsoon rains. It is sometimes fairlyJgpJcntitul in ' du ma t' fields which grow rice during the ' kharif,' and wheat, etc.,Sp during the ' rabi ' season.HI It is a true weed, and it is never seen in the drills in which the seed liasi sown through the " nali,' but in the soil between the furrows.It the seed were a constantly present contamination of the harvested crop, it.would be found also in the sowings, as no special pains are taken to purify thej seed which is sown, which is identical with that consumed. Its absence from the drills, which I was at pains to verify by a careful' study of a large number of growin g wheat fields, shows its absence from theseed and seems to afford a reasonable presumption of its absence from the

ftg| crop as it is eaten.p | | ; Everywhere the villagers were emphatic that it is bitter unpalatable stuffIgr, which is never eaten by man and that it is always weeded out and used as cattle| | f fodder. They say that if a field contain s an appreciable qu antit y of it, it musti p l be rare fully weeded out, else it will damage the crop an d reduce its yield.WM During February . I was everywhere able to see this work in- progress and| | | to mark the bundles of Akri being brought home as cattle fodder (Plate X LV I,|||j? Die villagers point out that the Ak ri pods ripen before the matr a pods andf||i that they burst and scatter their seeds on the ground before the matra isi | | | harvested, and that little or none of the A kri which ha s not already been| | | | . gathered for cattle fodder is mixed with a 'b er ra ' or a matra harvest. Matra^S 4 *s usually grown as a mixed cropa ber ra, and th is mixed crop is usually passed| | | | through a sieve to separate the more valuable wheat or barley from the cheaper


13/18

476 A Field Study of Lathyrism.only those whose circu mstances of life app roxim ate to famine conditionacquire lathyrism and the striking feature of a pre-lathyrism diet, apart from '-'the preponderance of lathyrus, is the absence from it of the protective food 'Msubstances of McC ollum. . Th e notes on Kotar village show that w here one of 9the recognised effects of a diet which lacks in fat-soluble A viz.. night blindness. #1is very prevalent, lathyrism is rife; whereas the 'control' Mohammedan villawji-tiof Amiriti, also using lathyrus as a foodstuff, but adding to 'its diet other ^ 8articles as eggs, fowls, fish and flesh meat, is entirely free from lathyrism . Theseindications seem to point to the possibility that lathyrism is allied to the defideocfagdiseases in the mechanism of its causation. "ff^pS

Fu rth er exami nation of the availab le data seems to show that such iHI&ihypothesis supplies some explanation of the epidemiological and aetiological fadingalready noted. In regard to the greater incidence in the years of greatest.physiafl gactivity, the ages 10 to 20, and 20 to 30, an analogy with the deficiency diseaieiragberi-beri and pellagra, may be noted, the incidence of which is highest among thoatSwhose work is hardest (M cCarrison , 1921 ). The influence of excessive phy si ad Sexertion in determining the attack of deficiency diseases has been noted ' \ 0 $ S 3 mMcC arrison who record s that ' the onse t of human b eri-beri is often renderedacute, or that of hunger cedema sudden'by excessive physical exertion' andquotes others in support of the view that 'exposure to cold favours theof scurvy, malnutrit ional cedemas and pellagra.' As we have seen, exertion andwettings are often the immed iate anteceden ts of lathyrism . . :'{^%^^

In regard to sex incidence, which is from 5 to 10 times greater in makfiillK]than in females, apparently only an essential sex difference can explain it, for the|| | | |jliwomen share equally in the work of th e fields and their diet differs in no ^-'d^ i'from that of the men. -McCarrison notes a different sex incidence in the deficiency diseases, beriand war cedema, and in experimental polyneuritis columbarum, and attrithis in part to ' different metabolism and endo crine action in the two st.No other explanation seems applicable to the markedly different sex inddin lathyrism and the analogy is perhaps significant. ;!-.^It has been shown in these notes that a common antecedent of lathyrism;an attack of malarial fever (which is often treated by ten days' sta' Upas ') or by dysentery, smallpox, or pneumonia.While such may be regarded as conditions tending to lowering of the vnand as such sufficiently explained, from the point of view of dietary stcthey may perhaps be regarded as periods of vitamin depletion which would ha*the appearan ce of a deficiency disease. Th e six months of starvation after;insufficient ' kharif' crop, which precedes the mass outbreak of lathyrism'famine year, may perhaps be similarly construed. ^MIn regard to a preponderance of the legume Lathyrus sativus in the diet of

community suffering from lathyrism and its bearing on the subject under?cussion, we niay recall views of recent workers in dietetics.McCollum (19 23 ) states that ' the protein molecule is a chain-like s..

T. C. McCombie Young. 477po.

of a we .gard to the influence of an unbalanced diet in determining the onset ofM C l l i A l d th i e a r d to a

,,,nions correspond to those existing in the body proteins into which they are.^formed.' In regard to legume proteins, he is of the opinion that 'th ey havepeculi' int 'es in then- composition which make them of relatively low value innutrition when they serve as the sole source of protein in the diet, or when theyf '3w arc combined with the more imp ortan t foodstuffs.'Ellis and Macleod (1922) state that- 'pea p rotein is an unsatisfactoryI diet ' and they deduce from anim al experim ent that ' pea protein containssomething which is injurious in large amounts over long periods.' Klsewhere it is stated that ' legumes lack fat-soluble A, and the m ineralcontents of a well-balanced diet.'the deficiency diseases, McCollum quoting Appleton and others, in regard to acommunity living in Labrador in a state of extreme nutritional instability, writes'small deviations in the constituents of a diet determine whether beri-beri,

scurvy or ophthalmia appear.'C O N C L U S I O N S A N D D E D U C T I O N S .

We have seen that1. When the legume. Lathyrus sativus, predominates in the diet, lathyrismmay result.2. When the general population is suffering from starvation and avita-minosis in a famine year, lathyrism is more common than in normal years, whenthese conditions are absent. -

3. A community suffering from lathyr ism is also in a state of markednutritional instability due to lack of the protective food substances, notablythose containing fat-soluble A.4. In an area in which lathyrism is particularly prevalent, the deficiencydisease, ' night blindness,' is also notorio usly prevalent.5. In a Mohammedan village using as much Lathyrus sativus as their. Hindu neighbours but supplem enting their diet by substances which tend torestore the dietary balance, lathyrism is unknown .6. There are some significant resemb lances in the astiology of the deficiencydiseases and lathyrism.. . v j I' m a y tentatively be suggested for experimental verification that lathyrism||| | | | | | may be to some extent a deficiency disease which is produced in persons living| | | | | ; to a state of nutritional instability on a diet noticeably lacking in vitamin A,| | | | | by a prolonged ingestion of a legum e, the amino acids of whose proteins areW S& "nsuitable as a diet and perhap s specially h armf ul, which is itself deficient, in| | | fat-soluble A.Wisl&p ^n regard to such experimental work it may be noted that while epidemio-^ ^ g _ logical observations point to a prolonged period of avitaminosis being an essential

^SBi *C I o r m

the production of lathyrism, experimental workers, Stockman (1917)',ijj|l|& so n > ""ward and Simonsen (1925), were at some pains to eliminateTSsglfc. far as possible, the influence of avitam inosis on their experimen tal animals .ll ll lg :. The observations cited in this report suggest that this failure 'to reproduce


14/18

V5 '*&:$4?8 A Field Study of LatkyrisWi. T. G. McCombie Young. 47 9

Fu rthe r exp erimen tal w ork, reprod ucing as far as possible in animal., ikpre-lathyrism avitaminosis as seen in men, would, therefore, seem to be desiraUtIf successful, the results of such work would yield deductions of considerablepractical value. . . Pending such confirmation, some practical preventive inferences seem eveanow, to be warranted. As A cton has pointed out (A cton, 1922), the ultimatecauses of lathyrism are economic. Its prevention turns on administrate*improvem ents aimed at reducing poverty, providing a better balanced diet aojpreventing the exclusive use of lathyrus in years of deficient rainfall.In Rew a, irrigation would preven t this dependence on rainfall, but as towhether a system of ' flow ' irrigation , utilising the w aters of the river Soois a practical eng ineering pro position an d one which is within the finaiidresources of the State, the writer is not competent to offer any opinion.'L if t' irrigation from wells,-using a water lift operated by bullocksis jpossibility which would similarly req uire technical consideration. Its introduce $tion would presumably require capital for initial expenditure and maintenawhich the ' ra ya t' has not got, and the State would presumably have to finance^it by loans. Jjfl

An obvious requirement is an increase in the village roads and cart track*?.*"This would make it worth while for the villager to grow more and liettetVgrain, which he could get away, and sell, and thus provide himself with better^. food and with some financial reserves to tide over a period of stress. It woalso enable the State to supply him with a grain not liable to produce lathyrismjswhen, in the absence of irrig ation, famine relief measures are required in a year ^*following a bad monsoon.If the writer's views are well founded that avitaminosis due to lack ofuse of dairy products and green vegetables, is an essential factor in the prodution of lathyrism, then measures aimed at increasing the yield of milkimproving the breed of cattle and at encouraging the growth and use of vegelabUwould be valuable in its prevention.The prohibition of the cultivation of Lathyrus sativus has been tried. Sta te adm inistrato rs in B undelk hand, and Baghe lkhand, following the exanof European rulers of the 17th century (Stockman, 1917).It has been shown that this vetch is normally sown as a mixture with wnor barley, etc., as an insurance against famine, and effective prohibition woleave the cultivator with nothing to eat in dry year when his wheat failed,order is usually evaded by a mixed sowing in which, it is claimed, the lathyrus Jself-sown, as indeed much of it undoubtedly is.Furthermore, this hardy and universally cultivated legume, some of wniais present in every wheat-field in R ewa, doubtless serves a useful functionconserving the nitrogen of the soil in fields which are not manured andcontinuously cropped, and it almost certainly serves a useful purpose for

, l i n e d its involuntary misuse by over-use, in preference to endeavouring!!i ft by legislation which cannot in the nature of things, be obeyed.REFERENCES.. Causation of Lathyrism in Man. hid. Med. Gaz JulyK ow A M an d^ M O KS ^ Studies on Lathyrism. ,,,d.Jo U ,Med.Re,,Vo,XU," No. 4, April.1 Report on Lathyrism in the Central Provinces, 1896-1902. Nagpore Civil and Administration Report.Edin. Med. Gas., November.Studies in Deficiency Diseases. London. HenryFroude and Hodder & Stoughton.The Newer Knowledge of Nutrition. New York.' McMillan & Co., C. and MACUOD, A. L. (.922) Vita. Factors of Food. New York. D. Van Norland

U r E . a n d PA KDIT J..K,. Centra. India State Gazetteer Scries, Rewa State.fa D (1907).

v { 1 9 , 3 )

'-'


15/18

E X P L A N A T I O N O K P L A T E XLIII.Fig. 1. Sepaiya, a crawler. 2. Chida, much addu ctor spasm and spastic equinus.

PLATI- XLIII.

Fig. 1-


16/18

E X P L A N A T I O N O F P L A T E XLIV.ffc Fig. 3. Lall Mun , marke d spastic equ inus . 4. Spastic equinus and adduc tor spasm.


17/18

E XPL ANAT IO N O F PL AT E XL V.1'ig- 5. Adductor spasm and spastic equinus.6. Cross legged scissor.gait due to adductor spas m.


18/18

It !!]it

EXPLA NA TI ON OF PLA TE XLVI.;. 7. Progression with bent knees due to flexor spasm.,. 8 and 9. Akri gatherer s.

lathyrism field study mccombie young 1928 par miles

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