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T H E I N D I A N M E D I C A L P A r7T7imrriT7iStaff

1 visiting physician.__ 2 trained full-time.ayahs to work by shifts.

1 boy.1 thoti (part-time).

The .last three on Rs. 40, Rs. 30 and Rs. 15.respectively each.Rent. etc.Rs. 50 per month (controlled

rent). Lighting and water charges Rs. 10 permonth.Contingencies.Rs. 10. including journals

R E. 5.The monthly expenses will come up to Rs. 200to Rs. 250. The initial equipment will be wellwithin Rs. 1.500, not including the microscope

or .-r-ray apparatus.Income.-Even if half the number of beds areengaged taking the average at Rs. 2 per dayper bed. the monthly collection will be aboutRs. 300. The medicine and treatment chargesare extra at the usual rates charged by theindividual general medical practitioner. 'Cost to the patients.Ward charges will beRs. 30 to Rs. 60 per month depending on costof medicines. The expenses incurred by thepatient will not be more than what they would

be if he has to go to a hospital or get a medicalman to his house. Government must take careto direct cases to the isolation centres in therespective mohallas instead of keeping them onthe waiting list and reserve the beds in the hos-pitals for the mofussil cases. The cases whichcannot afford any expense and others whichrequire surgical treatment for the duration maybe sent to Government hospitals.The general m-edical practitioner must inspire

enough confidence to this end. There is nodoubt that the assistance" of a proper specialistis necessary. So, the Government must deputethe specialist to visit each centre to help thegeneral medical practitioner. If the patient feelsthat he can get comfortable accommodation andat the same time facility for good medical aidi gffe&i, these isolation centres will be highlyattractive, convenient to the patient andattendants, relieve congestion in the existingsanatoria, isolate the sufferers and check thespread of the disease. The sufferer will getearlier aid, and thereby have a better chance of being cured, and the specialist will have an"opportunity of doing his job more easily. Thegeneral medical practitioner will have everything to be proud of. Most important, there

LATHYRISM IN BIHARBy S. B. LAL ' "I

Officer-in-charge, Nutrilicni Scheme, Bihar. Bankipore,PatnaLATHYRISM has been reported from the timeof Hippocrates. Mention has also been made of

this disease in old Hindu literature ' Bhava-prakash' where it is written that the pulseLathyrus sativus causes a man to become lameand crippled and irritates the nerves (-Chopra,1938). In India epidemics of lathyrism havebeen reported from time to time usually associ-ated with famine and food scarcity. The first .outbreak was reported by Colonel Sleeman in1844. Between 1900 to 1945 outbreaks of thedisease in epidemic form have been recorded inCentral Provinces, Rewa. Gilgit. the Punjab andUnited Provinces. In response to an enquiry,it was concluded by Megaw and Gupta (1927)that the disease was mainly confined to a belt which runs across Central Provinces, the eastof United Provinces and north of Bihar.Recently Shourie (1945) has reported an out- break of lathyrism from Central India.

In this paper is given an account of three epidemics of lathyrism which occurred in Biharand which came to the notice of the author.They were reported from the districts of Patna,Monghyr and Darbhanga. The first twodistricts are situated on the south of riverGanges and the third to the north of the river. The districts are all fiat country and there areno irrigation facilities, the farmers having todepend entirely on rain for the supply of irriga-tion water. Darbhanga and MonghjT districts-are seats of malaria and the spleen rate is high.In all the districts the entire population isengaged in agriculture. Besides the landlords there are the landless labourers who work in thefields of the former and get wages in kind con- sisting of the cheapest grains available. Lathyrussativus is known in these places as ' Khesari'. It is a good hardy crop and gives a good yieldwith the minimum of labour. It is usuallyplanted after paddy is harvested and withoutany further effort it grows and is reaped after a .few months. I t is a very favourable cropbecause it is cheap and eas}- to grow. It is used for cattle feeding as well. The green leaves are also consumed after cooking by a large number of people even of the well-to-do classes.

As a rule there is acute scarcity of vegetablesand fruits in the. villages except for mangoes during the season. Milk and milk products areeither not available to the poor or are available only in negligible .quantities. Meat and eggs,.because of the high cost, are also very difficult :.to obtain. ' ' 'The disease started in J u l y , 1947 i n t h e ; :

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1949) L A T H Y R I S M IN B I H A R : LAL 469engaged as labourers in .the fields of the villagelandlords and were getting wages in the formof grains of the cheapest type.. ' Khesa r i ' a lwaysformed, a major percentage of.the wages because.i t was cheap and easy to grow. The number .ofpersons affected together with' sex incidence isgiven in table I. .

TABLE INumber of persons affected together with sex 'incidence

District

PatnaMonjrhyrD a r b h a D g a

T O T A L . .

T o t a ln u m b e rofaffectedpe rsons14327

49219

M a l e

13S2746

211

Female

5

8

PERCENTAGE

M a l e

96.5100.093.9

96:2

F e m a l e

3.5e'.i

3.SI t is very difficult to assess ' the age of thepeople in villages, and an approximate ageincidence of the affected persons is given in table

TABLE II

Age groups

12 to 16 vears ..IS to 20 years ..25 and above

Male

15S1SS

Female

3

P ERCENTAG E

Male6.843.65So .83

Female1.362.28

Table I I I gives the in take of calories anddifferent types of food.

Types of food consumedDiet surveys were carried on all the affectedfamilies: .All the food taken was weighed twicea day, before cooking, for a total period of10 consecutive days on the lines suggested byAykroyd and Krishnan (1937). Altogether, thefood intake of 150 families consisting of 857..per-sons was investigated. Diet surveys -of . '.the!unaffected families were also carried on. Forbrevity the relevant figures only of theunaffected, families are given in table IV.Of the cereals consumed, maize, ragi andbarley were the most important i tems, while riceand wheat were in a A'ery small quantity.' K h e s a r i ' was the most important pulse con-sumed. . The consumption of other articles offoods too was below the standard suggested bythe Nu trit ion A dvisory Com mittee (1944-). Theonly source of fa t s . was mus ta rd oil. Ripemangoes and ripe jackfruits were the fruitsconsumed by the families in Monghyr whilethose in Patna were found to take only greenmangoes.Analysis of the diets of the affected andunaffected families for vitamins made with theuse of the tables , in Health Bulletin No. 23(1946) is given in t ab le IV.

" The affected, families of Monghyr were con-suming ripe mangoes and ripe jackfruits whichhave a high carotene content. It is because ofth is tha t though the consumption of leafyvegetables, fruits and milk was lower than thatof Patna, still the figures for vi tamin A arenearly the same.

The intake of v i t a m i n A was below thestandard laid down by the Nutrit ion AdvisoryTABLE III

Average intake of calories and types of jood~in oz. per consumption unit/day{affected families)N a m e ofdis t r ic t

P a t n aM o n g h y rD a r b h a n g a

Cerea ls

16.0612.6625.57

P u l s e s

135710.74 .3 2 9

Leafyv e g e t a b l e s

1.150.560.59

Non- lea fyvege tab le s

1.490.931.61

F a t s andoils

0.330.100.07

F le s hfoods

1.060.440.99

M i l k andm i l kp r o d u c t s1.160.17 s0.30

F r u i t sa n dn u t s0.790.60ni l

Co n d i -m e n t s

' 1.180.710.13

Calories

3,2212,4212.904

T A B L E . I V . .Intake of vitamin and percentage of 'Khesari' in the diet of affected and unaffected families . per consumption unit/'day -. - . . . .

-

District

P a t n a .Monghyr

Familiessurveyed

Affected '. ..UnaffectedAffect ed Unaffected

I1 P e r c e n t a g e of' K h e s a r i '

74.12.0I 545j 2.5

V i t a min A,I .U . ...

. 2.S34 ' '4;84S2.8794,012

V i t a m i n Bi,m g .

" 3 . 2- 1.8. ' .1.6.1.9 . .

Vitamin' C, . .-..'. m 5 - . .- 24.2 ' : 13.6

- - 3 7 5 102

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Co mm itte e (1944) and "the same vrn? true fo rvitamin C as well. " . State of nutrition

In order to assess the state of nutrition, ailthe children available were examined clinicallyon the lines described by M itra (1940) and ratedas ' good ', ' fair ' or ' poor '. Table V gives theresults of clinical rating by naked-eye examina-tion.

whether it is a deficiency disease. T h e low Sintake of vi tamin A b y families of D a r b h a n g adistrict does n o t reflect t h e incidence o f ' i t s rdeficiency in the children of the place, which' 'may be due to th e fact that t h e children whileplaying in gardens a n d orchards consume fruitswhich could n o t possibly b e recorded in thesurvey. Ther e does n o t appear to be significantdifference i n t he incidence of the diseasessupposed to be d ue to deficiency o f ' somenutrients, between t h e children of affected and'unaffected families. " "TABLE V .

Incidence of atate of nutrition amo ngst children of families a ffected and- unaffected withlathyrism

Familiessurveyed

M O N O H Y R I Affected

\ T , .. .| Dnafiecrnc!

DARBHAKGA I Affected

' T- ~ . ijlinanectedTOTAL

R A T I N G

Good Fair PoorActual Percentage Actual Percentag e ' Actual Percentage

PATNA ; AffectedT O T A L . .

T- a- i i S B o y s . .iUnanectod J, Girls: .TOTAL . .

( Boys} GirlsTOTAL . .

; Boys

TOTAL . .

TOTAL . .Boys

4340S3231740

403070302050

5126

312556

14.422,3

15518.2

1S.419.2

20.422.4

16.117.6

30.418.2

15194245

7450124

9876176

9070160

ISOS3

2639085.

175

51.052.1

51.353.7

45.14S.7

50.058 2

57.156.4

5S.463.1

1034G

14 9472 6

7950

12 96040

100

843812241

950

34.6

32 .029 ,S

36.432.1

29 .619.9

26 .625 .S

10.91S.6

Deficiency diseasesAykroyd and Rajagopal (1936) have stressedthe value of the presence of deficiency diseasesand their correlation with the state of nutrition.The children of the unaffected families werein a better state of nutrition than those of theaffected families. The incidence of phrynod ermaand xerophthalmia which are supposed to beassociated with the deficiency of vitamin A wasnot so high' as compared with angular stomatitis

Clinical findingsHistory of sudden onset of the disease w a selicited from a large majority of the pat i en t s .They stated that usually o n gett ing up in themorning they felt weakness in legs, whichprogressed on to their present condition. I na fe w cases t h e onset w a s after a n a t t ack offever. T h e fever mostly w a s malar ia . T h eother findings were those of upper motor neuron

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OCT.. 1949J LATKYRISM IN BIHAE. : .LAI/ 47 1

Percentage incidence oj diseaseiii

' District . Families

V- '' A a- i i \ B O V SPATNA iAfiected j G i ] . ] g'Unaffected { ^ ^ ' '

MoNOHYR , , I BovsAffected | G i ; . l s _ _; T - a t ] S B o v siUnaffected < Girl

DAHRHANCA . r. . , ( BovsAfiected \ G i r ] s _ _!TT /- I ( Bo vslUnaftecced -j Q J ^ , .

Totalnumber

297ISO14493217156ISO130

31 5147162119

TABU , VIsupposed to be associated

P e r c e n t a g e f o u n d to be

P h r y n o -d e r m a

8.610.47.613.9S.7S.97.G6.9

5.14.S0 . 7 .2.1

Xeroph-thalmia

7.08.S6.211.82.72.5 1.51.9

2.23.4mli nil

A n g u l a rs t o m a t i t i s

' 15.71S.714.524.712.412.112.413.5

4.16.15.22.0

with malnutritionsuffering from

C a r i e s

14.8. 14.715.918.2

11.713.4- . 10.714.5

3.46.S7.12.6

:Mal-

occlusion

G.o4.S9.6

5.97.1nilnil

1.92.0nilnil

T o t a lpe rcen tagesufferingfrom oneor otherdisease41.42S.349.32S.53 ' 723.730.224.5

16.123.117.312.6

DiscussionLathyrus sativus is mostly mixed with Vidasativa and is consumed along with the latter.Every villager in the affected localities believesthat the disease is caused by eating ' Khesar i '(Lathyrus sativus); but so far experimentscarried on animals in various laboratories haveyielded conflicting results. McCarrison (1928)could not produce the clinical picture of lathyrism

in rats even when they were fed on pureLathyrus sativa or on Vida sativa. Snook(1948) observed no ill effects when a wetherand two cockerels were fed on Vicia sativa.Bhagvat (1946) working on guinea-pigs couldnot produce any paralysis in them. Lewis et al.(1948) fed Lathyrus sativus at 50 per.cent levelto rats with no ' symptoms of lathyrism.Mellanby (1930) could produce experimentallathyrism in dogs by a diet composed of varietyof pea, Yicia sativa, and deficient in vitamin A.-Further suggestion that this vitamin mayfurnish protection against lathyrisin is supportedby the experiments of Geiger, Steenbock andParsons (1933). M ellanby (1930,. 1934) hasput forward the theory that lathyrism was due.to an active neurotoxin, the effects of which couldbe prevented by protective foods containingvitamin A and carotene even when much of thetoxic, agent in Lathyrus sativus is consumed.McCombie Young (1927) also was of the sameopinion. The present investigation showed thatthe intake of Lathyrus sativus was high with avery low or almost negligible consumption ofsuch protective foods which would be sources ofvitamin A and carotene. The intake of caroteneand vitamin "A too was very low and all of thishad been derived from leafy vegetables and

fruits. .The value of vitamin A has been calcu-lated from carotene of which only a very smallpercentage, from 1 to 2 per cent, can be utilizedby the system (Moore, 1933).A review of the literature mentioned hereshows that, the exact aetiology of the disease isstill obscure. The present survey revealed thatthe diet of the affected families was deficient inquality and quantity and contained a high per-centage of ' Khesari !. Surveys carried out inthis province have revealed a similar state ofintake except that nil or very little of ' Khesari'was in their diet. It appears that lack ofadequate nutrients in the diet lowers the generalbody resistance and concomitantly to that ofthe lower segments of the spinal cord too, tothis toxic agent. The low intake of vitamin Afor a long time coupled with the high intake of' Khesar i ' for a length of time possibly leads tothe development of the disease. This is furthersupported by the fact that families in the sameaffected areas with adequate vitamin A (tableIV) and low ' Khesari ' intake did not reveal anysymptom of the disease. Considering all the

facts it appears reasonable to conclude that poordiet with low vitamin A intake and high con-sumption of ' Khesar i ' {Lathyrus sativus) for alength of time allows the toxin or toxins presentin the pulse to act and damage the nerve cells,already devitalized by the individual living on apoor diet, till a time comes-when the paralysismanifests itself. The evidence collected and thesuggestions put forward are in consonance withthe theory of Mellanby and McCombie Young(loc. cit.).Jacbby (1947) too, from the study of a seriesof cases, found that 'Khesari' or ' Teora '

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472 T H E I N D I A N M E D I C A L G A Z E T T E [ O CT. , 1949(Lathyrus sativus) was invariably associatedwith lath yris m. Fu rth er, his findings with regardto a poor nutri t ional background are the sameas those reported inthis paper. He is also of asimilar opinion, that deficiency of vitamins mayform the clinical background upon which thetoxic agent of ' Khesari' exercises its effect. Theincidence of B complex deficiency amongst thepatients were 15.5 per cent, as against 14 percent reported by Jacoby {loc. tit.). .

No reason could be elicited from the surveyfor the high incidence of the- disease inmales. " The suggestion put forth by Shourie(loc. at.) t h a t thehigh incidence was due togreater intake of Lathyrus by males couldnot becorroborated in the present investigation.It has been noticed that' both males and femalesof the families surveyed worked for the samehours in the field, and hence the other suggestionthat since themales only work in fields, theircalorie ' requirements , and so their intake ofLathyrus sativus would also increase, has not-been borne out.Summary

1. An outbreak of la thyr ism in three' districtsof this province has been described.2. Diet surveys of the affected familiesrevealed high consumption of Lathyrus sativusand low intake of vi tamin A.3. The sta te of nutri t ion was commensuratewith the calorie intake.4. A suggestion based on the field studiesregarding the cause of the disease has been made.

AcknowledgmentI amgrateful, to myassistant Dr. A. Bose tor helpinsme in collecting and analysing the data.

REFERKXCE3ArKROYD, W. R... and Indian J. Med. Res., 24, 667.

K R I S H N A N . B. G.(1937).

ATKROYD. W. R.. and Ibid.. 24, 419.RAJAGOPAL, K. (1936).

BHAOVAT, K. (1946) .. Ibid., 34, S7.CHOPRA, R. N\ (1938) .. The British Encyclopaedia oiMedical Practice. 1, 651.Buttenvorth andCo., Ltd..London.GEIGEB, B. J., STEENBOCK. ./. Nutrition, 6, 427.

H. , and PARSONS. H. T.(1933).HEALTH: BULLETIN* No. 23 The Manager of Publica-(1946). t ions, Government of India' ; '" Press , De lhi.

JACOBY, H. (1947) .. Indian Med. Gaz., 82, 53.L E W I S , H. B.. et al- J. Nutrition, 38, 537.

(1948).MCCAKRISON, R. (1928). Indian J. Med.Res., 15, '797.M C C O M B I B " Y O U N G , T. C. . Ibid., 15, 433.(1927). 'M E O A W , J. W. D., and Indian Med. Gaz., 62, 299.

G U P T A , J. C. (1927).

j M E I J A X B Y , E. (1930) . .Idem (1934) ..

M I T R A . Iv. (1940)M O O R E , T. (1933)JN U TR IT IO K A D V I S O R Y

COMlflTTEIO (1944).

S H O U R I E , K. L. (1945) . .S L E E W A X . W. H. (1S44).

S X O O K . L. C. (194S) . .

Brit. Med. ./., i, 677.Nutrition and Disease.

Oliver and Boyd, London.Indian J. Med. Res., 27, 887.Biochem. J., 27, 898.Report of Sub-Committee onNutritional Requirements.Indian Research FundAssociation, Tsew Delhi .Indian J. Med. Res., 33, 239.Rambles and Recollectionsoi an Indian Official.H a t chard and Sons,London../. Agric. West Auslrnlirt 25,47 .

She 3irt>ian riDebical (Sasettejfi.ftvINSANITY IN INDIA

(From the Indian Medical Gazette. October1899, Vol. 34, p. 373)

TH E following tables, compiled from thereports upon the Lunat ic Asylums of Bengal ,Madras and the Punjab, show the relativenumbers of lunatics in theasylums at the endof the vear 1898 : '

IdiocyMania(a ) Epileptic (b) Other formsMelancholia(a ) Epileptic(6) Other formsDementia(a ) Epilepticib ) Other formsMental stupor ..General paralysisDelusional insanityMot j'et diagnosed orcovered.

TOTAL TREATED

*

re -

! Bengal

25

396264167

126..2

of)DOr> S

: . | LOSS

' Madras

33

43453

4o

1124 .141

714

Punjab

34

335

S2

42451713

55S

From this table it will be seen that in all threeprovinces the vast . major i ty of lunatics sufferfrom acute or chronic mania. Idiocy isapparently least found in Bengal asylums andmost in the Pun jab. Th e proportion of insanitydu e to epilepsy is somewhat greater in M a d r a sand Punjab than inBengal. Forms of dementiaappear much less common in the Pun jab .