Lathyrism India Field Study McCombie Young 1927 L

7/29/2019 Lathyrism India Field Study McCombie Young 1927 L

1/18

452 A Study of Renal (Edema.2. In twocases primary retention of water seems to have been thecause ofthe oedema.3. In the remaining cases it is probable that the dropsy wasof pre-renalorigin, due to abnormal capillary permeability to wa t e r and salt.4. Of the latter, one patient exhibited the features of pure lipoid nephrosis,and three those of nephrosis complicated byinflammatory renal changes. Incom-

plete investigations on another case pointed to a condition of pure nephrosis.In the remainder the findings indicated degenerative 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 Col lege, Lahore, for allowing us tomake use of his laboratory, to Dr, Raghbir Singh, Clinical Pathologist to theMayo Hospi ta l , formaking the blood urea est imat ions, and to Drs. MohammadYusaf andFakharud Din for assistance during the investigation.

BENNET, I., DAVTES. D. T. andDODDS, E. C. (1927).DYKE, S. C. (1924)ELWYN, H. (1926)EPPENGER, H. and STEINER(1917).EPSTEIN, A. A. (1926)

KENDALL, E. C. (1919)LEIBOFF, S. L. (1924)LOEB, L. (1923) ..MACLEAN, H. (1924)MCNEE, J. W. (1922)MAYRS, E. B. (1926)STRAUSS and GRUNWALD(1927).VOLHARD and F AH R (1914) :.DE WESSELOW, O. L. V. (1925)WHITEHORN, J. C. (1921) ..WIDAL, AMBARD and WEILL(1912).

REFERENCES.Lancet, I, p. 3.Quart. Jour. Med., X V I I I , p. 77.Arch. Int. Med., X X X V I I I , p, 346.Wein Klin. Woch., XXX, p. 77. Quoted by de

Wesselow (1925).Jour. Amer. Med. Assoc, LXXXVII , p.913 (contains

references to previous work).Endocrinology, III , p. 156.Jour. Biol. Chem., LXVI, p. 177.Medicine, II, p. 171.Modern Methods in the Diagnosis and Treatment f

Renal Disease, London.Jour. Path, and Bad., XXV, p. 425.Quart. Jour. Med., XIX, p. 273.Quoted by Beaumont G. E. and Dodds, E. C. (1927).

Recent Advances in Medicine, London.Die Brightioche Nierenkrankheit, Berlin. Quoted bde Wesselow (1925).Quart. Jour. Med., XIX, p. 53.Jour. Biol. Client.,XLV, p. 449.Sem. Med., XXXII , p. 361. Quoted by de Wesselot(1924). The Chemistry of the Blood in Clinical]Medicine, London.

A FIELD STUDY OF LATHYRISM.BY

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

' Karya matra, pir pisanUsk.e khae, gor nisanHale chandi, matke kidYe dekho 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 inNovember, 1926, to examine in the field the epidemiological and clinical aspectsof lathyrism.Bundelkhand and Baghelkand in Central India, being areas in which alarge number of cases had been located, were selected as the venue of the investi-fation, 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 motoring

road.REW A, General .Rewa State, the scene of the greater part of these observations, is a treatySlate in the Baghelkand Political Charge of the Central India Agency, of whichcharge it is the largest and most westerly State. It has an area of about 13,000vjuare miles, about the size of Bulgaria. A range of hills divides it into two'^natural areas. One, thenorthern area, consists for the most part of an uplandl*Duvial plain, the ' Uparihar/ about 1,000 feet above sea-level, which is continuousthe main Central Indian plateau; it is open cultivated country, with a^Population of 176 per square mile. southern area consists of hills which culminate in the peaks in whichSone and the Nerbudda rivers. It is forest-clad, has a population of( 453 )


2/18

454 A Field Study of Lathyrism. I72 per square mile, and is less fertile .than the northern area, cultivation hejj,,for the most part confined to the valleys of st reams.

In the plateau, 85 per cent of the population are HindusBaghels, Rajput,and lower castes, while in the hills the population are chiefly animist hillmenthe Gonds.

The average rainfall in the ' Uparihar ' is 42-2 inches: a maximum of64 inches was recorded in 1894, and a minimum of 26-34 inches in 1905, whichwas a year of shortage of crops and of famine.

With the except ion 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 the years of normal rainfal l it is self-supporting as to cereals, and exportgrain in considerable quantities, and only in a year following a failure of themonsoon rains is the normal outflow of grain exports replaced by an inflow ofimported 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. Apart ' from these, unmetalled roads and villacart t racks are conspicuously lacking, and owing to this lack of communicationthe villagers of the interior live in the circumstances and under the economicconditions which have prevailed since time immemorial. They are dependantfor their food supply on their own resources, and the shortage of food-grainjwhich 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 inthe subject under consideration.

The land owners are Brahmins, Baghels, Rajputs and others. The fieldwork is done by labourers, the harwahas, who belong to the lower castes, Kol%]Chamars, etc. With the field labour is associated a form of economic bondage,"^the ' harwaha' or ' lugwa' system, which is relevant to our subject. ^

A 'lugwa' is a low caste labourer who having incurred a debt of some]Rs . 60 to Rs. 80 by extravagant expenditure on a marriage ceremony, or suchjlike, has pledged the services of himself and his family to a landowner until sudljtime as he has paid off his debt. His master, in return for these services-guarantee*his bondman's food and clothing. The food is a ' kliawai 'a payment in kind olja daily ration of such foodstuffs as are available from the ' kharif ' and ' rab Jcrops and as may be expected under these circumstances, the ' lugwa's ' ratioOjconsists of the cheapest grains. It is unvaried and monotonous and they are 1first to feel the stress of scarcity.

Grazing grounds are abundant in area, al though poor in quality, and the catare small and degenerate. In a Hindu State none are killed for food, andeffort is made to control their reproduction or to eliminate the unfit. The avera^-,village cow yields only about \ seer of milk per day. Only the better classes dru*|milk or consume dairy products, and litt le enough at that ; and such of the poorei|classes as have cattle collect their milk for the preparation of ghee, which, bareasily portable, is sold to obtain the money which pays the land revenue of tlState. The only milk produc t which is consumed by them is ' matha 'butmilk. There is a noteworthy scarcity of fruit and of the leafy vegetables wi

T. C. McCombie Young. 455are cultivated and used in other parts of India, and only the better class villageinmilv obtains at rare intervals and on feast days some green vegetables, whicharc uiown and hawked by itinerant ' Kachhis ' or vegetable-sellers. Mangoprove- abound, and the mango in its season as the green or ripe fruit, as a decoc-tion called ' panna,' or a dried and powdered condiment' amchur,' is largelyucl. Mahua flowers are also used to a small extent in the ' Uparihar,' but theirv u , , u c fresh, fermented, or sun-dried,is greater among the Gonds of the hilltrad-, wb l' ve nn a variety of other jungle products which include the leafyvegetables. The Gond, unlike the orthodox Hindu of 'Uparihar ,' does not growam appreciable, quantity of Lathyrus (Rciva State Gazctter, 1907), and lathyrismis unknown among these hillmen.

Agriculture in Rewa.As has been noted, the Rewan crops are entirely dependant on rainfal l.There are no irrigation canals. A primitive water lift, the ' Dhenkuri,' is

used to irrigate from small kutcha wells the exiguous patches of green vegetables,tobacco, or sugar-cane, raised by the ' Kachhis,' but of the agricultural irrigat ionof the cereal crops from wells, as practised elsewhere, there is none. To conservethe rainfall and keep the fields moist enough to yield a ' rabi ' crop, earthen banksstyled ' bndhs ' are thrown across the lower ends of sloping fields to retain inthem as much moisture as possible. The Rewan farmer recognises several kindsof soil, to which frequent references were met in one's wanderings. Thus, therei> the ' Mair,' a rich dark loamy soil, retentive of moisture and fertile in the autumn. ' 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-: al)lc tor both ' rabi ' and ' kharif ' c rops, while there are other poorer soils, suitable* | only 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

ISf' tt l ' kharif ' crops are as follows:Rice .. . . .. Oryza sativa.Saman .. .. . . Panicum frmnentaceum,Jo war . . . . . . Jorghum vulgre.Kakun . . . . . . Sitara itlica.Bajra . . .. .. Pencalara spicata.Kodon . . .. . , Paspahim stoloniferum.

i Urad . . .. ., Pliascolus radiiaius.1 Mung > # _ _ Phaseolus mungo.\ Arhar . . ,. ., Cajanus in die us.

*"des non-cereals, such as cotton and oil-seeds. Of the above list, the poorer">es use Jowar, Bajra, Kodon, Saman and Kakun, and the rice is for the most[ appropriated for the use of the well-to-do.

k f e c r o P s a r e sown during the rains; much ploughing is done while rain^ j ^ a in' an t ' t ne wettings and exertion the ploughman then experiences oftenywernune the onset of lathyrism, as we shall see later.

J ,*a 1 3

. the


3/18

456 A Field Study of Lathyrism. T. C. McCombie Young. 457The pulses ripen in August and September, and the cereals, Kakun andSaman, ripen first about September or October, followed by Kodon, Bajra. rict/f|and last of all, Jowa r in Novem ber. The method of preparat ion of these cereal^for food is relevant to this enquiry.Kodon is husked w ith the ' chakara '. a soft grin d stone m ade of sun-dried!clay held together by rice husks. It is then cleaned in the ' supa ' or winnowinrl

basket and pounded with the Musal (the pestle) in the ' kari ' or mortar, and *husk' kanna 'is given to anim als or m ay be eaten by poorer classes,resulting gram is known as ' Kod ai.' This is washed and boiled, like rice, fceating a s ' Kodo ka bhat ' and the thick rice-water in which it is boiled, is fed (Jcattle.Saman and Kakun are similarly treated, Jowar and Bajra, after beiitrodden by oxen, and winnow ed, are gro und in a h ard stone C hakki and .tresulting whole m eal is cooked over a girdle (' Taw a ') into a girdle cake' roti.' Rice is reape d in Octo ber, trodden in the ' Kalihan ' and winnowedthe ' supa.' The gram is husked in the ' chaka ra,' shaken in the ' supa '^separate the outer husk, which is used to consolidate clay for bricks. Theat this stage is known as ' Bag ri.' It is now pounded in the ' musal '' kari ' to remove part of the pericarp. It is now ' Chawal/ and the br' kanna ,' is given to animals . It is not polished or parboiled. It isboiled, in the usual manner. It will be seen that a very varied selectioncereals is available from the ' kharif ' crop for the use of the lower classes,that its method of preparation is not such as seriously to lower its vitamin contAt this time of year, the poorer classes use small quantities of green leavof a wild plant, ' Chakaora,' which grows in the rains and is gathered and useAugust and Septem ber while still soft. It is eaten with salt, condimentsvegetable oils.

No othe r green vegetable food is available until ' Chuna ki bhaji ' comes Ugeneral use in Decembe r. This con sists of the green shoots of the young ChtJplant, gathered when it is big enough to admit of the young shoots being ' praneby being nipped off by the finger and thumb. This preve nts the plant gestalky and induces a branchin g which improves its yield. These pruningseaten raw with salt, or cooked, or dried for storage, and appear to be a valuasource of vitamin A, see later.Common salt is used by all, as required. The vegetable oil, mustardand 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 co nsist of the following :W heat . . . . . . Triticum aestivwn.Barley .. . . .. Hordum vulgre.Ma tra . . . . .. Lathyrus sativus.Chuna . . . . .. Cicer arietinum.Masuri . . . . . . Brvum lens.

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 through a tube ('n al i') attached to theplough, through which the seed is dropped into the furrow. It is thus easy todistinguish what is sown intentionally and what is self-sown ( 'la m er ' ). Matra(LiUhvrus sativus) is sown with the wheat, as a precaution against the wheat(ailing to germinate in a dry year, in which case only the matra comes up . It isalso very largely self-sown. The re sulting crop of such an yield of mixed sowingis known as ' berra ' and consists of a mixture of barley and matra(jao berra)or wheat and matra, or wheat, gram and mat ra. The wheat and barley havingbeen trodden and winnowed at the 'Ka lih an, ' is ground in the hard ston'iChakki. The coarser parts of the pericarp a re removed by sieving through a' Chhanni/ the bran being known as ' Ch oka r/ but much of the perica rp rem ainsin the flour which is eaten as a ' roti,' and the vitamin value of the seed doesnot appear to have been much impaired in the process of preparation of the flour.

Lathxrus sativusstyled matra and batra in Rewa, and variously known inIndia as ' kesari,' ' teor a/ etc., has now to be considered.The ' karya m atra,' o r black pea, which is the only variety of L. sativusgrown in Rewa, is the large-seeded dark-coloured variety which grows on uplandwheat land. If the seeds are sm all, the diminutive ' matri ' is applied to themvariation in colour yields another distinction , ' Bhura m atra 'which is of slightlypaler hue, and if the seeds are much flatte ned, it is called ' chipta ma tra.' Allappear to be substantially the same stuff. ' Goliya matra ' is the seed of anotherlegume which 1 have not been able to identify but it is a close relative of ourgarden pea. It is grown in the Cen tral Provinces in Damoh and Saugor, whereit is called ' batra ,' and there is used as a ' dhal ' but not as a ' roti.' ' Bagalpurimatra ' is the name given in R ewa to the small-seeded pale-coloured Lathyrussativus grown on rice lands of the Gangetic plain, which is imported duringfamine years. It is not grown in Rew a, and is not seen there in normal years.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 ' rabi 'cereals,of the general population in years of scarcity. The labouring manlikes it ; he considers ' matra roti ' to be ' filling at the price ' and thinks its energy-yielding value to be considerable. An Abair (R ewa ) kah awat exemplifies thisriew :

Matra .ki dhal men dal de hing,To reng dale Sambhar ke sing.Translation: ' Only put a dash of asafcetida in the dhal of matra, and even adried sambhar's horn will (come to life and) walk.'It is considered to be 'humble fairin ' and a Brahmin patient will not readily^n, ' coram publico,'. to its extensive use in his own household. W hen ques-t e d 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? on the faces of the listen ing audience , and from


4/18

458 A Field Study of Lathy rism. T, 0. McCombie Young. 459a knowledge of the paucity of such fare in the famine year in which, perchancethe case had developed.Those who can afford to be more fastidious in their feeding consider tlir' matra rod ' to be hard, difficult to masticate, and indigestible, while 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 circumstancesit never reaches one-third to one-half proportion of the diet, which Buchanan andother observers agree to be dangerous. There are areas, however, where itspredominance in the crops entails its being eaten in large quantities mixedwith wheat or barley as a ' roti ' {see notes on Kotar, where the amount omatra eaten is large, and the number of cases is considerable). For eating,matra is ground, unhusked, in the ' Chakki,' to form a yellow flour which isbaked into a ' roti,' eaten without 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 shelland turns out the yellow hemispherical endosperm, which is separated from thehusk by shaking in the ' supa,' and boiled and eaten with rice.Thus matra, and now for its ill effects.

CLINICAL. \The clinical manifestations of the disease have been recorded in great detailby earlier observers, who had, moreover, the opportunity in famine years, of;seeing large numbers of cases, of recent origin. Continued search has, in ^course of this investigation, revealed only 13 cases which occurred in 192


5/18

460 A Field Study of Lathyrism.relieved the monotony, such being beyond their mean s. Occasionally the ' nichthmatra ' or unmixed lathyru s, might be varied with a ' berra,' a m ixture of wheatand lathyru s, or ' jao be rra,' barley and lathyrus, in which lathyrus would pre-dominate. Another mixture, that of two legumes, gram and matra, seemed parti-cularly noxious, and the ' jao berra ' seemed more dangerous than the wheat berra.A fifty-fifty mixture seemed to be the dangerous proportion, which agrees withBuchanan's observations (Buchanan, 1904). It was interesting to contrast thi*pre-lathyrism diet of the poorer class patients with that of the household of thdremployers, the Brahm ins. Thus, in a Brahmin landowner's household of 6 persons ;4 adults and 2 children, with two lathyrism-la me ' lugwas,' all eating the 'same matra , about 5 seers of grain would be used daily. The basis of thejmorning m eal w ould be a ' roti ' of wheat and of th e evening m eal ' dhal ' and *rice, the ' dhals ' being of various pulses, among them lathyrus, which would bo]used in April, May and June, at other times ' arhar,' ' mung,' etc., would take tplace. This household had 7 buffaloes and 12 kine. About l i see rs of mfland 1 chhatak of ghee was used da ily, the rest of the ghee being kept for sale.']The buttermilk was used in the household and issued to the 'lugw as.' No fruit!was consumed except mangoes in their season, and green vegetables would occasioo*1ally be purcha sed from a Ka chhi. The wild vegeta ble ' chorai ' would be'gathered and used in its season. Pum pkins , rhuiya, etc., ' chuna ki bhaji ' in itliseason, salt, and other condiments, vegetable oils, and mahua flowers, fresh and idried. Con trasting the diet of a family of a caste and station of life which:ordinarily escapes lathyrism except in a famine year, with that of the low caste:lathyrism patient, one is struck by the absence from the diet of the lathyrisn^cases of the substances known to be rich in fat soluble A, viz., milk, butterthe fresh green leafy vegetables.

Mode of Onset.It is known that an attack of fever may precede the appearance of the sym]>|toms of lathyrism . 14 out of 51 cases gave a history of an attack ofintermittent 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 treatm ent, ' upas ' (ten da ys' starvati

which is ordinarily the village treatment of malaria), are suggestive ofhaving been the cause of the fever. Thre e cases gave a history of an attackdysentery h aving been an imme diate anteced ent of their lameness, one ofattack of smallpox, while in another, a medical man gave me a definite diajof pneumonia having been an antecedent. In ten cases, in whom no feveroccurred, an exposure to cold or wetting, or unusual exertion had been an immedianteceden t. Thu s one man had been on ' begar ' (forced l abour) on a ' sarfabund with short rations, for eight days, with rain falling. Another had bweeding a rice field in two feet of wa ter or pl anting ' singhara nut ' in aroofing a house, chasing run-away ca ttle and so on. The onset is always draitically sudden and unusually unheralded by prodromata. A typical history wobe that -the patient had had a heavy day's ploughing in heavy rain and had ta

T. C. McCombie Young. 46 1shelter and sat clown under a tree . O n getting up he found himself unable 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, with cold and shivering seizedhim. He went home and lay up for four days . He got up and went outside toobev a call of nature and tried to jump a gap in a bund. He fell down, could notrise again and was brought home by his moth er. In a very few cases prodromalsymptoms of tingling and numbness, pins-and-needles feeling in the legs, or painin the 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 thesigns and symptoms of a spastic diplegia.In none of the cases were there any symptom s of mental impairm ent. Speechwas 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. Impa irme nt of the tactile andpainful sensation in the lower limbs was always absent and so also was oedemaor wasting of the muscles of the lower limbs. The superficial reflexes, crem asteric,abdominal, and epigastric, were often hard to elicit, and in some cases seemedabsent. The knee jerks were always present and exagg erated , and sometimesa ta]) on the ligamentum patellae would set up clonic spasms of the lower limbs.A tendon jerk could usually be elicited by tapping the adductor tendons, thetcntio achules, and the ham string tendon s. The p lanta r 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 it wasflexor in type. Ankle clonus was present in nearly all cases. In extreme casesthe sphincter control may be lost at the onset but is regained late r. Sexualpotency is retained. Romberg's sign was always negative.

Electrical Reactions.In such cases as an opportunity of testing the response of the leg muscles tothe Faradic 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.

'^ ne gait >s v e t 7 characteristic and has been very fully described by earlierobservers." The writer found it most easily understood on the hypothesis thatthe disease is a lesion of the upper motor neurons, whereby the influence of thecerebral cortex in correlating the actions of different muscle groups has beendisturbed, and the control of the postura l reflex removed. Thi s, 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^^r po the abductors of the thigh..


6/18

462 A Field Study of Lathyrism. T. G. McComb ie Young. 463The. latter disorder furnishes the earliest sign of the disease, which can Idetected 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 termswhereas the lathyrism case, owing to adductor overaction, walks on a linear foottrack, as if he w ere walking on a rail. He has no difficulty in heeling and toeinga line, unless rigidity and weakness interfere (Plate X LV I, fig. 7).The next thing that attracts attention is the progression with slightly bentknees, owing to overaction of the hamstrings.Overaction of the gastronemius and soleus leaves the toes on the groundwhen the heels have left it and leads to a dragging of the toes as the foot isadvanced. In th e effort to achieve this movement, the pelvis is tilted, while tomaintain the balance disturbed by the linear foot track, the head sways from sideto side. Tho ugh a slight case may walk unaided, one stick or two sticks may berequired, according to the degree of disability. In more marked cases adductorspasm 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 thepatient walks like a ballet girl on tip toe (Plate XZLIII, 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 asitting position with wooden hand supports (P'late XLJII, fig, 1).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 recumbentposition.The degree of disability varies from the slightest possible malfunction indi-cated by a bent knee and a linear foot track, to one in which the patiert 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 condi-tion of such cases has not been recorded and the field notes may therefore begiven in full. Notes on Cases.

Case. No. 46.Ram Das, male , age 30, caste Gosain, vil lage Kotar . A professionbegg ar and lives on the alms of food gra ins wh ich he collects. His moth er is also a lathynsflcase of old standin g. He got lame 7 year s ago (in 1920a famine yea r) in the month ofSawa n ( July -Au gus t) . After an a ttack of fever which lasted some days he fe lt some panin the back and the legs. He awoke one mo rning to f ind himself tota lly unable to walk, andhas remained so. No hist ory of incon tinenc e of urine or fieces could be elicited from him.Before he fe ll i l l . he was ea ting a mixture of matra and barley got as a lms in the village .Present condition:He is totally unable to walk and crawls in the seated position withw oode n ba nd ' s up por t s . K ne e j e rks H \-. Ank le clonu s prese nt in both feet. Plan tar reflex _active and markedly extensor. Tendon jerks obta ined in tendo achules , adductors and

hamstrings of both legs. There is much spasm of the adductors , the thighs cannot be separa ted,nor can the knee joints he extended much beyond a r ight angle . The re is much wasting ofthe thigh and calf muscles. No analgesi a or anaesthesia of lower limbs. Cre maste ric reflexnot e lic ited, abdominal and epigastr ic reflex not obta inable as contrac tures 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 s tra ight, and the fac ia l movements are complete .So tremors or a taxia of the upper extremities .Case No. 22.Sepaiya . male , age 45, caste Chumar, pensioner a t Sutn a Lkne W ork s,where he was a coal breaker . Has been lame for 15 year s or so, being first attacked in themonth o A sar. The his tory' is tha t he f irs t got a pain in the lumbar region and found thatbe was unable to walk over uneven ground. This gradually increased and by O ctober he foundthat he needed two sticks to walk, when he came to the Lime W ork s as a coal breaker. Thenpins-and-necdles sensations began in his legs and he found himself unable to s tand uprightor to walk without ta il ing, so he took to crawling. These fee lings disappeared, but theinability to walk has remain ed W hen at his worst, he had some troub le in retainin g faecesnd urine./>iV/For three months betre getting il l , he was ea ting a bread of la thyrus and barley,the fermer predominatin g. The bread was prepared by making a f lour of the pea and eatingil without separa ting the husk. Buttermilk was drunk with i t , but no ghee , milk or greenvegetables were obta inable . He continued on the die t for s ix mont hs after f irs t ge tting lame.

'resent condition :He crawls in seated position, with fee t, buttocks and hands on thegrutuid. His genera l health is fa ir ly good, bowels regular , and no incon tinence of urine and(ces His lower l imbs are wasted, the range of passive movements a t the knee joints is to apoint -40 short of full extension, owing to contrac ture of the hamstring muscles . Theknee jerks are present, but weak. The add uctor muscles are jcontrac ted, and abduction ofthe thighs is very limited. An abductor jerk is e licited by tapping the abductor tendo ns.Ankle i-lonus is present. The pl antar reflex es are very' dull but an exten sor resp onse ofthe great toe was elicited in the right foot. Superfi cial reflexes, epigastric, abdo mina l,crcnia>teric and gluteal not elicited. Th e scapular reflex was obtai ned. Th ere is no anaesthesiaor analgesia of the lower extremities . No trem ors, no impairment of the mov ements ofK hands and arm s; nystagmus absent; fac ial and lingual mov ements unimpaired.Electrical Reactions:-With the Faradic current, in both legs some contraction wasuliuincd by s timula tion of the motor points of the Tibia lis anticus, Peroneus Longus, Adductors ,ami Quadriceps Extens or, Semimemb ranosus, Semitendenosus and Biceps.Ko reaction in the Gastrocnemius and Soleus over the motor points but some movementas observed with the electrode over the Sciatic nerve below the gluteal fold.This case i l lustra tes the complete crippling produced by continuing with a la thyrus die tafter the f irst symptoms have appeared. The e lec tr ica l reactions indicate an upper motorneuron lesion even in an extreme case such as this (Pla te XLIII , f ig. 1) .Case No. 27, is an example of an extreme case , just short of the crawling s tage .Chida , male , age 30, ca^te Kol, occupation, was a hurwaha. He g ot lame in a year oflamine, about 12 year-; ago when the crops failed and no grain was obtain able locally. W hea twas then 4 seer:, to the rupee and matra was 16 seers to the rupee and he had to eat this.He obta ined it from Su tua Bazar and it was Bagalpuri m atra , imported gra in. He couldelv es. No green vegetab le food was withi n his mea ns and the only flavouring*wh this ' roti ' was common sa lt . This matra die t was continued ti l l Kuar (Octo ber-November) when he got Kodon, and Dhan and other food. After a day a t earth-wo rk* a bandh in Sawan (Aug ust-Sep tember) he was sleeping on a charpoy outs ide . A ' ba d'* 'ind struck him and when he woke, he found himself u nable to wal k. He had no feverno pain anywhere .Oaii.Uses two sticks as he drags his trembling legs a long, with fee t turned in and toes;ng a long the ground. The knee jerks are much exagg erated and a tap on the pate llar" se ts up c lonus in a ll the leg muscles , which has to be controlled by his hands. Markedo the f lexors and adductors , which can be overcome by gentle passive pressure .

B


7/18

464 A Field Study of Lathyrism.Ankle clonus is marked and continues after the examining hand is withdrawn. The plantareflex is very active and extensor in type. Much adductor spasm and limitation of abductionwith adductor tendon jerk, ditto in hamstring muscles, which are thrown into a clon'contraction by a tap on their tendons. No marked muscular w asting or trophic changes 'legs. No anaesthesia or analgesia of lower extrem ities. The re is no appreciable impairmentof the functions of the hands and arms. He can grind the family grain, but a slight chorcicmovement of the arms was noticeable. Nystagm us was present, and the pupillary reactionto light was doubtful. He has a little difficulty in retaining urine when the bladder is fui)but no incontinence of faeces. He claims sexual potency and has one child 3 or 4 years oldThe nystagmus and slight choreic uncertainty of the arm movements are unusual featuresin this case.The history of his diet illustrates the state of affairs in a famine year (Plate XLIV%. 2) .Case No. 25.-Lall Mun, male, age 30, Chatri, cultivator, he got ill 18 years ago in thefamine year of ' Chhappan ' in the month of Asa r. He got fever, then the eruption of small,pox came out. Some 15 days after that, he fell down when at stool and got up to find himselflame. 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 matr a, which was 12 seers per rupee and wheat 5 seers. Matha was obtainabkfrom others but he had no cows of his own.Present cotidition:A well nourished stalwart man, who walks with a marked equinusposition of the f eet. On the mo rning 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 footis neither inverted nor everted. Knee jerks + + . Much spasticity of calf muscles and somespasm of adductor m uscles. The pla ntar reflex is extensor, there is marked ankle clonus andthe tendo achules tendon reflex is very active. An adductor tendon jerk is elicited by tapping,the 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 h'mbs.Reactions to Faradic current.A ll muscles respond; the response of the T ibialis Anticujis 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 village.She got lame inBhadon (A ugust-S eptemb er) of 1926. No fever or illness preceded hiappearance, and she had been going daily to weed the 'kharif ' crops during the rainy season.when a slight uncertainty of her gait was noticed by others. At this time she was ealinfthe matra-barley berra of Kotar, in which lathyrus predominates, as a ' roti ' in the morning,and in the evening, Bhat (boiled rice) with a ' dhal ' of matra (lathyrus) . W ith the 'roti 'she was getting1 'ma tha ' (buttermi lk), and mango ' panna ' during the mango season, but nowhole milk or ghee, and no ' chorai ' or other green vegetable food.Present condition:A comely well nourished adolescent girl who has not yet gone to her husband's house; menses normal.Qait,A little jerky, with a linear foot track. She can heel and toe a line with*,any difficulty and can walk on her heels with the toes raised. There is no ataxia. Toeknee jerks are present and somewhat active and there is a little ankle clonus. The thigo* ^can be fully abducted. The pla ntar reflex is inactive, but extensor in type, tapping the tendo achules elicits a slight contraction of the calf muscles, and so also in the adductors. No|tendon reflex in the hamstring m uscles. No anaesthesia or analgesia in the lower extremities "No nystagmus or symptoms of cranial nerve impairment.E P I D E M I O L G I C A SThe following notes deal with the circumstances of Kotar, a village locaujjknown as ' Lungra ' or ' lame ' Kotar, on account of the prevalence of l h a f l j

T. C. McGombie Young. 465moiifr its inhabitants and those of adjoining villages. This area well illustrate sthe conditions under which lathyrism prevails, and as such may be considered in

d c t a l L ' L U N G R A K O T A R . 'The village is some nine miles east of Jetwar station on the G. I. P. Railway,w-itli which a cold weather ca rt track connects it. It is situated on a hillock, and puiped round a ruined Eaghel fort, which is said to have been built byllabaraj Bhao Singh in 1675, and has for many generations been abandoned.The environs of the village show evidence of departed prosperity in the shape ofnumerous large tanks, now used for washing clothes and bathing, which doubtlesserved the needs of a population considerably greater than that which nowutilises them. The village is within a mile or two of the To ns river and s urroun d-ing the hillock on which it is situated, is low-lying ground, along which thedrainage of high ground to the north of the village runs to join the river. Thislow ground is intensively cultivated by Kachhis, but the green crop which theygrew l>y copious irrigation w ith w ater raised by ' dhenk uris,' is not one of thecdihlc vegetables, hut of tobacco, which is grown for export, as its flavour is muchesteemed locally.Cattle are numerous, but as is the practice in Rewa, most of the exiguousyield o milk is utilised for the manufacture of ghee, which is sold to raisemoney to pay the taxes and only the better class families consume a portion of thedairy products of their own animals.The people are all agriculturists, and there are no industries of any sort.The ' Kachhis ' export dried tobacco, and ghee, and a little superfluous food grainis exported and these form the only outside sources -of income of the village.There is little circulation of money, and in the weekly bazar and in the bania'shops the peasants purchase their simple needs of salt, gur, and the cotton fabricsused for clothing, by bartering an equivalent value of the food grains of theirown crops. The ' kharif ' crops a re rice and Kodon, chiefly the form er, andthey appear to be somewhat scanty. The people of the poorer classes who aredependant on daily wages or on ' khawai,' a pay ment in kind, tell me that theyKvc from December to M arch on the grain of the ' kharif ' harvest, viz., Kodonand rice, and for the remaining eight months of the year on the cheaper grainsof the " rabi ' corps. These grain s are wheat, barley, matra, the pulses, masoor,etc., and a little gram.

On nearing the village and crossing the fields, one is struck by the preponder-ance of legumes in the growing crops. - 'There are a few fields of wheat and matra, of poor and stunted growth,*nd lxtrley and matra is more plentiful. The re are many field s of niasoor*nd a little gram, and in all these there is a superabundance of Lathyrus sativus*nich is also grown by itself or mixed with the pea called ' goliya matra,' which* more common here than what one sees elsewhere.In the low-lying fields in which ' kharif ' crops of rice are raised, there is annusual amount of Akri (Vicia sativa).As is the custom elsewhere, this growth is assiduously weeded out and fedthe cattle.


8/18

466 A Field Study of Lathyrism. T. C. McGombie Young. 467In the neighbourhood o the village, in the fields which are irrigated by thinundation from the north, the crops chiefly of barley and lathyrus are rich andplentiful. A novel mode of manu ring these fields prevails. The sweepingsfrom the west end of the village are dumped on the lee side of a culvert andcauseway which traverses the main line of drainage. W hen the floods come, anOthe water pours over this causeway the refuse is carried away and spread bvthese waters over the fields which they flood, and thus their fertility is effectivelymaintained. An inspection of th e fields suggested a predominance of legume*especially lathyrus, in the crops that they yield. An examination of the foodgrains used in the village and the accounts given by the villagers as to their dietconfirm this. The heaps of ' rabi ' grain 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 variety, the ' karya matra ' of the wheat uplands of Rewa,with a small admixture of ' goliya matra,' another legume.The com monest mixtu re is the ' jao b erra,' of barley and lathyrus , theproportions varyin g, but in all cases lathyrus forms the larger portion. Themixture of lathyrus and wheat is less commonly seen, as the amount of wheatgrown locally is small. As it is a valuable grain , for w hich there is a demandelsewhere, it is sifted out from the mixed 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 drunk during themango season, in May and J une . Usually 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'consum ption, 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- Ma y-Ju ne) by the Kachhis and is bartered in thevillage by them. It is generally eaten during 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 shortage, no one can afford to obtain it.The staple diet of a better class B rahmin household, while the ' kharif 'crop lasts, is, in the morning, a ' roti ' made of barley and matra, the latter pre-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 occurred in 1926. The proportionof lathyrus in the diet varies in inverse ratio to the affluence of the family, andthe poorer classes live for eight months of the year on an exclusive diet olathyrus (nichela matra) and four months on Kodon, with a little dhan andsome matra.Families in comfortable circumstances can supplement this diet with sonKmilk or ghee, and a little green vegetables, the poorer labouring classes have

r.one of the former, and little of the latter, except for such small amount ofchuna shoots, ' chuna ki bhaji ' which they obtain in the cold w eather. Fleshmeat is hardly ever eaten, even by those castes who indulge in it, except on therare 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 whichsurrounds the village.The population of the village in the last census was 1,774. all Hindus exceptthree, who were Mohamm edans. 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 quarter afflicted with lameness. The figures thus obtained w ere11C males and 26 females, total 136.On these figures it would appear that 7-6 per cent of the total population,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 ar an under-estimate.It appears, therefore, thai the description ' lame Kotar ' currently applied to' this village, is justified by the condition of a population , 12-8 per cent of whose; adult 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 exp lainable. Fro m the foregoin g notesas tu crops and diet, it will be seen that the population lives very largely on a.laihyrus diet, which is the predominating food grain in this area. A local kahawatexpresses this dpendance on lathyrus in rhyme:' Matra ki roti, matra ki dhal,Matra hi pati rakhan har.'which may be translated as follows :' Bread of matra and matra as dhalMatra indeed is the guardian of all.'Possibly the b arley-lathyrus ' berra ' which they use is a m ore d angerous

diet than the wheat-lathyrus more common in other Mouzas of the Rewan' Uparihar ' and the lack of variety and the comparative shortage of the " kharif 'crops of Ko tar may also be an unfavourable factor.The villagers say that in former years they grew much more matra thanthey do now, and that this was the cause of the excessive lameness and of theepithet ' lame Kotar,' and they recall that in the famine years, to which all the olderd more seriously affected cases refer the onset of their complaint, nothing butfctra grew.Under present-day conditions, a small annual crop of mild cases is occurring.foe cases were reported to have occurred in 1926, of these 6 cases were seen andgnosed as lathyrism. O ne was absent from the village, one was not a caseL^k&yrism but of injury, and a third was of doubtful causation and may have|*cen syphilitic, 5 cases of 1925 were seen.


9/18

468 A Field Study of Lathyrism. T. C. McComb ie Young. 469Owing 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 is ajpresent fairly plentiful, the 1925 and 1926 cases were comparatively few, andtheir symptoms light. Nevertheless the amount of lathy rus in the diet of uu,community is unusually large and to this fact coupled with the poverty andprimiti ve mode of life, and th e lack of the protectiv e foodstuff in their diet, 1would ascribe the unusually large number of cases of lathyrism in this village.

A B A I R V I L L A G E .Abair is a village some three miles east of Ko tar. Its fields show the samepredominance of legumes in their crops, particularly of lathyrus, and the village;diet shows the same features, namely, a large proportion of lathyrus. Tbejvillage population consists cf 1,480 perso ns, 715 males and 765 females, and,there are 71 males and 7 females affected with lath yris m, i.e., about 10 per centof the male population and about 10 per cent of the female population?K U A N V I L L A G E .Kuan village, in this neighbourhood has a population of 393 males and399 females. Ther e are 53 males showing sy mptoms of lathyrism, and]

12 females, i.e., 13-5 per cent of m ales and 3 per cent of fem ales. All oldcases.A M I R I T I V I L L A G E .Having noted the prevalence of lathyrism.in Hindu communities who subsitjon a diet in which lathyrus predominates and the protective food substances rtjlacking, it was now thought desirable to investigate, as a control, the prevalent]or otherwise of lathyrism in a community using lathyrus in the diet and lmnunder sim ilar conditions, but w ith the addition to their diet of the ' protedhfood substances.' It was thought that a Mohammed an village should yield satinformation, and although such are few in Rewa, a scrutinity of thereturns showed that one such village existed, viz., Amiriti, a remote agrievillage in the Huzur Tahsil, containing 464 Mohammedans in a total poptLof 597. This village, was, therefore, visited for me by Sub-Assistant SurJ. P. Shuk la, and the following observations were recorded by him :

' The fields contain wheat, barley, gram and matra cro ps. The p r C j -vof matra is about one-fourth to one-sixth of the total crop and several JOfields of goliya matra were observed. A ' berra ' of m atra and otherin the form of ' roti,' is eaten here, as elsewhere, as the staple diet, withand masoor dhals ; vegetables are eaten once a fortnight. The village isbank of a river, and fish, caught by netting, is eaten every second day throngthe year. Flesh meat is also eaten, mutton, and goa t's flesh, also flesh oiAhares, tortoises, crabs, etc. $fLittle ghee is eaten although some families use it. the custom beingand sell the ghee to pay land rent.There are 118 houses in the village, with a total population ofMohamm edan males and 260 Moh ammedan females. Th e rest are K

f chaman who are ' lugwas ' of the cultivators. Five persons are reported to bef jjjne, three females and two males. Tw o Mohamm edan females have been lame since birth or early childhood and a Kol woman has a fractured leg. Of thew 2 male ca.ses, one. a Mohammedan, became lame 12 years ago after smallpox.He was not examined, but his gait with widely spread foot-track was not thatof lathyrisni. The second has a sinus in connection with the knee joint. Th ereare no old lathyrism cases of the famine year in this village. In 1897 when theiood grains were short, they supplemented their diet with fish and game, andthe superfluous cattle were probably killed off and eaten ' (although this wouldnot be expressly admitted in a Hindu State).> The ' lugwas ' in ordinary years share in the flesh diet of their masters, andI none of them have ever developed lathyrism even in famine y ears.'' The state of affairs in this village as compared with Hindu villages is signi-ficant. Matra forms as large a proportion of their cereal crops as it does in theHindu villages, but it would, in Rewa, be almost impossible to find a HinduTillage of this size which is free from some cases of lathyrism . Its im mun ityg. teems to suggest that a better balanced diet with a higher vitamin content enables^population to use lathyrus in considerable amount without harm accruing. 'DIET AND LATHYRISM.It will be seen that nothing has come to light in this investigation whichcasts any doubt on the age-long experience of the human race that a lathyrus diet' produces lathyrism. The kah awat w hich heads this report was related to thewriter by an intelligent peasant in a Nagod village and embodies their experiencethe results of eating matra.Ample confirmation was also obtained of Buchanan's dictum that a threeiths' diet of one-third to one-half of lathyrus is dangerous.This, however, is not the whole story ; for many there be who eat lathyrus,_o do not get lathyrism and it seems from these investigations that certain^conditions. of nutritional instability are important, and perhaps essential factors the production of the disease.It has been shown that in the diet of the Rewan peasantry the green leafytables and dairy products are conspicuous by their absence. Durin g the dry

. weather months green vegetable food for man is lacking and the cattle arestarvation diet, meagrely fed on the few pickings they can obtain on there lands, supplemented by dried fodder, the straw of the ' rabi ' crops.*t milk they yield is presum ably deficient in A. Th e supplies of v itamin Athe human diet, ordinarily small, are in this period especially in defect, andare the months from April to September w hen the ' rabi ' crops are the~e food, and the poorer classes, and, in a famine year all but the richest, live lathyrus diet. July is the month when a period of three mon ths of lathyrus' u *ccomplished, and the lathyrism cases begin to appear.Moreover, in a year of deficient rainfall and famine, when such cases aren>ns, the ' kharif ' crops, normally varied in kind and plentiful in quantity,1 which the poorer classes depend for their nourishment, have been inadequate,


10/18

470 A Field Study of Lathyrism. T. C. McComhie Young. 471and the population, especially the poorer classes, who suffer most from latlivr"has been exposed to privation, malnutrition, and vitamin depletion, and are 'condition of grave nutritional instability, caused by a diet deficient in fat-solub|e \Some evidence in regard to the existence of an avitaminosis of A is afford!by certain facts that came to light regarding night blindness in association withthe prevalence of lathyrism.

McCollum (1925 ) states that 'th is is a condition w hich seems related to fdeficiency of fat-so luble A in the diet of man .' He r egar ds it as 'a specific isyndrom e of dietary o rigin ' and suggests that ' a diet derived too largely from!cereal products, tubers, and other foods having similar deficiencies, inducenlowered vitality which becomes manifested, among other ways, in faulty visionjlMy observations indicate that this condition is very common in Rewa.Major C. H. Smith, I.M.S., Supe rintendent of the" medical departmentRewa State tells me that it is common in the jail, mostly in the hot weatheflmonths when vegetables from the jail garden are lacking and in this connection!it is noteworthy that the fat element of the jail is derived from vegetable]oils, not ghee.The Sub-Assistant Surgeon in charge of the Nagod State Dispensaryme that he sees a number of cases in the hot weather months and that he connect*!its occurrence with a lack of fat in the diet.Mr. Jar dine , the Manager of the Sutna Lime W orks , sees cases of this]disorder of vision among his labour force and he first drew my attention to the!belief in the efficacy of chuna leaves' chuna ki bhaji,' as a remedy.For this complaint, known as Rataondhi, the traditional Indian remedy of adiet of goat's liver (a source of fat-soluble A), with a poultice of goat's liver to|jthe eyes, is well-known.Ghee is also esteemed as a remedy and is used as such by those who caa\obtain it.A Brahmin cultivator expressed to me the unprompted opinion that those who\seat ghee do not get Rataondhi and that the first milk of a newly calved cow is-jialso efficacious as a cure.'Chuna ki bhaji,' the green prunings of the young chuna plant is, however, 1the most universal remedy among the vegetarian poorer classes. Thu s in the ;family of a lathyrism case No. 5 1, the story w as told me that the young wife of^the patient had, in August of the year in which the husband developed lathyrism,*suffered for six days from night blindness. He r old mother-in-law produced jsome dried ' chuna ki bhaji ' which was kept in the house, soaked it in water, put]it up on the roof of the house overnight, and fed the patient on this, who found ^herself cured in two days.

It is significant that in one family the man developed lathyrism and the wife]night blindness in the same month and on the same diet.That the association is not fortuitous is suggested by the observation thatKotar village where, as we have seen, 12 per cent of the male population arejafflicted with lathyrism, night blindness is extraordinarily prevalent.

This is embodied in a local kahawat, a jibe against Kotar, which runs asfollows : ' Ekai andliar, ekai lui,Ekai chale matkawa t kul,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 ' Andhar ' wa s night blindness,while i lie tilting and wriggling movement of the pelvis in lathyrism' matkawat^,1 s considered a diagnostic feature of that disease.My 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 leafyvegetables, and of whole milk, ghee or dairy products containing butter fat, whichare believed to be the most p lentiful sources in a well balanced vegetaria n diet offat soluble A, while in regard to Kotar it is seen that this community 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 contrasted the state ofaffairs in the ' control ' village of Am iriti, whose inh abitants grow and eat asmuch, matra as the average Hindu villagers do, but being Mohammedans they

supplement their cereal ration with fish and flesh meat and substances containinga modicum of fat-soluble A. This village has no lathyrism cases.In Sind, which the writer subsequently visited on another inquiry, it appearsthat Lathyrus sativus is grown and eaten, but cases of lathyrismknown as"matar mandai ' are very rare, and occur under exceptional conditions of scarcity.The Sind villager grows and eats Lathyrus sativus, but he also keeps herds offine upstanding cattle and buffaloes, which give a plentiful yield of milk, which isconsumed by the owners, and they also grow and eat green vegetables in con-siderable quantities. The conditions w hich, with a lathyrus diet, are in Rewaassociated with the occurren ce of lathyrism are absent in Sind . I am indebtedlo Dr. Shiveshwarkar, Assistant Director of Public Health, Sind RegistrationDistrict, for the opportunity of perusing his report on an outbreak of scurvyi 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 symptomsi lathyrism. This observation would also appear to mark an association ofihyrism with nutritional instability and avitaminosis, in this case of C.ACTON'S AMINE THEORY.

It is now for consideration what bearing the observations have on the two"dories of causation which it has been the work of the writer to investigate in' &c field. In regard to Acton's theory of the formation of a poisonous amine byifennination, it may be noted that his investigations (Acton, 1922) were made inAugust 1921, i.e., in a period following the year 1920 when the rains and the kharif ' crops had failed and the people were subsisting after eleven months ofJ, MR - H


11/18

472 A Field Study of Lathyrism.

haagf

edible]

privation, on the inadequate ' rab ' crop of 1920-21, supplemented byimported grains . It has been shown that in a normal year, no importation of grain occurs andthat the ' Bagalpu ri m atra ' whose germination he sugg ests to be the cause ofthe disease, is never used. He suggests that the indigenous vetch is pernon-poisonous, but of the 13 recent cases, seen by me all had been eating locgrown matra and of the eight samples of such grain that were obtainablewere of the large-seeded variety, the ' karya matra ' of the wheat uplandsRewa.From this it would appear that the locally grown matra is as potent to prolathyrism as is the imported ' Bagalpuri matra ' whose consumption in a fa:year has earned it an undeservedly evil reputation in Rewa,a disrepute probdue to the circumstances of its use rather than to any inherent and special toxiuHe noted that the majority of cases seen by him gave the month of Julythe time of onset, and he suggested that this indicated the possibility that gerntion of the grain occurs during the rains, which produces the poisonous ato the ingestion of which he considers the symptoms of lathyrism are due.Buchanan (1904) paras 52 and 64 to 67 of his report, has shown that wmonths of lathyrus diet at any time of the year will determine the onsetlathyrism, and it would appear that the facts which he cites afford a ereexplanation of the appearance of the cases in July when three months of.j-ponderating lathyrus diet since the harvesting of the ' rabi ' crops in April, hadbeen accomplished, without assum ing germination and a poisonous amine to bethe explanation.The possibility of the occurrence of such germination was, however, ca.v-fully investigated. In none of the specimens of Lathyrus sativus which hadformed the staple diet of eight cases before the onset of their disease, was anysign of germination detectable, and this was confirmed by the Director of theInstitute of Plant Industry, Indore, A. Howard, Esq., d.E., to whom sampleswere sent for examination. \It does not appear likely that such can occur. The g rain is harvested inthe hot dry month of A pril. It is stored in the houses in a large sun-bakedearthen jar called the Kutuli. ';;Grain which is to be used for seed is mixed with wood ashes to prevent theinroads of weevils, while that required for use is kept in the Kutuli and takefl^out and spread in the sun at frequent interv als to keep off weevils. It is unhusked,_and the pericarp is thick and resistant and unlikely to permit of the germ beingactivated by an increase of atmospheric humidity. . '.I was informed by all whom I questioned, that only such grain as has been plentiful in " dumat ' fields which grow rice during the ' kharif,' and wheat, etc.,nriny the ' rabi ' season.It is a true weed, and it is never seen in the drills in which the seed has^beta sown through the ' nali,' but in the soil between the furrows.\ If the seed were a constantly present contamination of the harvested crop, itwould be found also in the sowings, as no special pains are taken to purify the\ seed which is sown, which is identical with that consumed.Its absence from the drills, which I was at pains to verify by a carefulstudy of a large number of growing wheat fields, shows its absence from thesown seed and seems to afferd a reasonable presumption of its absence from thecrop as it is eaten.Everywhere the villagers were emphatic that it is bitter unpalatable stuffwhich is never eaten by man and that it is always weeded out and used as cattlefodder. They say that if a field contains an appreciable quan tity of it, it mustwe carefully weeded out, else it will damage the crop and redu ce its yield.During Febr uary. I was everywhere able to see this work in- progress andto mark the bundles of Akri being brought home as cattle fodder (Plate XL V I,fis- 8 and 9).1 lie villagers point out that the Akri pods ripen before the matra pods andthat they burst and scatter their seeds on the ground before the matra isl "* rvested, and that little or none of the Akri which has not already beeni.gathered for cattle fodder is mixed with a 'b er ra ' or a matra harvest. Matrak s usually grown as a mixed cropa berra, and this mixed cr op is usually passedthrough a sieve to separate the more valuable wheat or barley from the cheaperOatra. The matra seeds being the larger, are retained by the mesh through whichthe wheat passes, and this explains why a very occasional seed of the minute


12/18

474 A Field Study of Lathyrism.seeds of Akri may be found in a handful of wheat from the bottom of a heapThe large-grained ' Karya matra,' the cheap grain which is fed to ' lugwas ' andwhose consumption causes lathyrism, ordinarily contains no Akri.Th e "Duly 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 liefallow u nder a self-sown, unw eeded cro p, 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.KesariAktaEarthWeevils

SAMPLE I .25 028

13

22

48954

A greatdeal.Weevilledbut no liveweevils.

SAMPLE II .18

891

657

Very little.Many liveweevils.

SAMPLE II I .293

36

303

15None.Fewweevils.

SAMPLE IV. SAMPLE V. SAMPLS VI.

807

16

497

None.Veryweevilled,many liveweevils.

32

60

657

None.Very fewweevils.

28

864

A greatdeal.No weevils.

The weevils which infest matra were sent to Mr. Bainbrigge Fletcher, ImperialEntomologist, Pusa, for favour of examination.He repor ted ' that they are not real w eevils, 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 areconcerned in cases of lathyr ism.' '

T. C. McCombie Young. 475%i r Howard for examination as to the presence in them of Akri contamination.. specimen No. 1, which was the leavings at the bottom of a grain bin, tohe bottom of which the small seeds of Akta and grains of earth, and otherdebris had found their way, 54 seeds suspected to be those of Akri were1*parated from a total of 489 of Kesari, not including seeds of other foodpains . The average weight of Kesari seeds to Akta seeds is about 5-5 to 1 andthe 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 containedbarlev and other food grains, was still lower. In specimen N o. 3, also one ofleavings, the proportion by weight of Akta to Kesari was about 111 to 1 andiras considerably less in the total m ixture .It has been remarked that the weed is more abun dant in ' dumat ' fieldswhich grow rice in the ' kharif ' and are more moist than the wheat lands. W erethis contamination the cause of lathyrism, one would expect the disease, withthe 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 up landwheat 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 ownrain is worthy of credence.They clench the m atter by po inting out that ' Akri grows only in moistfields and that in a famine year when lathyrism cases occur in great numbers,the fields are all dry and no Akri g row s: how then can it produce lath yris m'?Taking everything into consideration, therefore, I can find no confirmationof the theory that lathyrism is caused by a contamination of Lathyrus sativus bvthe weed of Vicia sativa. DISCUSSION.Having failed to find evidence that lathyrism is due to an amine formed bytermination 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 w hen monsoon rains fail, the ' kharif ' crops on which the poo rerdasse? depend for a varied and cheap variety of cereals are in defect, and thePeople are now ill-fed and half-starved . The wheat and barley of the ' rabi 'Crops fail to germinate in the dry soil, only the lathyrus grows, which is harvested01 April, and the bulk of the population has to live chiefly on that and on^ch 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,Beginning in July and continuing until the resumption of a better balanced diet01 September and October when the 'kharif' crops become available if the*Qcceeding monsoon rains have been more bountiful. In a year of normal rainfall


13/18

476 A Field Study of Laihyrism. T. C. McCombie Young. 477only those whose circum stances of life app roximate to famine condition*acquire lathyrism and the striking feature of a pre-lathyrism diet, apart fromthe preponderance of lathyrus, is the absence from it of tbe protective food Jsubstances of M cCollum. The notes on K otar village show that where one othe recognised effects of a diet w hich lacks in f at-soluble A viz., night blindne is very prevalent, lathyrism is rife; whereas the 'control' Mohammedan villa*,of Amiriti, also using lathyrus as a foodstuff, but adding to its diet other'articles as eggs, fowls, fish and flesh meat, is entirely free from lathyrism. Tindications seem to point to the possibility that lathyrism is allied to the defiriediseases in the mechanism of its causation.Further examination of the available data seems t show that suchhypothesis supplies some explanation of the epidemiological and astiological facts]already noted. In regard to the greater incidence in the years of greatest, physicyactivity, the ages 10 to 20, and 20 to 30, an analogy with the deficiency disberi-beri and pellagra, may be noted, the incidence of which is highest among jwhose work is hardest (M cCar rison, 19 21). The influence of excessive physiaf]exertion in determining the attack of deficiency diseases has been notedMcC arrison w ho records tha t ' the onset of hu man beri-beri is often rendeacute, or that of hunger oedema sudden by excessive physical exertion ' and faiejquotes others in support of the view th at ' exposure to cold favours theof scurvy, malnutritional cedemas and pellagra.' As we have seen, exertionwettings are often the immediate antecedents of lathyrism. ; '*'In regard to sex incidence, which is from 5 to 10 times greater inthan in females, apparently only an essential sex difference can explain it, for thtjwomen share equally in the work of the fields and their diet differs in nofrom that of the men.McCarrison notes a different sex incidence in the deficiency diseases, beri-and war cedema, and in experimental polyneuritis columbarum, and attributthis in part to ' different metabolism and endocrine action in the twoNo other explanation seems applicable to the markedly different sex incidein lathyrism and the analogy is perha ps significant.It has been shown in these notes that a common antecedent of lathyrisri*an attack of malarial fever (which is often treated by ten days' stai' Upas ') or by dysentery, smallpox, or pneumonia.

W hile such may be regarded as conditions tending to lowering of the vit jand as such sufficiently explained, from the point of view of dietary stthey may perhaps be regarded as periods of vitamin depletion which wouldthe appearance of a deficiency disease . The six months of starvationinsufficient * kharif ' crop, which precedes the mass outbreak of lathyrisnifamine year, may perhaps be similarly construed.In regard to a preponderance of the legume Lathyrus sativus in the dietcommunity suffering from lathyrism and its bearing on the subject under*'cussion, we may recall views of recent workers in dietetics.McCollum (1923) states that 'the protein molecule is a chain-like stof amino acids ' and points out th at ' the nu tritive value of a protein deon its yield of the indispensable amino acids and the extent to which

oroportioiis correspond to those existing in the body proteins into which they aretransformed.' In regard to legume proteins, he is of the opinion that 'they havepeculiarities in their composition which make them of relatively low value innutrition when they serve as the sole source of protein in the diet, or when theyare combined wivb the more im port ant foodstu ffs.'Ellis and Macleod (1922) state that 'pea protein is an unsatisfactoryjet ' and they deduce from animal experiment that ' pea protein containsomet h ing which is injurious in lar ge amounts over long periods.'Klsewhere it is stated that ' legumes lack fat-soluble A , and the m ineralcontents of a well-balanced diet.'In regard to the influence of an unbalanced diet in determining the onset ofthe deficiency diseases, McCollum quoting Appleton and others, in regard to aCommunity living in Labrador in a state of extreme nutritional instability, writes'small deviation^ 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, lathyrisni is more common than in normal years, whenthese conditions are absent. 3. A community suffering from lathyrism is also in a state of marked" nutritional instability clue to lack of the pr otectiv e food substa nces, notably, those containing fat-soluble A.4. In an area in which lathyrism is particularly prevalent, the deficiencydisease, ' night blindness,' is also notoriously prevalent.5. In a Mohammedan village using as much Lathyrus sativus as theirHindu neighbours but supplementing their diet by substances which tend torestore the dietary balance, lathyrism is unknown.6. The re are some significant resembla nces in the setiology of the deficiencydiseases and lathyrism.It may tentatively be suggested for experimental verification that lathyrismmay be to some extent a deficiency disease which is produced in persons livingm a state of nutritional instability on a diet noticeably lacking in vitamin A,oy a prolonged ingestion of a legume, the amino acids of whose proteins areunsuitable as a diet and perhaps specially harmful, which is itself deficient infat-soluble A.In regard to such experimental work it may be noted that while epidemio-"ical observations point to a prolonged period of avitaminosis being an essentialj. ** clr in the production of lathyrism, experimental workers, Stockman (1917), Anderson, How ard and S imonsen (19 25) , were at some pains to eliminatear as possible, the influence of avitaminosis on their experimental animals.The observations cited in this report suggest that this failure to reproducec conditions which attend the onset of lathyrism in man may have been thei wuse of their lack of success in reproducing the disease in animals.


14/18

478 Field Study of Lathyrism.Further experimental work, reproducing as far as possible in animals ik,pre-lathyrism avitaminosis as seen in men, would, therefore, seem to be desirableIf successful, the results of such work would yield deductions of considerablepractical value.Pending such confirmation, some practical preventive inferences seem

now, to be warranted. As Acton has pointed out (Acton, 1922), the ul t ima^causes of lathyrism are economic. Its prevention turns on administ r t!improvements aimed at reducing poverty, providing a better balanced dietpreventing theexclusive use of lathyrus in years of deficient rainfall.In Rewa, irrigation would prevent this dependence on rainfall, but aswhether a system of ' flow ' irrigation, utilising the waters of the river Scis a practical engineering proposition and one which is within the financresources of the State, the writer is not competent to offer any opinion.' Lift ' irrigation from wells, using a water lift operated by bullocksispossibility which would similarly require technical consideration. Its introdition would presumably require capital for initial expenditure and maintewhich the ' rayat ' has not got, and the State would presumably have to finait by loans.An obvious requirement is an increase in the village roads and cart tracThis would make it worth while for the villager to grow more and 1>grain, which he could get away, and sell, and thus provide himself with bettefood and with some financial reserves to tide over a period of stress. It wealso enable the State to supply him with a grain not liable to produce lathyriswhen, in the absence of irrigation, famine relief measures are required in a yifollowing 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 prodition of lathyrism, then measures aimed at increasing the yield of milkimproving the breed of cattle and at encouraging thegrowth and use of vegelabwould bevaluable in its prevention.The prohibition of the cultivation of Lathyrus sativus has been triedState administrators in Bundelkhand, and Baghelkhand, following the exaof European rulers of the 17th century (Stockman, 1917).It has been shown that this vetch is normally sown as a mixture with wr.or barley, etc., as an insurance against famine, and effective prohibition \vn ^opinion of the writer, efforts should rather be made to obviate, by the measu

T. C. McCombie Young. 479t l i n e d its involuntary misuse by over-use, in preference to endeavouringc!s U by legislation which cannot in the nature of things, beobeyed.

REFERENCES.Causation of Lathyrism in Man. Ind. Med. Gaz July.

and'siMONSEN Studies on Lathyrism. Ind. Jour. Med. Res., Vol. XII,No . 4, April. . 1 0 0 / L _- ' . n m ) .. Report on Lathyrism in the Central Provinces, 18 96-*AN, A- ( 1 9 t H ) 190 2. Nagpore Civil and Administration Report.

r, / i om Edin. Med. Gaz., November.*" i, noVn " '.' Studies in Deficiency Diseases. London. HenryI I S U ' Froude and Hodder & btougnton.v (1923) .. The Newer Knowledge of Nutrition. New York.l' ' " McMillan & Co.

C d M - , A. L. (1922, Viul F.c.ors o. Food. New Yor t D. V NoH.ndCoy. , .C. E. and PANDIT JANK, Central India State Gazetteer Scries, Rewa State.

ISHAD (1907).


15/18

E XP L AN ATION OF P L ATE XLIII.Fig. 1. Sepaiya, a crawler. 2. Chida, much adductor spasm and spastic equinus.

PLATE XLIII.

Fig. 1.

Fig. 2.


16/18

.4

O

E XP L AN ATION OF P L ATE XLIV.Fig. 3. Lall Mu n, marked spastic equinus.,. 4. Spastic equinus and adductor spasm.


17/18

E XP L A N A TION OF P L A TE XL V .Fig. 5. A dductor spasm and spastic equinus . 6. Cross legged scissor gait due to adducto r spasm.


18/18

E XP L AN ATION OF P L ATE XLVI.. 7. Progression with bent knees due to flexor spasm.8 and 9. Akri gatherers.

Documents

Lathyrism India Field Study McCombie Young 1927 L