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V T I960]

LATHYRISM : RUDRA.& KANT

415

j <-miin result of our enquiries shows that ttruion due to dietetic deficiency is very ,- lent among school children of Hyderabad :and South Indian towns. lie it is only to be expected that children on diet largely composed of rice, with no milk and very few vegetables show obvious signs of malnutrition, it is iful to have some exact data on this point and ce this study was undertaken. BIBLIOGRAPHY
MEDICAL

"HEALTH

B. T. (1924). J. Amer. Med. Assoc, 82, 1. OFFICER Ann. Rep. Chief Med. Officer. Board oj Editcatiqn,_ 1927. Rev. Hlth. Dept., OFFICER (1935). Ann. Corporation, of Madras, 1934. L. (1936) Ceylon J.'Sci... Sec. D., 4, 1.

y A FIELD INVESTIGATION INTO .-',., LATHYRISM


v

are therefore'of. the_ utmost. : importance to 'the country and the community. v .We,.' therefore, decided to conduct .a., field .investigation into lathyrism on a fairly 'large '.scale in:'the''"first instance. ' . ' '' On the morning of the. 28th August, 1947, we visited the village Banki which is about 35 miles to the north-east of the headquarters, station of Darbhanga. Here we saw about half'a dozen cases of lathyrism. These cases have been excluded from the present review.: We next moved on to the village Kurson about 7 miles farther... A large number of lathyrism patients and some other cases had collected there from the neighbouring, villages as our arrival at this centre had been notified beforehand.. In .-.this place we examined altogether 138 .persons, out of which 133. i.e. .96.4 per cent, were clinically diagnosed as. affected with-lathyrism. They were Hindus and Mohammedans,'males, females and children of all ages, from a child of 2 years to old men of 60 years or perhapsv.rnore. An analysis of. these cases gives.the following results.. .. Age distribution.Table I gives an. analysis of the.age distribution. . >; ..: . . " A graphical picture of lathyrism cases in different age groups is.shown'in figure IV ':
is

^r; ^. ,.
.

By M. N. R.UDRA Professor of Medical Chemistry


and-.. .

' ; . ecturer in ' J!


S

L. KANT . Hygiene. Darbhanga Medical College-. Laheriasarai, Bihar

LATHYHISM is one of the major health problems L, or Bihar. The total disability from it imposes \*~ & heavy drain on the agricultural man-power of ,1 ^tli'e country which certainly interferes with r '' ^much-needed food production and results in loss >*~jx>< wealth to the country. It is endemic in i ^ o r t h Bihar and in some other parts of India. 1 *Tne continued low nutritional status in the t /("untry would be expected to show an increase : /-U 'the incidence of the disease as lathyrism can ; jjliu'-' truly called an economic disease. Thisf i^pectation was not belied indeed. Beginning .', " ith the middle of 1947, reports from various >'T irts of the Darbhanga district (North Bihar) IS 20 25 Jo $3 40 45" 50 55 60 ** - well as attendances in the medical outh iiatients department of the-Darbhanga Medical f College Hospital made it clear, that lathyrism * h td broken out in an epidemic form. Statistical analysis oj the observations ^ Our present knowledge or rather lack of know^. \ d g e of the disease indicates that.once it is Estimated variance7.03, standard deviation ! 2.65. y established, or even,-in the early stage, it - incurable. Its prevention and early detection Sampling variance0.053. standard error 0.23. . ' i d a sustained study into its various aspects TABLE I

Age distribution of 133. lathyrism cases


-,'' Age grpup . . 4 .. 3.0 0-5 5-10 25 . 18.8 10-15 12 9-0 .15-20 16 12.0 20-25 19 14.3 25-30 24 1S.0 30^35 7 5'.3 "35-40 . 40-45 11 8.3 . 8 6.0 "45-50 . 2 ". . 1.5 50-55 1 0.S '". 55-60' 4 3.0

''*; Number i Percent

416

THE INDIAN MEDICAL GAZETTE

[S:

'Error, of random sampling0.025. . It is surprising to note that the largest number of incidence occurs in the very voung age group of 5 to 10 years (18.8 per cent)" That the next highest incidence (18.0 per cent) is in the age group of 25 to 30 years is not surprising because apparently healthy young persons are easily and readily affected. It is also noticed' that the number of cases among the older age groups 45 to 60 are much fewer. It is surprising that even a. partially breast-fed child of 2 years only was found affected. Its mother also ' suffered from the same disability. The significance of this observation has been discussed later. Sixty was found to be the maximum declared age of the examined persons. This does not necessarily mean that older persons are immune. Certainly it cannot be expected that illiterate and ignorant people would or could keep a correct count of their respectiA'e ages. Three score is indeed a very high and serviceable figure to them and might represent any age of 60 or higher. Sex distribution.In tables I.I and III the distribution of the cases by sex is given. It will be seen that 18 of the cases, i.e. 13.5 per cent of them, were women. This observation is in agreement with the reports of earlier observers that females were usually found to be less affected. Whether females are actually less susceptible to lathyrism -or this observed lower rate of incidence is due to the natural shyness of Indian women to come forward for examination cannot be settled at, the moment.
TABLE.II

community is more susceptible -to the although we are inclined to think, afteci^ ing all the known .facts about;iathyrii Muslims, as meat-eaters, would be-mbrSl. But taking into account the fact that the! usually occurs among the people in.tnejf income group of the society, it is not.surf that the. rate of incidence is a fair index! proportional distribution of the two.; edu in the population. It is also import"" remember that the Hindus (including Bra_ of this locality are usually fish and meat!
TABLE IV ^

Distribution
Religion Hindus

by religion of 133 lathyri&rr&i


Number 102 Per cent
76.7

E.EMAB

Muslims

23.3

Proportional? tribution -W fair indexf community! ia. pqpulatio

Distribution
Sex Male Female

of 133 lathyrism cases by sex


Per cent S6.5 .13.5
REMARKS

Number 115 IS

Distribution indifferent age group. In table III.


TABLE

Rate of incidence to overall population total population of the villages from patients had collected at the examination cj is estimated at about 14,000. Even if assumed that all person.? suffering from lath; had gathered, though this contingency > happens, the percentage of lathyrism becomes nearly 1.0. On the assumption^ only a half of the cases assembled, the raj incidence comes to about 2 per cent, indeed a very disturbing and distressing Remembering the fact that most of the exa: and affected persons (80 per cent) were attacks of the year and that lathyrism mi practically total disability (as far as manis concerned), an incidence of 1 or 2 per cen|| each year represents a loss of man-power whp will be continually on the upgrade a s n o from lathyrism has been discovered yet. Inde
III

Age distribution of 18 female lathyrism cases


Age group Number ..
0-5 0 0.0

5-10
6

10-15
6

15-20
0 0.0

20-25
0 0.0

25-30 1 5.6

30-35 3 16.7

35-40 0 0.0

40-45 2 U.I

45-50 0 ' 0.0

50-55 0 0.0

o3
oo3

Per cent ..

33.3

33.3

It is interesting to note that not one case between the ages 15 and 25 was found. One of the explanations may be the unwillingness of the young married girls to come for examination. Distribution by religion.From table IV we see that out of 133 affected persons 102 were Hindus and 31 Muslims. This gives a percentage ratio of 76.7 to 23.3 respectively which is in close agreement with the proportional distribution of the two communities in the population. There is thus no evidence that either

Buchanan found as many as 13 per cent of villages affected with epidemic spastic paralys which is not surprising and which can be expect* in other affected villages if a census is taken. , | Discussion Lathyrism is clinically diagnosed by spastici'ty in the lower limbs, exaggerate reflexes, ankle clonus and Babinskrs Incontinence of urine and impotence are u; not in evidence although these symptoms

LATHYRISM. : RUDRA & KANT


in some cases. The disease iE - i ' ^ e d l y of nutritional origin and is;- as ~~% ' t t before,.essentially an economic one. ieories about the aetiology of lathyrism een advanced but none are entirely sa-tisor convincing. ,'ttffo(1922), Anderson et'al. (1925)", Dilling 4801 Geiser et al. (1933), Jimenez Diaz " A . |(1943)~ Howard et al: (1923), McCarrison -rfitrishnaii (1934), Mellanby (1930), Rudra fllfoattacharya (1946), Shah (1939), StockJji'f'(1934), Stockman and Johnston (1933), Gtt (1930),'Traland and Moharram (1932) and rj&uj r, (1927) have all advanced hypotheses Sir. [ing the aetiology or refuted those of .others. "jfaTiin A deficiency can produce nervous gp sration but so can vitamins Bt and E icfii >ncies. In fact, Einharson and Ringsted 5V described motor nerve degeneration from 1^5 !iicy of vitamin E. The degeneration of lip,' :entral nervous- system by vitamin B1 cl" ;ncy and its cure bj' vitamin B t alone is o* * ill known as to need no reference here. lbach has therefore cautioned against the afieptance of Mellanby's \utamin A deficiency slbry, asnot only can deficiencies of vitamins A. jfe.E and of other- vitamins but sundry other jauses also may bring about the degeneration. example, Zimmerman and Burack (1934) rved nervous lesions in animals given jfeicient vitamin A but deficient in the black ""ague factor (hicotinic acid). The investigaihs of Professor Jimenez Diaz et al. (loc. tit.) ye focused the importance of animal foods ._ : the- diet for preventing lathyrism. Bhatta efiarya working in the laboratory of Rudra JBplated an albuminose-like substance from the \esari grains but it is unfortunate that the vestigation could not be pursued further owing \\ itfiits sudden termination. ' ^?^ i n o w agreed that lathj'rism can be and is , -produced by the exclusive or predominant use of ^ khesari in the diet This fact does not exclude f. the possibility of other grains producing the I flisease. Stockman (loc. cit.) claims that it can 1 f>5 produced by other pulses and even cereals. II ^siger ep^tt. (loc. cit.) reported that lathyrism ten induced in the white rat by feeding ^2t\:'pea (Lathyrus odoratus). Recently, ^ewis et al.. (1948). experimental ) have produced p p ^ j in rats by feeding them sweet pea and .- lertain species of Lathyrus peas other than Lathyrus sativus. Minchin (1940) reported cases v ,'ii-the Madras General Hospital which he con:r-" eluded were lathyrism "but doubted if these 'infected persons had had any hhesari in their "diets,.as this pea is usually not grown in the. area ,,-from which the patients, came. \ -On. interrogation a l l . the. affected persons ^etamined replied that they had. been subsisting . * on: Jchesari for some time past. ' It should be ~remem'bered that when these people start taking 'kiis pea, they, have exhausted:.their stock of all - other grains and. they consume practically only

417

this substance. "They either cook .the peas-like rice or make.them into chapatii-s with the.pea meal and eat the rice or chapattis : with '' dal made from the same grain.'"There "is''.usually none of other foodstuffs.. More than" 80 "percent of the examined and affected persons :were recent and fresh cases of from' fifteen days.vto three months' duration. It is evident that'most of the chronic cases had stayed at "home although we had one or two of about ten years' duration.:: Minchin {loc. cit.) quoting Basu et al. (1937) thinks it may be due to tryptophane deficiency. But Basu et al. have given ho.data or proof that khesari. is deficient or how much deficient .in tryptophane. Stockman {loc. cit.) thinks."that lathyrism is caused by the toxic action of phytic acid and possibly other substances. Jimenez Diaz et al. (loc. cit.) reports that the khesari lacks in some vitamin-like substance which, is present in foods of animal origin. This observation fits in very well with the results of.investigations now being conducted in the senior'author's laboratory. I t has been found (Rudra and Chowdhury. 1950). that- khesari is. very -poor-in methionine content, having only about a quarter of the methionine content of most other dais. It is very probable that the methionine deficiency with other multiple deficiencies present is really the aet-iological factor of lathyrism. In the absence of .adequate methionine'in' the diet a disturbance' in the creatine metabolism may follow which may result in the degeneration of the nervous system specially-of the pyramidal tract. The experiments of Bodian andMellors (1947) in experimental neurone regeneration is interesting in this respect. The possibility of some toxic substance abetting the action of methionine deficiency is not altogether excluded. We have already mentioned that a child of 2 years and practically breast-fed was also affected with lathyrism. The pertinent question then arises: Is. the toxic principle transmitted-from the mother to the child if the disease is of toxic origin ? This is very much .unlikely. ..For example, we cannot visualize the phytic acid taken by the mother being transmitted to. the child through the milk. On the other hand," if the disease is actually a deficiency one like methionine deficiency, the child's illness canV-be explained. Since the mother's diet was Iv.ery poor in.methionine content, her milk, would.also be poor in methionine and, although' the child was taking milk, it was continually being deprived of this essential amino acid. We. have- also observed that fewer female cases are "usually lo.und." Are females "less "susceptible ? We cannot settle this question-here and now. But if a disturbance in the creatine metabolism is, the real .cause o'f lathyrisrn, we will not be surprised if females are actually found more resistant to' the . disease

418

THE INDIAN MEDICAL .GAZETTE


;BASU,
1
1

[SEE Rei
:%.

McCarrison and Krishnan {loc; cit.) found no female cases in the Gilgit agency. It is probable that his investigation was not exhaustive. Cruickshank (1947) described a similar spastic syndrome among European prisoners of war in the military camp at Singapore occurring first in September 1942. This most probably happened on account of the very poor diet of the prisoners lacking in calories, proteins, fats, minerals and vitamins. Treatment with good, nutritious and balanced diet and adequate vitaminization gradually altered the patients' conditions but' there was no total cure as. in lathyrism. Jacoby (1947) reports that in Bhopal lathyrism usually occurs during or after the rainy season and once the disease has affected,, the condition of the patient continues to deteriorate even if the diet consists of 50 per cent of wheat. He further suggests that the disease may be due to fungus growth on the Lathyrus grains because of bad storage condition during the rainy season. Suggestions The best treatment that we can recommend from our present knowledge, .is an all-round improvement in diet rather than medication. We appreciate that this is rather a tall order and extremely difficult of realization in the present economic state and food supply. position of the country. Jacoby (1946),,. .we think, was first in introducing prostigmin in the treatment of
lathyrism. . - . .::. v : _.-. :_-.'..':.'...

K.
C,

-P.,
and

' NATH, Indian J .Med.


MUKHER

M.

- .."'

JEE, R. (1937). . . . BODIAN, D., and MELLORS,.

'

J. Biol. Proc.

Chem,,'r Nutrition'Si

R. C. (1947).
CBUICKSHANK, E. K.

(1947).
DILLING, W. J. (1920) ..

J. Pharm. and Expt 14, 359. GEIGER, B. J.. STEENBOCK. /. Nutrition, 6, 42


H., and PARSONS, H. T.

(1933).
HOWARD, A., J L.. and SIMONSEN, ' ANDERSON.

Indian J. Med. Res

" l

I. A- P- (1923).
JACOBY, H. (1946)

' Hem;

(1947)-

Indian Med. Gaz., Ibid:, .. and 122. Sev. Clhi. Espanola J. Nutrition, 38, 53

JIMENEZ DIAZ, C ORTIZ . DE LANDAZXTRI. E., .and

RODA.. E. (1943).
| LEWIS. H. B.. FAJAKS. R. S., ESTERER, M. B.. SHEN. CHAO-AVEN, and.

OLIPHANT, M. (1948)..
! MCCARRISON, | KEISHNAN. R.. B. and G.

Indian J. Med. Res.. Brit. Med. J., i, 677. Ibid., i, 253;


i, 68S. '''

(1934)..

'.

.
L. H.

MELLANBT, E. (1930)' ..
M I N C H I N . R.

(1940). IjRuDii1., M.
f

N..
K.

and Lancet,
P. and M.

BHATTACHAHYA.

(1946).
RODRA, M. N.. CHOWDHUBV. L.

Proc. o7Lli Indiar. Congress, part. 111,-n


-A

With a:. generous gif t: from -'the manufacturers, I SHAH, S. R. A. (1939). .Indian Med. Gaz., -74 the'Roche firm, one of \is- (M'"N. R:}-rwith H. C. !}STOCKMAN, R. (1934) .. J. Hyg., 3 4 , 144'. Ghosh, had- the... opportunity, of .testing the J STOCKMAN, R.. and JOHN- Ibid., 33, 204. ' efficacy of this drug in' lathyrism.; -We must ' STON, J. M. (1933). confess that in our experience .prostigmirf. does Indian I: Mod. Res.,]'-STOTT.. H. (1930) not promise to be & remedy for lathyrism. TRALAND. J.. and MOHAR- Rev. Med. France, 1.3. There have been some improvements in some RAM (1932). cases, no doubt, and in our opinion it can be YouNfi, T. C. M. (1927). Indian J. Med. Res-, '1J used for relieving.some of the signs and sympV ZIMMERMAN. L., and /. Expcr. Med., 59," 2 toms. The biochemistry of , lathyrism is now BTJRACK, E. (1934). being investigated in the laboratory of one of us (M, N. R.). . : We must also emphasize the role that the plant geneticist has to play in this connection. T H E RISK OF POLLUTION OF GROjL An alternative crop must be evolved which will WATER FROM BOREHOLE LATRIN be as hardy and cheap as khesari and still have a nutritive value equal to that of the best of By K. SUBRAHMANYAN ;^ our pulses. and -it We offer our best thanks to Lieufc.-Colonel H. J. T. R. BHASKARAN -0 Curran, I.M.S., lately Principal and Superintendent, (All-India Institute oj Hygiene and Public .Be Darbhanga Medical College and Hospital, for his keen Calcutta) !;<| interest in this investigation. - Two important problems, in rural sanita REFERENCES . . .. in India are the collection and safe disp.osa. ACTON, HrW;. (1922) ... Indian Med., Gaz.,.G7,\2il. human excreta and the provision of safe. .wj. ANDERSON, ' .L. A... P., . Indian J. Med. Res., 12,613. supplies which, cannot be-contaminated! HOWARD, . A., and human excreta. The two are to a -ce SIMONSEN,J.L. (1925). extent interrelated. Villagers, as a ruley^jj: BASU, K. .P., NATH, Ibid., 24. 1027. no latrines for defalcation. They pollutefj M. -C, GHANI, M. 0., soil, wash themselves in rivers and tahksiHj and MUKHERJEE, R. use them as sources of drinking water alsbi. (1937).

(1950).

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