THE INDIAN MEDICAL Staff 1 visiting physician. __ 2 trained full-time.ayahs to work by shifts. 1 boy. 1 thoti (part-time). The .

.last three on Rs. 40, Rs. 30 and Rs. 15. respectively each. Rent. etc.Rs. 50 per month (controlled rent). Lighting and water charges Rs. 10 per month. Contingencies.Rs. 10. including journals RE. 5. The monthly expenses will come up to Rs. 200 to Rs. 250. The initial equipment will be well within Rs. 1.500, not including the microscope or .-r-ray apparatus. Income.-Even if half the number of beds are engaged taking the average at Rs. 2 per day per bed. the monthly collection will be about Rs. 300. The medicine and treatment charges are extra at the usual rates charged by the individual general medical practitioner. '

P A r7T7imrriT7i

LATHYRISM IN BIHAR By S. B. LAL

: ' "I

Officer-in-charge, Nutrilicni Scheme, Bihar. Bankipore, Patna

LATHYRISM has been reported from the time of Hippocrates. Mention has also been made of this disease in old Hindu literature ' Bhavaprakash' where it is written that the pulse Lathyrus sativus causes a man to become lame and crippled and irritates the nerves (-Chopra, 1938). In India epidemics of lathyrism have been reported from time to time usually associated with famine and food scarcity. The first . outbreak was reported by Colonel Sleeman in 1844. Between 1900 to 1945 outbreaks of the disease in epidemic form have been recorded in Central Provinces, Rewa. Gilgit. the Punjab and United Provinces. In response to an enquiry, it was concluded by Megaw and Gupta (1927) that the disease was mainly confined to a belt which runs across Central Provinces, the east of United Provinces and north of Bihar. Recently Shourie (1945) has reported an out- break of lathyrism from Central India.

Cost to the patients.Ward charges will be Rs. 30 to Rs. 60 per month depending on cost of medicines. The expenses incurred by the patient will not be more than what they would be if he has to go to a hospital or get a medical man to his house. Government must take care to direct cases to the isolation centres in the respective mohallas instead of keeping them on the waiting list and reserve the beds in the hospitals for the mofussil cases. The cases which cannot afford any expense and others which require surgical treatment for the duration may be sent to Government hospitals. The general m-edical practitioner must inspire enough confidence to this end. There is no doubt that the assistance" of a proper specialist is necessary. So, the Government must depute the specialist to visit each centre to help the general medical practitioner. If the patient feels that he can get comfortable accommodation and at the same time facility for good medical aid i gffe&i, these isolation centres will be highly attractive, convenient to the patient and attendants, relieve congestion in the existing As a rule there is acute scarcity of vegetables sanatoria, isolate the sufferers and check the and fruits in the. villages except for mangoes j spread of the disease. The sufferer will get during the season. Milk and milk products are earlier aid, and thereby have a better chance of either not available to the poor or are available ; being cured, and the specialist will have an" only in negligible .quantities. Meat and eggs,. . opportunity of doing his job more easily. The because of the high cost, are also very difficult :.1 general medical practitioner will have every to obtain. '''.$. thing to be proud of. Most important, there The disease started in J u l y , 1947 i n t h e ; : g will be a check on the spread of diseases. The villages of Patna and Monghyr districts while next step is to wait for improvement in the in August 1947 in those of Darbhanga district. -. economic condition of the country and discovery All the persons affected were landless labourers of specific remedies to combat the disease. and were very poor economical^. They were

In this paper is given an account of three epidemics of lathyrism which occurred in Bihar and which came to the notice of the author. They were reported from the districts of Patna, Monghyr and Darbhanga. The first two districts are situated on the south of river Ganges and the third to the north of the river. . The districts are all fiat country and there are no irrigation facilities, the farmers having to depend entirely on rain for the supply of irrigation water. Darbhanga and MonghjT districtsare seats of malaria and the spleen rate is high. In all the districts the entire population is engaged in agriculture. Besides the landlords . there are the landless labourers who work in the fields of the former and get wages in kind con- ? sisting of the cheapest grains available. Lathyrus sativus is known in these places as ' Khesari'. : It is a good hardy crop and gives a good yield with the minimum of labour. It is usually ; planted after paddy is harvested and without any further effort it grows and is reaped after a .. few months. It is a very favourable crop because it is cheap and eas}- to grow. It is used ;; for cattle feeding as well. The green leaves are ; also consumed after cooking by a large number ; of people even of the well-to-do classes. -

1949)

LATHYRISM IN BIHAR : LAL Types of food consumed

469

engaged as labourers in .the fields of the village landlords and were getting wages in the form of grains of the cheapest type.. ' Khesari' always formed, a major percentage of.the wages because. it was cheap and easy to grow. The number .of persons affected together with' sex incidence is given in table I. .
TABLE I

Number of persons affected together with sex ' incidence

District
Total number of Male Female affected persons 143 27 49
.. PERCENTAGE

Male Female 96.5 100.0 93.9 96:2 3.5 e'.i

Patna
Monjrhyr DarbhaDga

13S 27

46 211 8

TOTAL

219

3.S

It is very difficult to assess' the age of the people in villages, and an approximate age incidence of the affected persons is given in table
TABLE I I
PERCENTAGE

Diet surveys were carried on all the affected families: .All the food taken was weighed twice a day, before cooking, for a total period of 10 consecutive days on the lines suggested by Aykroyd and Krishnan (1937). Altogether, the food intake of 150 families consisting of 857..persons was investigated. Diet surveys -of .'.the! unaffected families were also carried on. For brevity the relevant figures only of the unaffected, families are given in table IV. Of the cereals consumed, maize, ragi and barley were the most important items, while rice and wheat were in a A'ery small quantity. ' Khesari' was the most important pulse consumed. . The consumption of other articles of foods too was below the standard suggested by the Nutrition Advisory Committee (1944-). The only source of fats. was mustard oil. Ripe mangoes and ripe jackfruits were the fruits consumed by the families in Monghyr while those in Patna were found to take only green mangoes. Analysis of the diets of the affected and unaffected families for vitamins made with the use of the tables, in Health Bulletin No. 23 (1946) is given in table IV. " The affected, families of Monghyr were consuming ripe mangoes and ripe jackfruits which have a high carotene content. It is because of this that though the consumption of leafy vegetables, fruits and milk was lower than that of Patna, still the figures for vitamin A are nearly the same. The intake of vitamin A was below the standard laid down by the Nutrition Advisory unit/day
Condiments Calories ' 1.18 0.71 0.13 3,221 2,421 2.904

Age groups

Male

Female

Male
6.84 3.65 So .83

Female
1.36 2.28

12 to 16 vears IS to 20 years 25 and above

.. ..

15 S 1SS

Table I I I gives the intake of calories and different types of food.

TABLE I I I

Average intake of calories and types of jood~in oz. per consumption {affected families)
N a m e of district Patna Monghyr Darbhanga Cereals Non-leafy Fats and Leafy Pulses vegetables vegetables oils 1357 10.74 . 329 1.15 0.56 0.59 1.49 0.93 1.61 0.33 0.10 0.07 Flesh foods 1.06 0.44 0.99 Milk and milk products 1.16 0.17 0.30

Fruits and nuts 0.79 0.60 nil

16.06 12.66 25.57

TABLE.IV

Intake

of vitamin and percentage of 'Khesari' in the diet of affected and unaffected families . per consumption unit/'day -. ....

District Patna. Monghyr Darbhanga

Families surveyed Affected Unaffected

Affected '

I 1

Percentage of ' Khesari' 74.1

Vitamin A, I.U. ...

. 2.S34 ' '

Vitamin Bi, mg.

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

-

'. ..

Unaffected Affected Unaffected

I j ! .

545 2.5 79.6 .

2.0

4;84S 2.879 4,012

-1,830

" 3 . 2 1.8. 1.6 .1.9

' . . .

3 7 5

3.5

4,142

.25 1.6

'

42.4

102

3.0

Committee (1944) and "the same vrn? true for vitamin C as well. " . State of nutrition

In order to assess the state of nutrition, ail the children available were examined clinically on the lines described by Mitra (1940) and rated as ' good ', ' fair ' or ' poor '. Table V gives the results of clinical rating by naked-eye examination.

whether it is a deficiency disease. T h e low S intake of vitamin A by families of D a r b h a n g ar ^ district does not reflect the incidence of' i t s a deficiency in the children of the place, which''^ may be due to the fact that the children while 3 playing in gardens and orchards consume fruits which could not possibly be recorded in the survey. There does not appear to be significant difference in the incidence of the diseases supposed to be due to deficiency of' some ., nutrients, between the children of affected and' -h unaffected families. " "

TABLE V .

Incidence of atate of nutrition amongst children of families affected and- unaffected with lathyrism
RATING

Families surveyed

Good Actual
43 40

Fair Actual
151 94 245 155 18.2 74 50 124 1S.4 19.2
98 76

Poor Percentage
34.6

Percentage
14.4 22,3

Percentage ' Actual

51.0 52.1 103
4G 149

PATNA

; Affected
TOTAL T.. ..

S3 23 17
40

iUnanectod
:

a-

JS

, Girls
.TOTAL

Boys

51.3 53.7

47 26

32.0 29 ,S

..

MONOHYR

I Affected

( Boys } Girls
TOTAL ..

40 30 70 30 20 .. 50

45.1 4S.7

79 50 129

36.4 32.1

176
20.4 22.4

| Dnafiecrnc!

\ T,

..

; Boys
TOTAL

90 70 160

50.0

582

60 40

29.6 19.9

100

DARBHAKGA

I Affected TOTAL
' T -

51 26
..

16.1 17.6

ISO S3 263

57.1
56.4

84 38 122

26.6 25 .S

jlinanected

Boys
TOTAL

31 25 56

30.4 18.2

90 85. 175

5S.4 63.1

41
9 50

10.9 1S.6

Deficiency diseases Aykroyd and Rajagopal (1936) have stressed the value of the presence of deficiency diseases and their correlation with the state of nutrition. The children of the unaffected families were in a better state of nutrition than those of the affected families. The incidence of phrynoderma and xerophthalmia which are supposed to be associated with the deficiency of vitamin A was not so high' as compared with angular stomatitis and caries. There is yet no agreed opinion by different nutrition workers on malocclusion and

Clinical

findings

History of sudden onset of the disease was elicited from a large majority of the patients.' They stated that usually on getting up in the morning they felt weakness in legs, which progressed on to their present condition. I n : a few cases the onset was after an attack of fever. The fever mostly was malaria. T h e other findings were those of upper motor neuron lesion. Table.VI gives the findings of the survey.

OCT.. 1949J

LATKYRISM IN BIHAE. : .LAI/

TABU ,

471

VI
Total percentage : suffering from one Malor other occlusion disease 41.4 2S.3 49.3 2S.5 3'7 23.7 30.2 24.5 16.1 23.1 17.3 12.6

Percentage incidence oj diseasei supposed to be associated with malnutrition

i i

Percentage found to b e suffering from Families Total number

' District

Phrynoderma 8.6 10.4 7.6 13.9 S.7 S.9 7.G 6.9 5.1 4.S
0.7 . 2.1

Xerophthalmia 7.0 8.S 6.2 11.8 2.7 2.5 1.5 1.9 2.2 3.4 i ml nil

Angular stomatitis ' 15.7 1S.7 14.5 24.7 12.4 12.1 12.4 13.5 4.1 6.1 5.2 2.0

Caries

V-,

'' A a-

\ BOVS

PATNA

iAfiected 'Unaffected

Gi].]g

297 ISO '' 144 93 217 156 ISO 130 315 147 162 119

14.8 14.7 15.9 18.2 11.7 13.4 - . 10.7 14.5 3.4 6.S 7.1 2.6

G.o 4.S 9.6 5.9 7.1 nil nil 1.9 2.0 nil nil

{^^

MoNOHYR
;

, , Affected T- a t ] iUnaffected . r. . , Afiected

!TT

I Bovs | G i ;. l s S Bovs < Girl ( Bovs \ Gir]s

I

__

DAHRHANCA

__

lUnaftecced

/-

-j Q J ^ , .

( Bovs

Discussion Lathyrus sativus is mostly mixed with Vida sativa and is consumed along with the latter. Every villager in the affected localities believes that the disease is caused by eating ' Khesari' (Lathyrus sativus); but so far experiments carried on animals in various laboratories have yielded conflicting results. McCarrison (1928) could not produce the clinical picture of lathyrism in rats even when they were fed on pure Lathyrus sativa or on Vida sativa. Snook (1948) observed no ill effects when a wether and two cockerels were fed on Vicia sativa. Bhagvat (1946) working on guinea-pigs could not produce any paralysis in them. Lewis et al. (1948) fed Lathyrus sativus at 50 per.cent level to rats with no ' symptoms of lathyrism. Mellanby (1930) could produce experimental lathyrism in dogs by a diet composed of variety of pea, Yicia sativa, and deficient in vitamin A. -Further suggestion that this vitamin may furnish protection against lathyrisin is supported by the experiments of Geiger, Steenbock and Parsons (1933). Mellanby (1930,. 1934) has put forward the theory that lathyrism was due. to an active neurotoxin, the effects of which could be prevented by protective foods containing vitamin A and carotene even when much of the toxic, agent in Lathyrus sativus is consumed. McCombie Young (1927) also was of the same opinion. The present investigation showed that the intake of Lathyrus sativus was high with a very low or almost negligible consumption of such protective foods which would be sources of vitamin A and carotene. The intake of carotene and vitamin "A too was very low and all of this had been derived from leafy vegetables and

fruits. .The value of vitamin A has been calculated from carotene of which only a very small percentage, from 1 to 2 per cent, can be utilized by the system (Moore, 1933). A review of the literature mentioned here shows that, the exact aetiology of the disease is still obscure. The present survey revealed that the diet of the affected families was deficient in quality and quantity ! and contained a high percentage of ' Khesari . Surveys carried out in this province have revealed a similar state of intake except that nil or very little of ' Khesari' was in their diet. It appears that lack of adequate nutrients in the diet lowers the general body resistance and concomitantly to that of the lower segments of the spinal cord too, to this toxic agent. The low intake of vitamin A for a long time coupled with the high intake of ' Khesari' for a length of time possibly leads to the development of the disease. This is further supported by the fact that families in the same affected areas with adequate vitamin A (table IV) and low ' Khesari ' intake did not reveal any symptom of the disease. Considering all the facts it appears reasonable to conclude that poor diet with low vitamin A intake and high consumption of ' Khesari' {Lathyrus sativus) for a length of time allows the toxin or toxins present in the pulse to act and damage the nerve cells, already devitalized by the individual living on a poor diet, till a time comes-when the paralysis manifests itself. The evidence collected and the suggestions put forward are in consonance with the theory of Mellanby and McCombie Young (loc. cit.). Jacbby (1947) too, from the study of a series of cases, found that 'Khesari' or ' Teora'

472

THE INDIAN MEDICAL GAZETTE

[OCT., 1949

(Lathyrus sativus) was invariably associated j M E I J A X B Y , E . (1930) . . Brit. Med. ./., i, 677. with lathyrism. Further, his findings with regard Idem (1934) . . Nutrition and Disease. to a poor nutritional background are the same Oliver and Boyd, London. as those reported in this paper. He is also of a MITRA. Iv. (1940) Indian J. Med. Res., 27, 887. similar opinion, that deficiency of vitamins may MOORE, T. (1933) Biochem. J., 27, 898. form the clinical background upon which the JN UTRITIOK A D V I S O R Y Report of Sub-Committee on toxic agent of ' Khesari' exercises its effect. The COMlflTTEIO (1944). Nutritional Requirements. Indian Research Fund incidence of B complex deficiency amongst the Association, Tsew Delhi. patients were 15.5 per cent, as against 14 per SHOURIE, K. L. (1945) . . Indian J. Med. Res., 3 3 , 239. cent reported by Jacoby {loc. tit.). . SLEEWAX. W. H. (1S44). Rambles and Recollections No reason could be elicited from the survey oi an Indian Official. for the high incidence of the- disease in Hat chard and Sons, London. males. " The suggestion put forth by Shourie (loc. at.) that the high incidence was due to SXOOK. L. C. (194S) . . ./. Agric. West Auslrnlirt 25, 47. greater intake of Lathyrus by males could not be corroborated in the present investigation. It has been noticed that' both males and females of the families surveyed worked for the same hours in the field, and hence the other suggestion She 3irt>ian riDebical (Sasette that since the males only work in fields, their jfi.ftv calorie ' requirements, and so their intake of Lathyrus sativus would also increase, has notbeen borne out.

INSANITY IN INDIA
Summary 1. An outbreak of lathyrism in three' districts of this province has been described. 2. Diet surveys of the affected families revealed high consumption of Lathyrus sativus and low intake of vitamin A. 3. The state of nutrition was commensurate with the calorie intake. 4. A suggestion based on the field studies regarding the cause of the disease has been made. Acknowledgment
I am grateful, to my assistant Dr. A. Bose tor helpins me in collecting and analysing the data. REFERKXCE3 ArKROYD, (1937).
ATKROYD. W. K. R.. and Ibid.. 24, 419. RAJAGOPAL, (1936).

(From the Indian Medical Gazette. October 1899, Vol. 34, p. 373) T H E following tables, compiled from the reports upon the Lunatic Asylums of Bengal, Madras and the Punjab, show the relative numbers of lunatics in the asylums at the end of the vear 1898 : '
!

Bengal ' Madras Punjab 25 39 626 4 167 33 43 453 34

Idiocy Mania (a) Epileptic (b) Other forms Melancholia (a) Epileptic

335

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

B. G.

KRISHNAN.

(6) Other forms

Dementia (a) Epileptic ib) Other forms

4o

S2 4 24 5 1 7 13

BHAOVAT, K . (1946) .. CHOPRA, R. N\ (1938) . .

GEIGEB, B. J., STEENBOCK. H., and PARSONS. H . T .

Ibid., 34, S7. Mental stupor . . The British Encyclopaedia oi Medical Practice. 1, 651. General paralysis Buttenvorth and Co., Ltd.. Delusional insanity London. Mot j ' e t diagnosed or recovered. ./. Nutrition, 6, 427.
TOTAL TREATED

126.. 2
of)

1 124 . 14 1

DO

r>S

(1933).
HEALTH: BULLETIN* No. 23 The Manager of Publica-

: . | LOSS

714

55S

(1946). JACOBY, H. (1947)

LEWIS, H. B.. et

';'" ..
al-

tions, Government of India Press, Delhi. Indian Med. Gaz., 82, 53.
J. Nutrition, 38, 537.

(1948). MCCAKRISON, R . (1928).

MCCOMBIB"YOUNG, T . C.

Indian J. Med. Res., 15, '797.

. Ibid., Med. 15, 433. Gaz., 62, 299.

(1927).
MEOAW, J. W. D., and GUPTA, J. C. (1927).

'
Indian

From this table it will be seen that in all three provinces the vast. majority of lunatics suffer from acute or chronic mania. Idiocy is apparently least found in Bengal asylums and most in the Punjab. The proportion of insanity due to epilepsy is somewhat greater in Madras and Punjab than in Bengal. Forms of dementia appear much less common in the Punjab.