|Sm: g>

FEB.', 1947] CAUSE, SYMPTOMS AND TREATMENT OF LATHYRISM : JACOBY

53-

quiet, no wound of entry seen. Cornea "dear, I well. Minchin also noted affection of the pupil dilated and regular, lens clear. The I bladder. Ruge and his co-workers (1925) and vitreous was full of blood and no fundus details J Ranjan (1944) described' incontinence of urine could be seen. The left eye was normal. and faces as well as sexual impairment. It has ~X.-ray localization.One foreign body about been postulated that the disease is never pro2 mm. in diameter was seen to be 13 mm. to the gressive after a few days or weeks beyond the nasal side, 13 mm. posterior and 1 mm. below initial paralysis (Bickncll and Prescot't, 1942): the horizontal. The foreign body was thus Ranjan (1944), however, notes rapid progress localized to be on the sclera under the internal of the disease. The published accounts of rectus muscle just behind the equator. the reflexes in lathyrism are equally puzzling. Minchin (1940) observed normal cremasteric Operation was performed and the foreign body and abdominal reflexes along with spastic legs was found on the sclera under the muscle. and extensor plantar responses. Trabaud and The case demonstrated that this method of Mouharram (1932) found completely normal localization can be accurate to 1 mm. reflexes, including the plantar responses, though Another case is as follows : there was spasticity and clonus of the legs. A W. D., male, aged 27, was injured by a common symptom associated with lathyrism is Japanese grenade about 70 days before being night-blindness according to McCombie Young seen by us. (1928), and- Ranjan (1944) ' reports marked Examination: Right eye.Vision 5/60. dimness of vision. Cornea clear. No wound of entry seen. Eye quiet. Pupil dilated, lens clear. A yellow mass Even the diseases which can experimentally be was seen on the retina at the equator in the produced in animals by feeding them on certain species 4 o'clock meridian. Left eye normal. of legumes of t-he genus Lathyrus have also been willed lathyrism, although they do not show the characteristic X-ray localization with the ring.The foreign symptoms of the human lathyrism. Geigei- ct al. (1933) body (about 2 mm. in diameter) was measured fed rats with a diet consisting of Lathyrus odoralvs, to be 14 mm. posterior, 6 mm. nasal and 12 mm. the flowering sweet pea (at levels of 80, 50 and 25 per cent of the diet). Characteristic symptoms were lamebelow. ness, paralysis and contracture of the spine and sternum. This corresponds with the mass of scar tissue In other experiments on white rats also fed with a seen ophthalmoscopically. No operation was perLathyrus odoratus diet, carried out by Lewis aud Esterer formed in this case as the ophthalmoscopic and (1943). these authors produced a disease which they call lathyrism showing the following symptoms : Inconradiological evidence showed that the foreign tinence, lameness, paralysis of limbs, spinal curvature body was in the scleral wall well sealed off in of the thoracic region. Another nutritional disease by fibrous tissue and hence siderosis bulbi was not feeding sheep with a certain species of legumes, viz, cull beans, has experimentally been produced bylikely to supervene. Willman and his co-workers. They call the resulting Comment.X-ray of a 12 mm. silver ring sewn disease ' The Stiff Lamb Disease', which shows the on the lirabus is a very simple, yet very accurate, following symptoms : The animal concerned has diffimethod of localizing intra-ocular and orbital culty in -walking and rising. It gets tired very soon after walking and tries to lie down whenever permitted foreign bodies. No complicated, appar&tus or to do so. On standing and walking there is disturbance elaborate calculations are necessary and the of keeping the balance; later on, inability to rise at all, accuracy of the centering at the time of x-ray is not even -with help. apparent from the resulting pictures. Since the author is working in an area where Summary lathyrism patients are a common sight and since all of them show a uniform symptomatology, it A description of the method of the localizaappears advisable to establish first of all a tion of intra-ocular and orbital foreign bodies by record of the symptoms of this disease, which means of the lirnbal ring is given and its accuracy we regard in this area of Central India as indisshown by illustrative cases. pensable for the diagnosis of lathyrism. REFERENCES Symptoms.The following trail of symptoms , Ross (1945) .. .. Brit. J. Ophihalmol, 29, 545. is in our experience found in every lathyrism patient : . ' ....: . . STALLAKD, H. B. (1942). - Brit. Med. J., ii] 629. 1. Spastic and painful rigidity in.the muscles CAUSE, SYMPTOMS AND TREATMENT of the lower extremity, including .loin"muscles. From this results a typical spastic-ataxic gait, . OF LATHYRISM frequently associated with a so-called scissorA SPECIFIC NUTRITIONAL NEUROPATHY gait. . ' . By H. JACOBY, M.D. 2. Exaggerated deep reflexes in the legs, Chiej Physician, Prince oj Wales Hospital, Bhopal, generally clonus. . ..' '.". . ',. [_'. Bhopal Slate 3. The complete absence'of disease-symptoms ' Introduction,There is considerable difference in other" parts of the body, especially in the : upper extremity and the head. ''.''".'' ":".;-r '. in the descriptiorrof symptoms in lathyrism by 1. " '. The"i flexor-- and i- frequently'.' alsoy the::;; d i f f e r e n t a u t h o r s , - r / r v , -' -.-,. -'-'"'.'/ ),,;/ . - Shah (1939) and. Minchin _ (1940),: report, adductor.muscles of:'calf and thigh; particularly^' the M/ gastrocnemius, feel hard and are. tender^ besides spastic paralysis'-of the legs, also involveon squeezing.-;: All these muscle3 are invariably^ ment' of- the arms:. and. sensory impairment as

THE INDIAN MEDICAL' GAZETTE

[FEB.,

1947

deviation in any direction (Barany's Pointim well devploped and never flabby or atrophic. Test). ' The patients complain of permanent pnin in these muscles which is increased on standing (c) If the patient is made to walk forward; and walking. In more advanced eases even the and backwards with his eyes shut, he will noi sleep is disturbed due to the pains. The present the peculiar deviation of the so-called ; examination of passive movements shows percompass gait' (Krolm, 1938). manent muscle resistance to flexion and extension 2. The following reflex reactions are also at the knee- and hip-joints. The degree of this significant of pyramidal lesion. Without excepresistance runs parallel to the advancement of tion a greatly exaggerated knee-jerk is elicited, the disease. In very far advanced cases the the ankle-jerks often being diminished or absent.. resistance is such that it is not possible at all In some cases, however, also the ankle-jerks are to achieve these passive movements by force. exaggerated. Almost always ankle-clonus is In this late stage all such movements are possible present and frequently also ' dancing of the only by the patients themselves actively, very patella '. Far advanced cases showon sudden.' slowly and with the help of their own hands. brisk passive dorsiflexion of the foot to elicit ankle-clonusan involuntary complex reflex Most characteristic is the gait of the patients. movement consisting of flexion at the hip-joint The onlooker gets the impression as though these and flexion at the knee-joint. Frequently this patients walk against the obstacle of their own ' flexion reflex' occurs already by a gentle muscles. They generally walk with a slight, stimulus, like deep pressure or pinching of the apparently voluntary flexion at the knee-joints, skin of the distal part of the lower limb. Either which is associated or caused by a foot-drop, reflex, i.e. the flexion reflex as well as the in an involuntary attempt to compensate for increased deep reflexes, is indicative of hyperthe latter, resembling the so-called Striimpell irritability of pyramidal origin. So is. the phenomenon. Or another way of involuntary flexion reflex a prominent feature of " the compensation is achieved by swinging the leg in usual flexor contracture (the tendon reflexes a convex arch instead of lifting the foot (circumbeing frequently decreased) and exaggerated duction). The patients seem to walk on their deep reflexes are an equallj1 characteristic toes only. Another group of patients who do not feature of extensor contracture. The latter form show the above flexion at the knees will drag is indicative of a less severe lesion than the the feet on the ground, as though their soles are flexor contracture (Babinski). Babinski's sign pasted to it. These patients describe their gait by stroking the sole along the lateral border themselves as ' scratching the ground'. All rather than the median border is as a rule these symptoms which appear on walking are extensor and signifies a less severe pyramidal ' associated movements, as they are known to affection than does an extensor response elicited occur in pyramidal lesions, but are not enfrom the median border as well as from the lateral countered in extra-pyramidal motor lesions nor border of the sole (Krolm, 1938). There is elecin the normal individual. These modes of walktrically no reaction of degeneration. The senses ing rather belong to the advanced stages of the of position and of movement are always and disease. In the initial stages only the slight definitely unimpaired as well as the temperature muscle resistance and the slightly bent knees on and touch senses. The Romberg sign, if positive," walking prevail. In many cases of all stages, is of little significance on account of the above in whom the spasm of the adductor muscles of described inco-ordination of muscle movements. the thigh dominates, the so-called scissor-gait The superficial reflexes vary : All or some of the results. The patients walk; with crossed legs, abdominal reflexes as well as the cremasteric resembling the somewhat opened blades of reflexes are in less advanced, stages normally scissors. The movements of the arms, normally elicitable, but are missing in far advanced cases; accompanying the gait of healthy persons, are This pathological abdominal reflex is generally always unimpaired in lathyrism. Walking and associated with the ' flexion reflex' and the in more advanced stages standing of these extensor plantar'response all belonging to the patients is complicated by a peculiar kind of order of ' reflexes of spinal automatism ' and are' swaying (ataxia). This goes frequently along signs of pyramidal involvement. Anyhow,"rewith fibrillary twitchingsof the muscles of the appearance of the previously absent superficial lower extremity, which in combination with the reflexes and of a normal plantar response and contractures result in inco-ordinated movements. This disturbance of inco-ordinatio'n of different . the disappearance of the '.flexion reflex' are among the signs denoting improvement under muscle, groups is certainly the cause of this successful treatment.-. . . . . : - . particular kind of ataxia of lathyrism patients. It is not due to cerebellar lesions, because the 3. There are definitely no abnormal nervous following tests exclude this type of ataxia : signs whatsoever in any other part of the : body. Never was any disturbance of sensa-: (a) There ' is no ' decomposition' in the tion encountered, nor. of the functions of the sequence of complicated single movements. .. bladder, of the bowels, of the sex and of the ' (6) The test of moving the .leg and big toe mentality. -..}. ^:v-;;.f;:;;^\/;; away from and back to the examiner's finger as Examination of the cerebrospinal' fluid-as'-to:a' target, with :; eyes shut, does not show- a' pressure,-cell count, albumin content and' Kahti;

SYMPTOMS. AND. TREATMENT OF LATHYRISM : JACOBY '"test shows no abnormalities. There arc also no "pathological findings in urine rind blood. Blood pressure is normal. Radioiogically, lungs and shape of the heart are always found normal. 'Differential diagnosis and cctioluyy.By the ell defined signs, as described above, lathyrism There is ( in be diagnosed with full certainty. onh one other disease, the signs of which arc identical with lathyrism. that is spastic spinal -CICIOMS of Erb (Beaumont. 1942) or the pure -pi^tic type of amyotrophic lateral sclerosis of other authors (Price, 1941). Both diseases are caused by lesions in the upper motor neurone of the pyramidal tract. The lesion of ' spastic, spinal sclerosis' is confirmed by post-mortem examinations. Records of post-mortem examinations of the spinal cord and the cerebrum of lathyrism patients appear not to be in the literature. But the difference between these two nervous diseases does not lie in a divergence of their signs. Their only difference is the a'tiology. Whereas we are not aware of the cause of spastic spinal sclerosis, the cause of lathyrism is well known, viz, consumption of certain species of legumes of the genus Lathyrus for a period of usually not less than about a month, This consumption is, therefore, to be regarded as indispensable for the.diagnosis of lathyrism: We in this area of Central India found invariably that it was only Lathyrus sativus (teora or khesari clal) that was consumed by our patients. To the same conclusion comes also Shourie (1945) in his comprehensive review of lathyrism in Central India. This experience does, however, not exclude the possibility that other species of Lathyrus may also cause nutritional diseases which may more or less resemble the disease which is our subject.
Ruge and his co-workers slaie lhat besides Lathyrus

55

sativus, Lathyrus ciccra and Lathyrus dymenum also can cause lathyrism. But they associate with the disease disturbance of sensation, urine incontinence and impotency. Epidemics in Trance in 1770 and in England in 17S5 were thought to be caused by eating vetches of the species Lathyrus ciccra. This or Lathyrus dymenum was held responsible for an outbreak in Syria (Trabaud and Mouharram, 1932), but Shah (1939), investigating an outbreak in a Punjab village in 1939, found that seeds of Vicia sativa and not of Lathyrus had been eaten mixed with corn. McCombie Young (1928), however, reports that his cases had eaten Lathyrus but little or no Vicia sativa and Minchin (1940) describes ' lathyrism without Lathyrus'. . The latter's diagnosis appears rather doubtful in the light of our above stated experience. In connection with McCombie .Young's report on Vicia sativa being the cause of., lathyrism,-examinations of Lathyrus sativusstocks, as" consumed by lathyrism patients, in Mho Imperial Agricultural Research Institute, New Delhi, failed to. reveal t he presence of Vicia sativa seeds (quoted by Shourie, 1945). The above quoted experiments on animals also show that legumes other than Lathyrus sativus are apt to cause" nutritional diseases somewhat similar to lathyrisrn (Geiger el al:; 1933; , Lewis and Estcrer, 1943)-.. . . . . .

them state that before the occurrence of the first symptoms there was fever with shivering, resembling malaria/ Frequently, this statement was confirmed by malaria relapses taking place in our presence in the hospital. A minority of all lathyrism patientsless than 20 per cent remember to have had diarrhoea previous to their falling sick from lathyrism. Actually, we found occasionally am cob a- in their stools. It is. therefore, quite possible that the latter diseases acted in these cases as a conditioning cause for the deterioration of a latent background disease, viz. vitamin B deficiency state, on which the toxic influence of Lathyrus was grafted. On the other hand, the majority of oiir patients did not give any history of a previous disease. All our patients are, however, unanimous in their statement that the' disease, generally during or after the rainy season, started slowly, at first only with heaviness in their legs, followed by gradually increasing pains in the loin, thigh and calf muscles. These symptoms deteriorate to the cripple stage, unless consumption of teora is discontinued. Even if it is continued in a mixture with wheat, containing about 50 per cent of teora, the condition goes on deteriorating. But if consumption of teora is completely stopped, the condition remains steady, showing neither improvement nor further deterioration. The latter statement of the patients could be confirmed by our own observation in the hospital; there was in a batch of eight patients neither improvement nor deterioration for a period of a month, in which no treatment was given. We must, however, mention in this connection that .during this time of observation the hospital diet itself was deficient, consisting mainly of chapattis about 8 oz. and of dal about 2 oz. and occasionally of ghee 1 oz. and of milk 6 oz. per day. Nutritional background.Besides the consumption of a special variety of Lathyrus, very important for the type of symptoms appearing in different parts in the world, is in our view the nutritional background of lathyrism. Although we have not had the facility to prove this experimentally, by giving the same amount of teora to one volunteer with normal nutritional background" and to-.-another volunteer with deficient nutritional background, clinical experience shows that outbreaks of lathyrism occur at all.times and in all countries only among the poor and ill-fed classes of people.
Special observations ori the particular ingredient deficient in the diet are reported by McCombie Young (1928). He stresses a vitamin A deficiency among his lathyrism patients. He not only found night-blindness common in a village suffering from lathyrism, but also noticed that the disease did not occur in neighbouring villages, where the diet contained as much Lathyrus but more vitamin A, fish and meat; while Shah (1939) has reported great improvement in patients, when vitamins A and D were given.'1 Apart from night-blindness no. apparent,, deficiency; diseases have been:. reported;; aa-:. occurring^' with: outbreaks-, of: lathyrism.; \A.y. latent;" vitamin B! '.deficiency..however is suspected as' a -result.." of the investigations on serum phosphatase of lathyrisrrr..

"}fr Course^of". lathyrism.With, regard to the onset of- the'disease we- entirely.depend' on the patients',-' own- reports.- About 30 per cent- of

THE INDIAN MEDICAL GAZETTE

patients by Rudra and Bliatiacharya (1SM6) in. Faina. They found a high .serum phosphatase and a consequent possible cocarboxylase deficiency in lathyrism and related these findings to the jetiology of the disease. They consider it, however, also possible that the high serum phosphatasc is the effect and not the cause of lathyrism. But, of course, lack of other substances in the diet, apart from vitamins, may be important, as suggested by Basil ct al. (1037), who found that the seeds of Laihyrus antivus, .which, often form the staple food in famine villages, are a very poor source of protein, being especially deficient in tryptophaue.

[FEB.,

1947

The author (Jacoby, 1946) has found in this area here that the nutritional background of a vast proportion of (lie population is a vitamin B complex deficiency. Although symptoms of this deficiency are visible in only about 14 per cent of our lathyrism patients, the result of the therapeutic test {see under treatment) suggests that a latent vitamin B complex deficiency exists in a far greater proportion. It is a hitherto unexplained fact that in lathyrism villages the disease attacks generally only one or two members of a family, but leaves the others untouched who eat the same food and live under the same conditions.- Children arc affected roughly in the same proportion and manner as adults, but the female sex to a much smaller proportion as compared with the male sex. In Shourie's (1945) statistics only about 13 per cent were females. Treatment.This present description of the curative influence of prostigmin in lathyrism is based on the analysis of 50 patients treated with prostigmin. There has been no effective treatment of lathyrism until now. . Jacoby (1946a), however, discovered that lathyrism responds well to prostigmin treatment. This response differs in degree in the different stages of the disease. The first stage in our classification comprises all those patients who can walk with slightly bent knees and only some active and passive resistance in their muscles as' well as with the . just noticeable scissor-gait and slight muscle pain. Their deep reflexes are, of course, greatly exaggerated, the superficial reflexes as a rule being normal and plantar response extensor, elicrtablc from the lateral border, of the sole. No ' flexion reflex' is present. In this stage an apparently complete clinical cure is achieved through and during the treatment with prostigmin injection; in the beginning about 10 intramuscular injections of 2 c.c. are given daily, after which a course of another ten daily injections with 1 c.c. only follows. Afterwards, injections on alternate days may be sufficient to keep the achieved condition unaltered. If the treatment is discontinued, we invariably found a re-occurrence of the former symptoms. It was not possible to substitute, either for the shortterm or the long-term treatment, the injections by tablets of prostigmin. The tablets have proved to be ineffective in lathyrism. The required duration of the treatment of lathyrism with prostigmin .is thus the same'as in.-. Myasthenia gravis... Discontinuance of/ the/

treatment causes re-occurrence of symptoms in either disease. The second stage in our classification of lathyrism comprises the more advanced cases with marked painful muscle spasm and a clearly visible spastic ataxic scissor-gait. Muscular fibrillations are present. These patients are still in a position to walk, although with considerable difficulty and discomfort, either just without or preferably with one or two sticks, .according to the advancement of the case. The treatment of this stage with prostigmin injections does not achieve the same result as in the first stage. The symptoms are only considerably relieved, but it is generally only possible to reach an improvement which resembles the earlier first stage in our classification. Those who were previously able to walk with tiie described obstacles, but without a stick, can under the influence of the prostigmin treatment walk like untreated first-stage patients, and those who required the stick are enabled to walk without it. The third-stage patients are those who are permanently confined to bed. The muscle spasm and contractures are so extreme that. they prevent practically any movement with the legs. The pains in the muscles of the lower extremity, of the calves, thighs and loins are permanent and severe. These patients have thus become cripples. At the same time all other functions of the body are unimpaired, the vegeta-' tive as well as the mental functions. The reflexes are such as we have described under 'symptoms' for the far advanced stages. The prostigmin-injection treatment in this third stage achieves little with regard to the crippled state of these patients, but succeeds in so far as the pains almost disappear and the muscle rigidity becomes less. This results sometimes in an ability of these patients to leave their bed, slowly crawling on the floor for short distances. These third-stage patients are, of course, not in a position to work. The patients, however, who belong to the first and second stage, are by the treatment with prostigmin enabled to do almost every kind of work. ... The achievements under prostigmin treatment can in every case and stage be" accurately checked and even measured in the following way : The exaggeration of the knee- and ariklejerks becomes less and in early cases practically normal so that also the clonus may disappear; the extensor Babinski response in the early cases will equally approach the normal. If in the more advanced stages the superficial reflexes were not to be elicited before, they will reappear in the course of the treatment and the ' flexor reflex' disappear. The most accurate evidence of improvement is the gait,-, which ' can be measured as follows : The patient is asked to walk in his usual manner with wetted feet on ', the dry floor. The heel-to-heel distance - is measured with a;. tape.. This, distance, shows under prostigmin treatment a marked diminution

t 1947] CAUSE, SYMPTOMS AND TREATMENT OF LATHYRISM : JACOBY ^aboiit 3 to 6 inches. Vice versa, if the injections are. discontinued, the length of steps slowly increases again till after about a month the original length is regained. The symptom Kvhich shows improvement last is the ataxia. It fit-Aakcs about 20 daily injections before the W- patients can for instance stand quietly on one P:: leg or are able to stop walking immediately on fei sudden order. Before the treatment they were |tf not able to do so but had to proceed one or two i t steps further in order to keep their balance. fe The improvement of ataxia can generally not be ft--' achieved in late stages. We tried to enhance I* the effect of the prostigmin treatment by jE-.f administering at the same time massage, light l|v or electric treatment to the lower extremities of |. lathyrism patients. We did not, however, find '.. any response to these methods. S.'" . Vitamins.Several authors report improveii ment of the disease by the administration of ;v certain vitamins. Ranjan advises, plenty of '<*: vitamin A besides all other vitamins and Ahmad :) (1944) reports relief of pains and regained : ability to walk about freely after parenteral and -:. oral administration of vitamin B. Mellanby (1934) classes lathyrism among the deficiency ;;/ diseases, since protective foods containing '; vitamin A and carotene, green vegetables, milk }: and eggs can prevent the detrimental effects of 7 the toxic agent in the Lathyrus peas. Strongly against the argument of vitamin deficiency causing the disease is the fact that. in our experience the administration of '." vitamins in large closes does not improve the condition to any significant degree. We have tried in different batches these vitamins A and D in the form of cod-liver oil for a period of two v months. - AVe administered the vitamins B 1; B2 j: complex with crude liver and the vitamin C ?.. daily by oral and parenteral route for a period '-' of one month. But no response was ever apparent. On the other hand, we do not know of any vitamin deficiency state which does not respond at least to some extent to the therapeutic application of the deficient vitamin alone or in . combination with the other common vitamins. , . Another, clinical evidence against, the view of vitamin deficiency being the cause of lathyrism, is the.feature that no visible sign of any such deficiency occurs in the bulk of our lathyrism patients... Only about 14 per cent showed symptoms of vitamin B complex deficiency in the form of a characteristic glossitis, showing also the so-called inkspots. That is a very small percentage..in .view of the high incidence of, vitamin B deficiency states, which the author (Jacoby, 1946) found in this area:' These facts show that the cause of lathyrism is surely not a. deficiency .of. the. above-quoted vitamins/ as . tried by us/therapeutically. This.; statement, - however, is in. no contradiction of the likelihood '-.. of,, the presence' of.:.a latent. vitamin deficiency, 'A;:' forming the clinical background upon which, the Qk Lathyrus grain; may.; exercise its toxic effect on 0 \ t h e n e r v o u s ^ s y s t e m ; : / : /., 'K< , : . / ' . H / ' { : . . , ; W :.:..:

57

Two important factors have induced us to believe in the existence of such a background : firstly, the nature of food which the lathyrism patients commonly consume. They live practically on teora and dal only. Few of them can very rarely afford some milk and green vegetable also. As a rule they do not eat fish, meat, eggs and fruits. This diet resembles in quantity and quality (except for teora) the diet of those people among whom a great percentage in this area suffers from the different stages latent and visibleof vitamin B complex deficiency (Jacoby, 1946). There is therefore much likelihood to presume that the majority of lathyrism patients here also live in a permanent, although invisible, i.e. latent, state of vitamin B complex deficiency. Secondly, our practical observation at the bedside of lathyrism patients has taught us that the response to prostigmin is more immediate and more marked if vitamin B complex treatment precedes the prostigmin treatment. In a few cases this vitamin treatment seemed even indispensable to the usual prostigmin effect. On the strength of these two clinical experiences of ours we have made it a rule to give to our lathyrism patients first a course of about 12 vitamin B complex, fortified with 1 c.c. of crude liver extract, injections before starting on prostigmin treatment. Prevention.It is the duty of public health authorities in all countries to prevent diseases rather than to cure them. The tackling of the disease ' lathyrism' represents such a public health problem to. be undertaken by men of science in unison with the state's administrations. It seems to be a tough task, because of its manifold implications. In any case, science has given the lead in this field also by dispersing any mysticism as to the cause of this disease. To put the verdict of science in a nutshell : No lathyrism without consumption of Lathyrus. The first task resulting from this scientific knowledge is enlightenment of the public. . The writer has found that the villagers in lathy.rismaffected places are alive to the' fearful consequences of Lathyrus consumption.. They have been taught this lesson being confronted, daily with the sight of their crippled brethren who have consumed teora. The next task of the authorities concerned with the promotion of public health is a statistical one; a study of the incidence of lathyrism" in former years and nowr. On the initiative of the former Revenue Minister of Bhopal State, Sir C. C. . Garbett, such a study was undertaken by; a nutrition expert (Shourie, 1945) ' for> the year 1944-45. It estimated the'occurrence in this district as ' a t least 1,200 cases'.'.. Since then no further statistical data" have been available, and. .the writer depended,, therefore,"'on observations of individ- . uals. ^The writer has' attempted .to;" gather such obserYations"as"originate fronTpolice/officials in._

58

THE INDIAN MEDICAL GAZETTE

BEAUMONT, G. E. (1942).

[FEB.,

1947

charge of the villages concerned. They point to an increase in the incidence of lathyrism there during the year 1946. Whatever significance might be given to such reports in view of the absence of official data, the writer has actually come across and treated patients whose disease represents new outbreaks in 1946. If this fact of new outbreaks iu 194G or of an increase in the incidence of lathyrism in general is recognized and appreciated by the authorities, the third task should be a legislative. one. This should not prove too difficult, since this district (Bhopal) is a grain surplus area. The awareness of the villagers to the fearful consequences of teora consumption had apparently not the effect of inducing them to leave teora voluntarily to cattle only instead of using it for their consumption. They should, therefore, be prevented by law from consuming teora themselves. This ought to be a humanitarian duty and should not be governed by any other consideration. Such a step was in fact taken in November 1945 hy the Department Commissioner of Jubbulpore, banning the sale of teora in the Sihora telisil. Along with the legal prohibition of teora consumption should go the scientific research with a view to investigating a mixture of teora mixed with other grains, i.e. mainly of wheat, in which the proportion of teora is too small to exercise its toxic effect on men. Such research, which the writer had no facilities to carry out, would be of greatest importance in view of the presentworld food scarcity, because it would assist in overcoming this scarcity by stretching the available food resources with the help of teora, which grows abundantly even on rocky soil in spite of hailstorm, blight, excess of rain, etc. Summary Lathyrism is a specific disease of the . pyramidal tract, due to the consumption of teora, a species of the genus Lathyrus. in this area of Central India. " A full account of its manifestations and a description of the treatment with prostigmin injections is given. The.role, which vitamins, if deficient in the diet, play in the causation and treatment of the disease in men and experimental animals, is discussed. Suggestions for the prevention of the disease are made. Acknowledgment
The author desires to express his thanks to Sir Colin C. Garbett, former Revenue Minister, Bhopal State, for his keen interest and kind encouragement throughout the work. Thanks are also due to Messrs. HoffmannLaRoche, Switzerland, Branch Bombay, for the liberal supply of prostigmin. REFERENCES
AHMAD, S. K. (1944) . . Antiseptic, 4 1 , 514. BAETJ, K. P., NATH, Indian J. Med. Res., 24, 1027. M. C , GHAUT, M. 0., ; . and MUKHERJEB, R: .

Medicine. J. and A. Churchill Ltd., London. BICKNELL, F., and PRES- Vitamins in Medicine. COTT, F. (1912). William Heinemann Ltd., London. GEIGER, B. J., STEEXHOCK. J. Nutrition. 6, 427.
H.. and PARSONS. IT. T

(1933). Antiseptic. 43, 301. Indian Med, Ga'z., 8 1 , 246. KROHX. G. H. M. (193S) The Clinical Examination <// the Nervous System. U.K. Lewis and Co., London. LEWIS, H. B.. and Proc. Soc. Exp. Biol. and ESTERER, M. B.'(1943).Med.. 53, 26.3. MCCOMME \rOUKG, T. C. Indian J. Med. Res., 15, 453. (192S). ' and Disease/ MEIX.AKBY, E. (1934) . . 'Nutrition Oliver and Boyd, London. MIXCHI.V, R. L. H. Brit. Med. J., i, 253. (1940). PRICE, F. W. (1941) . . .4 'Textbook oj the Practice of Medicine. Oxford L'niversity Press, London. RAXJAX, M. P. (1944). Antiseptic, 41, 652. RCDRA, M. N\, and Lancet, i, 6SS.
JACOUV. H. (1940)

hlnn

(1946r/)

BHATTACHARVA, K.

(1946). xn\d Hygiene RUCE, R,, MUHLEN-S, P., Krunkheiten der Warmen Lander. aud Zuit VERTIT. M. W. Klinkhardt, Leipzig. (1925). Indian Med. Gaz., 74, 3S5. SHAH, 8. R. A. (1939). SHOURIE, IV. L. (1945) . . Indian J. Med. Res., 33, 239. TRABAUD, J.. and MOUHAR- Rev. Med. Franc, 13, 449. RAM (1932).

POST-MORTEM EXAMINATIONS IN THE PUNJAB : AN ANALYTICAL STUDY OF 669 EXAMINATIONS FROM 1923 TO 1944
By T. R. TEWARI and AMAR NATH GOYLE (From the Department of Pathology, K. E. Medical Colle-je, Lahore)

(1937).
BAEU,
M.

P.,
and,- M C K H E R -

' '
- Ibid^
' '

. . . . .
. . v 24, .1001;
.

A 'STATISTICAL generalization of. disease inci. dence based on post-mortem findings has its drawbacks as well as its' advantages. In India where autopsies among the not-too-poor class of patients in the hospitals and the private patients outside are ' t a b o o ' , where the subjects are mostly unclaimed bodies of beggars, vagrants and inmates of jails and asylums an adequate cross-section of the population cannot be said to come on the post-mortem table.. A considerable wastage of valuable post-mortem materialcould be avoided and more comprehensive population .groups could be studied if the pathologist-s were associated or worked in co-operation with the police surgeon, a practice which obtains at only a few places in India. The statistical advantage of post-mortem findings lies in the fact that.the basic pathology is discovered which ultimately led to death by a terminal disease. of minor import which however is more likely to. be entered as the cause of death in the clinical
records. . ' '' ' -- ":" - "'~-

K.
C,

NATH/ ..
.

JEE, R. (1937).

' " . ; L "

'."_'.'

With the appreciation' of the above facts an analysis of the available aut-ops3r records of the