May. 1899.

THE

OP TBOPICAL MEDICINE.

261

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SPECIAL ACCOMMODATION FOR INVALIDS.

Original Comnronieations.
A NOTE ON LATHYEISM.
By W. J. BUCHANAN, B.A., M.B., Dipl. State Med. (Dubl.).

Capt., I.M.S. ; Superintendent, Central Jail, Bhagalpur, Bengal.

THE accompanying photographs (see plate) illustrate, as far as stance and gait are concerned, the results of poisoning by the prolonged use, as a food, of Lathyrus sativus, called in the vernaculars of India kesdri or tebri. The patient photographed is one of eleven cases of this disease which I have met with in India during the past year. They all came from areas afflicted by the recent famine (1897). The and healthy condition of the patient here -presented does not recall famine conditions, but this is : only because he has been over a year well fed in the [Central Jail, Bhagalpur. Lathyrus sativus (nat. ord. Leguminosa) is one of genus of annual herbs, seven of which are natives f India.1 It is indigenous all over northern and central India. It is grown wild as a cold-weather fcrop on land which will raise no other kind of pulse. |Itis grown largely in the North-west Provinces and (Central Provinces of India. It is principally cultivated 8 a fodder, but being cheap and easily grown, lathyrus V . considerably used as a food by the poorer classes largely so in times of scarcity. The following deal composition is given by Church (" Pood irains of India") : Water 10-1, albumenoids 31-9, rch and fibre 53-9, oil -9, and ash 3-2. pulse is usually to be met with in bazaars, but * Watts' "Dictionary of Economic Products," vol. iv., p. 590.

the people of the country are well aware of its noxious properties and only use it as a food in times of scarcity, and then only with the hope of being able to soon stop its use. The occasional use of this pulse, or its use along with Other food grains, is harmless or attended with symptoms of colic, dyspepsia, &c, only ; but if freely employed, especially for long periods, the form of paraplegia known as lathyrism is a very frequent sequel. In olden days, when famines were looked upon as visitations of Providence, to be regretted but scarcely prevented, we heard much more of this disease. Now a-days it is rare, and I have only been able to hear of a few cases during the recent famine in the district of Gaya and Shahabad in Bengal, and in the Central Provinces. Whereas, in 1860, Dr. Irving has recorded that in one Bengal district no less than 4 per cent, of the population suffered from its toxic effects. Colonel Sleeman's account of the disease, as seen by him in Oudh in the famine years 1831 to 1833, is as follows : " I n 1833," he writes, " the younger part of the population of the villages of Eastern Oudh, from the age of thirty downwards, began to be deprived of the use of their limbs below the waist by paralytic strokes, in all cases sudden, but in some more severe than in others. About half the youth of these villages of both sexes became affected during 1833 and 1834, and many having lost the use of their limbs entirely are unable to move. . . . The youth of the surrounding villages in which hesri formed the chief article of food have suffered in an equal degree. . . . no person once attacked has been found to recover the use of the limbs affected. They describe the attack as coming on suddenly, often during sleep and without any warning." That we have heard so little of this disease of recent years is due to the fact that Government has recognised it as part of " t h e white man's burden" to " fill full the mouth of famine." Symptojns of Lathyrism.The onset of the disease is usually sudden, but it is probable that this is so described because the patients do not recognise that indigestion, colicy pains, and diarrhoea are also due in many cases to the toxic action of this pulse. The muscles of the lower extremities become affected and paraplegia results ; the trunk and upper limbs appear to escape entirely. There is said to be a stage of hyperaesthesia. The chronic state is that usually met with. In this the patient presents a characteristic appearance, and in famine-stricken districts they are easily recognised. The gait also is characteristic and is thus described in the article in Allbut's " System of Medicine : " " A peculiar gait, rigidity of the dorsilumbar muscles on the side opposite each leg, as it is moved forward, giving a throw of the trunk backwards and sidewards against the weight of the advancing leg. The body is thrown into a series of curves, describing a screw or figure of 8 [vide photograph, No. II,] the leg with the toes pointed, and heel drawn up is thrown out in tremulous extension and adduction, the toe reaching the ground before the heel, or the heel does not reach the ground, the gait becoming a tripping on the toes." An older writer, Dr. Kinlock W. Kirk, of the East India Company's Service (who was killed in the

262

THE JOUENAL OF TEOPICAL MEDICINE.

[May, 189

Mutiny in 1857) gives a description to the same effect : " Limbs and joints appear loose, weak, and agitated, and give so much at every step that while the person is walking the figure has a constant upand-down motion . . . the patient walks dragging his toes along the ground." The two illustrations show this stance and characteristic movement of the limbs. The skin reflexes are usually lessened, and the kneejerk and ankle-clonus exaggerated. The patient is usually emaciated, and often takes up the trade of beggar, and hops with the aid of a long stick all over the district. The condition appears to be incurable. The Pathology of this disease has been inferred briefly from the symptoms, which point to implication of the posterior and lateral columns of the cord. Cantarri, of Naples, has described the post-mortem appearances in some cases. He appears to have found no affection of the spinal cord, but describes a fatty degeneration of the muscles, especially the adductors of the lower extremities, the transverse striae being diminished and the ultimate fibres containing little drops of oil. JEtiology.That these symptoms of paraplegia will frequently follow the prolonged and excessive use of Lathyrus sativus is well known to the people in India, but it is only in times of scarcity that they make much use of this pulse.2 Its use is forbidden in all Government institutions in India. Astier is quoted by Watt (op. cit., p. 592) as having found by analysis a volatile liquid alkaloid probably produced by some proteid ferment, which exhibits the toxic effects of the seeds, and which is destroyed by heat. The importance of this discovery lies in the fact that the alkaloid is volatile. It is therefore probably absent when the food is thoroughly cooked. The toxic effects of this pulse are not confined to the human species. Similar effects have been noted among cattle and horses. In Smith's " Veterinary Hygiene," instances of its acute toxic effects on horses are given when used as food for them even in England.3 Don also states that swine fattened on this meal lose the use of the hind limbs. It is also probable that many cases of the disease known to Englishmen in India as " kumree," or " gone in the loins," a not infrequent disease of horses, are due to feeding on this pulse, which is often used to adulterate gram (Phaseolus mungo).

THE ETIOLOGY AND TEEATMENT OF BLACKWATEE FEVEE.

B Y L. W. SAMBON, M.D. (NAPLES).

London.

II.
Is IT QUININE POISONING?

PROFESSOR TOMASELLI, of Catania, being aw: that the clinical features of blackwater fever diffei widely from those of the co-endemic malarial d eases, and having observed that the administrati of quinine frequently aggravated the blackwai paroxysms or seemed to provoke new relaps< argued that the disease was not malaria per se, b a form of quinine poisoning peculiar to malar cachectics. Tomaselli's theory was built up in Sicily, whe blackwater fever is not very frequent, and was B O < widely diffused through Europe and North Americ where the disease is still less frequent. Quite recentl Koch gave it very rashly the support of his name, b the English physicians who have had much experien with the disease in inter-tropical Africa axe unan mous in protesting against this theory. Quinine never produces haemoglobinuria in health persons, not even when administered in highly toa: doses. In malaria, it is a specific remedy. Indeiek with the exception of iron in anaemia and of mercer and iodide of potassium in syphilis, we have lie amongst the whole ten thousand drugs of the macopia a more directly beneficial remedy. Tomaselli and his school first advanced that globinuria was produced by quinine in malarial < tics, but the English physicians in East and Africa, the French in Madagascar and most Am authors in the Southern States, repeatedly ol the disease in people who had suffered only slightly from malaria and were by no means ms ' cachectics. On the other hand, blackwater fei never seen in the numerous cachectics of most ofj intensely malarious regions of the East. Finding that malarial cachexia could not account for the haemoglobinuric action of qt' a special congenital idiosyncrasy to the d g j put forward ; but then how is it, we would ask,|| this peculiar idiosyncrasy is found year after almost all those who go to certain districts of tropical Africa yet never in any of those who go malarial districts of China, India and Australia?*! how is it that those who suffer from haemoglot fever never show any peculiar idiosyncrasy to qt LIEUT.-COL. CBOMBIE, I.M.S., has been appointed Lecturer on Tropical Diseases at the Middlesex Hos- either before or after the attack ? The quinine theory of blackwater fever was lot pital. on the assumption that its administration aggnn the haemoglobinuric paroxysms and provoked relapses. In studying the literature of so-called " 2 In the brief reference to this pulse in Notter and Firth's "Hygiene" (p. 348), L. sativus is quaintly called " dal," as if this haemoglobinuria ' ' we find the following to were the English or vernacular name. The word " dal " is real facts. used by Europeans to denote any pulse used as food, but the In regions in which blackwater fever and term only means" split " (as in the expression " split peas"). are co-endemic, a patient may have suffered rej All the peas and pulses when split are called by natives of India attacks of tertian fever or of summer-autumn "dal," but they more usually call them by the name of the which were satisfactorily treated with quinine, grain, viz., masur, kalai, kesdri, &c. 3 day, suddenly, instead of an ordinary malarial Vide also Veterinarian, April, 1885.

JOURNAL OF TROPICAL MEDICINE, MAY, 1899. LATHYBISM.

PARALYSIS CAUSED BY THE CONSUMPTION OF THE PULSE OBTAINED FROM Lathyrus Sativus.

Some 60 years ago Dr. Buchanan Hamilton drew attention to the injurious consequences resulting from the consumption, for any considerable period, of that form of dl derived from the Lathyrus sativus. Since then' the symptoms described by this astute observer have been frequently confirmed and on all occasions famine and destitution have preceded and accompanied the ailment. The herb Lathyrus sativus belongs to the natural order Leguminosas and to the great Vetch family. It is one of the plants which contribute to form dl, a generic term bestowed on all leguminous seeds met with, in some form, in every household and bazaar in India. Of the various forms of dl the following are those met with in India : 1. Urhur or Toar (Cytisus cajan) is considered the best of the pulses, but owing to its cost is consumed only by the richer classes. It is pleasant eating, and the natives, even although aware of its bad effects, are unwilling to discontinue its use. The symptoms consequent on its consumption are those of ' intestinal catarrh and cutaneous affections such as urticaria, bronzing of the surface, dry skia and burning of hands and feet. In course of time the bones of the legs become painful, the periosteum thickens, the moral sense and physical powers deteriorate, and women become barren. The pernicious effect of the consumption of Urhur is most marked when it is consumed without the separation of the skins. 2. Oordh or Marsh Dl (Dolichos pilosus) is more largely used than any other legume in India, it is the staple article of diet among all classes except the richest and the very poorest. Without the skins it is wholesome food but when consumed with the skins it induces colic, indigestion, and a dry harsh skin. 3. Moong (Phaseolus Mungo) is the variety of dl which usually finds its way to the table of Europeans in India. It is a rather tasteless food but is by far the safest form, being light and wholesome. 4. Motth (Phaseolus aconitifolius) is grown in India for the sake of its straw, which is a valuable food for . cattle ; and its fruit is eaten by only the very poorest of the poor. 5. Chunna or gram (Cicer (or Ervum) Arietinum), and 6. Mussoor (Ervum lens), are not in frequent use as a food. 7. Khesaree, Kesari or Teori (Lathyrus sativus) is the least wholesome of all the pulses met with in the1] bazaars of India. An excellent description of the paralysis induced by its continued consumption is given at I page 261, No. x., vol;i., of this Journal by Gapt W. J. Buchanan, I.M.S. It is said that the extent of poverty ins,] village may be estimated by the amount of the Lathyrus sativus dl met with in the bazaar. It is only during! periods of famine or utter destitution that people take to its use. The natives are quite aware of the evils likely to j follow its consumption, but they partake of it rather than starve, either mixing it with more wholesome food, or j if such is unattainable it is used as the sole article of diet, in the hope that a short period of its use may not bel followed by evil consequences. An interesting reason, as showing the low estimation in which the dl froml Lathyrus sativus is held, is given by Dr. K. W. Kirk : " The villagers said that if they sowed a better kind of] grain, it would be plundered by the Beloochees from the hills, but that they would not take this." The plant is] not sown, but is left to grow among the wheat and other grains. When the grain crop fails the Lathyrus sativus J flourishes and a rich crop of the latter may be gathered with the blighted grain. On this the natives subsist withl the result that many become paralysed. At the present day the effects of famine are happily less evident in IndiJ than formerly ; communication is more rapid, and consequently the paralysis resulting from the consumption! of Lathyrus sativus is more rarely seen. General Sleeman, writing in the " thirties," states: "The deleterious] effects of eating Lathyrus sativus come on insidiously, gastric irritation, and intestinal catarrh preceding the] paralytic symptoms." The poor people, condemned'to this form of subsistence, believe that by ceasing to] consume the pulse when these symptoms obtain, further effects will not ensue. In this they are sometimes] correct, but frequently paresis supervenes, and if the food is persisted in complete paralysis of the lower! extremities results. The signs which betray the onset of the paralytic seizure are a difficulty in walking and] balancing the body. During progression, the body weight is thrown perpendicularly first on one lower ; extremity and then on the other causing a waddling, rolling gait ; and when the patient attempts to stand still, ' one foot is planted below the centre of the axis of the trunk, whilst the other is either advanced, retracted, abducted, or crossed over the supporting limb so as to maintain the balance. This condition is admirably exemplified in 3 the accompanying photographs. When the paralysis is more complete the patient can progress only on crutches, ; the lower extremities being dragged forwards with the toes scraping the ground. In the most advanced stage of ' the disease the patient can only move about in a sitting posture, the upper extremities being used as a pair of crutches or supports on which the body is swung forward. The paralysis affects the lower extremities only, the trunk and upper limbs remaining unaffected. The signs and symptoms point to an affection of the posterior and lateral columns of the cord, but no anatomical changes in these tracts have been seen. Cantarri has had the opportunity of studying the disease in Italy and states that post-mortem appearances were confined to a fatty degeneration of groups of muscles in the lower extremities. So decided is the evidence of Lathyrus sativus being the cause of this peculiar form of paralysis that it U prohibited as an article of diet in Indian Jails and institutions over which the Government have direct control. Thorough cooking lessens the pernicious effects of this form of food and it would seem, as stated by Astier, that the toxin contained in Lathyrus sativus is weakened if not destroyed by heat. No cure is known, and although the general health of victims of poisoning by Lathyrus sativus may be re-established, the paralysis remains.

LATHYRISM. Photographs illustrating the paralysis resulting from the prolonged use of Lathyrus Sativus as a food in Iudit. By Capt. W. J. BCHAKAN, I.M.S.

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*, Ltd., London.