26, I9O3-J

SECTION OF TROPICAL MEDICINE.

707

search revealed malignant tertian parasites nnd quinine treat^ resumed ; and, with the exception of a slight rise on the LATHYEISM. ,1 ague .on May 4th an:1. 7th, no more fever occurred : the By Major A. G. HENDLEY, I.M.S. improved,, and he left hospital on May iSth, the case at this THE best definition of this affection is Scheube's, which not iving been one of biliary colic complicated by malarial fever, ember 18th. 1002. he returned to hospital, and came under my only sums up in a few words prevalent opinions as to its i] since 7tli in bed. Has passed several gall stones since the causation, but at once recalls the nature of a too narrowlyich he brought with him. the largest being about J i n . in known disease of importance. He says : " Lathyrism is a . The liver dullness extended from the fourth space to 3 in. disease of the nature of an intoxication with a spastic spinal f costal margin. Spleen not enlarged, well-marked jaundice paralytic course, which is attributable to poisoning with h pain of a colicky nature requiring morphine. Temperature various kinds of the family of Papiiionaceae lathyrus (chick0 to 1020, with profuse perspiration. pea or common pulse). ,er continued, aud on December 2?nd he coughed up a quanDr. Watts, in his Dictionary of tlie Economic Products of scid irothy mucus. Temperature, ot a hectic type, continued 103 aud 104 in the evening. The vocal fremitus was slightly India, says : " Lathyrus, a genus of annual or perennial plant icd. but there was only partial loss of resonance at the right of the natural order Zeguminosae, which comprises some 170 diagnosed suppuration in the bile ducts in the liver, and species, seven of which are natives of India." The specimens operation for the purpose of draining the ducts and removing I have here are of the commonest cultivated Indian variety, stones. After a consultation 4his was agreed to. On the morn- lathyrus sativus, known in different parts of India under e 75th he coughed up a small quantity of pus. but in view of the utioned above, in which a fatal termination ensued in an various vernacular names, as khesari ddll, Uora, lakh, or of this kind, in spite of the opening through the lung, and Idkhori. To quote Dr. Watts again: "Lathyrus sativus certain knowledge of gall stones having been passed, it was (jarosse or gesse) is indigenous from the Southern Caucasus to to proceed with the operation as previously arranged. Captain Northern India ; it has spread as a weed of cultivation from in, I.M.S., kindly helping me. . , . its original home, and is now cultivated all over India." In inn.An incision was made in the right linea semilunaris with the Central Provinces some 358,000 acres are under lathyrus ; over the lower edge of the liver. The gall bladder was eoin- cultivation ; and it is in these provinces that the disease has iidden beneath the edge of the liver, but its fundus was reached of late years become so increasingly prevalent as to call for ned, and a number of small gall stones were extracted. On Government inquiry, which inquiry his been entrusted to sing the finger along the bile ducts beneath the liver, a large Major Andrew Buchanan, I.M.S., who has for the past six gall stones were felt deep under the liver, which could only cached. The wound was now enlarged upwards and downwards, months or more been devoting his entire attention to this transverse incision made across to the middle line, so as subject. IListory. le the lower edge of the greatly enlarged liver to be up. The mass of' stones in the right hepatic ducts Lathyrism is no newly-discovered affection. Its history ow be readied and opened, and with very considerable dates from very early times, being, according to Huber, a. mass of large gall stones, some 3 in. in length and over an alluded to in the Hippocratic writings, where mention is diameter in places, were removed, some of which were well made of the fact that " A t Ainos those men and women who K: liver substance. As it was quite impossible at such a depth to : opening in the duet to the surface, and as the patient was in a continually fed on pulse were attacked by a weakness in the In Don's System of . a glass drainage tube was inserted and gauze carefully packed legs which remained permanent." ; and the wound united around the tube. The patient suffered Gardening, again, it is recorded, in describing lathyrus from shock, but rallied .somewhat in the afternoon, but was sativus, t h a t : " I n several parts of the Continent a white mbled by coughing up mucus. At 10 in the evening he was pleasant bread is made from the flour of this pulse, but it ud coughing up mucus more easily. However, he never fully produced such dreadful effects in the seventeenth century ram the shock of the prolonged operation and died at 5.30 a.m. that the use of it was forbidden by an edict of George, Duke '//The same morning the body was examined. There were :'.iod adhesions around the gauze packine and no trace of leak- of Wurtemberg, in 1671, which was enforced by two other ischarge into the peritoneal cavity. The liver was removed edicts under his successor Leopold in 1705 and 1714." In stomach and duodenum and right lung altogether. Only one Italy and France the disease was also observed during the il stone in the depth of the liver in j the right hepatic duct was seventeenth and eighteenth centuries, and in the earlier half 'Inch was much smaller tlian some 01" those removed at the of the nineteenth century, large numbers of persons becoming ii. so would easily have escaped through the opening made in affected in France, British India, and Algiers, attracted :. and would doubtless have escaped through the wound. apparently some considerable attention. irom the years 1 too deep in the liver to be removed at the operation. Behind 1857-68, when Dr. James Irvingthen Civil Surgeon of ic the bile ducts were much dilated and full of pus in a limited of the upper posterior portion of the right lobe of the liver, Allahabadcontributed five very interesting and exhaustive eking abscess had opened posteriorly by the side of the inferior papers to the Indian Annals of Medical Science on the subject a. and travelled up through the diaphragm and the base of the of an epidemic of lathyrism then prevailing in the North-, ig into the inferior broncJil. The common bile duct was dilated, West Provinces, down to 1893, when I described in the opening into the duodenum was large and free. Indian Medical Gazette a localized outbreak I had met with

YC 7- %

* is;

I
It

is case a correct diagnosis of suppuration in the intrabile ducts was made very shortly after admission, and ration undertaken without any unnecessary delay, eat enlargement of the liver and depth of the in its hilum caused unusually great difficulty, yet :cts were completely cleared' with the exception small stone mentioned, and but for the unfor. "pening of the tracking abscess into a bronchus on the i:: arranged for the operation leading to a serious extra the patients strength in coughing up the muco-pus, I i favourable result might reasonably have been hoped i'e the conditions revealed post mortem clearly showed thing short of removal of the stones impacted in the ducts, and free drainage of the pus-distended intra ducts, could have relieved the symbtoms and averted il termination of this very deadly affection. In short, case had come under my care a week earlier his life lave.been saved by a still earlier operation, which empha:ie importance of. early diagnosis with a view to very peration. / ve not had . time, to search the literature of the years for cases of this nature, but I think that ate cases in which suppuration in the intrahepatic ave been diagnosed gnosed and an operation undertaken with ct object of draining the abscess through opening the -'is are:sumciently.rare to be worth placing on record, e eases? V are quite, distinct from, and require totally oUh. i e t r e a t m e n t t o ' t h e ordinary amoebic tropical

in the Central Provinces, the disease seems to have attracted no notice, save at the hands of a few veterinary surgeons, who noted its effects on cattle, and may in consequence be assumed as practically non-existent. The circumstances under which I first made acquaintance with the affection were as follows : Towards the end of July, 1893, I came across a village where quite suddenly some 10 per cent, of the male population had during the previous five or six weeks (that is, since the commencement of the rainy season), become paralysed, more or less severely, in the lower limbs. At-that- time I had never heard.of such an affection as lathyrism, but careful investigation and inquiry into the circumstances of the outbreak soon convinced me that they owed their condition to poisoning with lathyrus sativus, a pulse on which all the affected, poor hand-to-mouth labourers had largely subsisted for some eighteen months on account of the failure of their more regular crops, in consequence of which the village landlord had paid his labourers in kind with the cheapest grain availablenamely,'lathyrus sativus. For some,:years I saw.no further case of this disease; but with years of scarcity culminating in the terrible famine of 1S96-7, the local conditions artificially produced by the village-landlord in 1893 became general-; the poorer agi-icultural labourers were driven to resort extensively to the cheapest foodstuff procurable (lathyrus), and with most disastrous consequences. In the average village a dozen or more victims would be found,., whilst in a famine relief. camp of some 4,000 persons it became easy to pick out one or two hundred such cases. , . The disease has, in the.Central Provinces.and ^adjoining

LATHYSISM. native States, gone on spreading ever since, helped by the second severe famine of 1S99-1900 ; until at the present time Major Buchanan writes to me that he has an incomplete census of 2,700 cases in one district and 1,400cases in another; and in a reeeni letter says, " I have seen 190 cases this morning." I will now pass on to a description of the symptoms and mode of onset of the disease. For reasons, given above, it will be seen that only the poorest classes are liable to this disease ; those who are forced to subsist on the grain unmixed or diluted only slightly with other grain. All the affected will be found to belong to this class. They eat it either ground into flour as bread, cooked as porridge, or boiled with or without oil as lentils, much as we eat haricot beans. Practically all are field labourers, and the wonderful unanimity with which all agree as to the onset of the disease is most striking. A man will say, "I-went to sleep perfectly, well and very tired after a day's ploughing or other field work in the rain (it is always in the rainy season) and awoke in the morning to find my legs stiff, weak, trembling, and very heavy to lift when I rose to walk.'1 1 have never been able to elicit any history of premonitory symptoms.) This weakness and trembling, you will'be told,.increased so rapidly that within ten days progression became difficult, even with the aid of sticks. Still the patients have no sense of illness and no pain ; they have good appetites, sound digestions, and natural sleep at.night. .Both legs are usually affected simultaneously, first the calves, then the thighs, and soon after this all sexual appetite and power was lost. All complain bitterly of this. ...... . On examination of any typical case, of some six weeks' duration, you will find that the gait is very peculiar. Aided with a long two-handed staff walking is possible, the rate of progression being under two miles an hour. The body.above the hips sways from.side to side, whilst the feet, which seem clogged with invisible weights, are lifted with.evident difficulty and dragged forward, tbe toes scratchingalong or barely clearing the ground. The leg bearing the wefght of the body is bent at the knee and trembles, whilst the advancing leg, dragged wearily forward strongly adducted, is planted unsteadily directly in front of its fellow, the toes reaching the ground first. In short a kind of paralytic goosestep. The general effect is one of laboured unsteadiness, due to great weakness. The evident spasm of the thigh adductors ceases to be very apparent when the. patient reclines on his back, when the thighs can be separated, usually without resistance, toa normal extent. There is no wasting, no loss of muscular tone, no true tremors, only tremblings of the entire limbs when weight is put. on them. Sensation seems quite unaffected. The tendon reflexes are much exaggerated, both knee-jerk and ankle-clonus ; the slightest stimulus starting the latter phenomenon going for a long time. There is no loss of power or undue excitability in bladder or rectum. The arms, trunk, head and neck muscles are unaffected. The mind is clear, speech natural, pupils normal and reacting naturally to light and accommodation. The urine is often of rather high specific gravity (1030), acid, and contains abundant urates. Such are the symptoms as I have found them. I am aware that some writers state that digestive disturbances, colicky pains, and diarrhoea are usually precursors of the paralytic state ; and that sensory disturbances such as hyperaesthesia, anaesthesia, and formication, with bladder troubles, such as incontinence and retention of urine, are common. I have never met with a case in my experience of many hundreds where the slightest history or evidence of any such complications could be traced.
Etiology. Symptoms.

lKPT IS: -'

other theories, .ind can only say that the occurrence f iv disease in epidemic form among lathyrus eaters and <.~-* no others, seems to me Very strong evidence that a h't'f'0*^' diet is primarily responsible. The idea that diseased r * only is injurious is an argument probably borrowed frorrffu analogy of ergotism. I know of no facts to support th< H That exposure to sun or some local hot wind can li'.) ^J responsible is at one disproved by the undoubted fact tliiiUK disease has occurred (amongst lathyrus eaters) equally iii trously in India, Italy, France, Algiers, and "VVurt('in|,(^f" countries with vastly dissimilar meteorological condiiio Also, if exposure to cold and wet alone could induce lathvriHm England surely should be full of such cases. As r"i<ei' Manson's suggestion that the affection, like beri-beri, nir a "place disease," one has only to remember thai'th paralysis is incurable, and that removal from the localit where the person was attacked is in no sense beneficial j& to what the actual poison is, and how it acts, that is a matter still left for our eminent physiologists and chemists to decided Church has stated the chemical composition of the grain as * water, 10.1; albuminoids, 31.9; starch and fibre, 53.9; oiL 0.9; ash, 3.2; and has further observed that " the 'ofl expressed is a powerful and dangerous cathartic." ]t,Astier says " there is present in the grain a volatile liquid" alkaloid, probably produced by some proteid ferment, which exhibits t h e toxic action of the seeds, and the action oj which is destroyed by heat." On this volatility and destroy tion by heat notion has been based much speculation aa to possible variations in methods of cooking, explaining h& capriciousness of the effects of a diet of this grain on different Vf individuals. Scheube says, "Several poisonous, alkaloids., have been extracted but further investigations are n e c e s s a r i l y also, " that by the administration of preparations made fioiff*V the grain, a disease giving rise to symptoms similar to "* lathyrism has been produced in animals." <^*t_ Professor Dunstan, of the Indian Institute, is now working v at this subject. So far his investigations and experiments on animals are inconclusive, but go to show (1) That only certain * samples of lathyrus are poisonous ; (2) there are some reasons r to think the poison is contained in the skin or husk of the seed, b u t no fungus has been discovered ; (3) that poultry are j& i m m u n e , but that rabbits and guinea-pigs are sometimes ;j affected. Professor Dunstan also tells me that in Canada ^f lathyrus is largely grown and freely used as poultry food so ' / probably birds are immune. My own pigeon feedinjp <r experiments in India were all negative and so support this view. ,r There remain two points of interest in connexion with the causation of. lathyrism, namely, its marked preference for jf* males and its seasonal incidence, that is, during the rainy season. Dr. Irving found that the proportion of females to^ males attacked was about 1 in 12. Major A. Buchanan,' * I.M.S., with a recent very large experience, tells me he finds it 1 in 10. I personally have only seen 3 female cases against many hundreds of males. Major Buchanan accepts the com- , parative immunity of females as an unexplainable fact, but .. says t h a t the reason for the seasonal incidence of the disease is very simple, namely, that "he finds that the ordinary r grain pits or granaries are closed in June, and that l a t h r r n s ^ grain is only issued to labourers in the rains." . ."** Sr The difficulty in the way of accepting this explanation is ^ that (1) I do not believe the custom he alludes to is general ^ * that of only eating lathyrus during the rainsit certainly was not during the recent famines; and (2) the fact ina<^ according to this idea cases occurring quite early in t l i e j ? " ? ~ *""" must have been caused by a very few days' dietary of u ^ poison ; and this is opposed to all my experience of histories >. given me by patients. I prefer an even simpler solution*'.V both difficulties. As long ago as 1S5S Dr. Irving quoted u i prevalent opinion amongst intelligent educated natives^at being, that " t h e lameness produced by eating lathyru c really a mixture of palsy and rheumatism," and added seem to think that living on this particular grain-la.the pre?J disposing cause, and exposure to cold, rain, and damp weai t h e exciting cause." ?\. ,

1. That lathyrus eating has nothing to do with it. 3. That if it ;has, it is only diseased grain which is capable of poisonous effects. . . '. 3. That exposure to snn or some local hot wind is the true cause. 4. That the paralysis is due entirely to cold and damp. 5. One eminent authority on tropical medicine (Mansonl has thrown out the suggestion that, like alcoholism and probably beri-beri, the disease maybe due to the entrance into the body of a toxin gene-rated by germs-whose habitat is outside the body. ' -6. Lastly, I am quite prepared to hear some champion of parasitism arise and suggest that some organism, so minute as to have hitherto .escaped observation, is really the author of all the mischief.

As regards the etiology of the disease, it is, I think, generally conceded now that the paralysis is in some way due to lathyrus poisoning.. Other mam theories of causation are:

,. .In the time at my disposal I cannot fully.discuss these and

I believe the native idea is the correct one. I peiie^e lathyrus, whilst it may possibly cause paralysis by ordinarily only predisposes to it, that it makes the s rjady or ripe for the attack of paralysis, but th to severe wet and cold is required actually to sudden seizure. This seems to me to explain the iDg history of the sudden unexpected attack during tne season only ;. for nearly always the attack occurs alter BU usually thorough wetting whilst ploughing, watching cru

SETT- 26,

SECTION OF TROPICAL MEDICINE.

IHtnuuT, ,

|i flnd prolonge . . . t" comparative i m n i u n l ' ' y - I " a v e suggested to Major Buchanan * . j^nt the respective shares which exposure and a iathyrus dietary have in producing the paralysis might well be tested - during the extensive animal-feeding experiments which are t< be carried oat at the Bombay Research Laboratory.

Satisfactory observations on the morbid anatomy and path ology oi the disease are wanting. From the clinical sym ptoms one would be justified in assuming it to be a form 0 lateral sclerosis, but in AVatts's Dictionary I find a statemem thnt "' Cantarri of Naples has published'a number of cases in . which he has carefully observed the conditions after deatl: JCo nil'ection of the spinal cord was discovered. The muscles of the lower extremities, especially the abductors, were found to have undergone a fatty degeneration, etc." Scheube mentions one published necropsy (where death resulted from malarial cachexia) where '' a softening of the spinal cord above tlic lumbar enlargement was found." Allbutt refers to two examinations of horses which had died of Iathyrus poisoning. In these the symptoms were apparently mainly those of onrdiac and respiratory oppression, and after death "the mischief was found mainly;in the cells of the anterior horns of the cord, which were diminished in number and atrophied. There was also thrombosis of small arteries, which were also thickened. There,was, too, fatty degeneration of the heart and intrinsic muscles of the larynx." ftom this he suggests that the nerve mischief may be secondary to the vascular lesions, which would suggest a similarity to ergotism. The prognosi of this disease as regards life is favourable. It does not seem to cause death directly, but the paralysis is incurable. Treatment, I believe, is quite futile. A PLEA FOE THE PROPEK MEDICAL SUPERVISION OP " REFRESHMENTS " PURVEYED ON RAILWAYS IN THE TROPICS :
WITH SPECIAL REFERENCE TO INDIA, AND FOR BETTER LATRINE AND LAVATORY ACCOMMODATION" FOR THE TRAVELLING INDIAN PUBLIC. By H. D. MCCULLOCH, M.B.,

Morbid Anatomy and Pathology.

way Defects," referring to the very candid report of the Special Commissioner, he is represented as having stated that, speaking generally, he thought the present administration and working of the Indian railways cannot be regarded as satisfactory, etc. He advocates -the provision of dining cars'on all fast through-service trains to economize time, and thinks that' railways in India are not sufficiently appreciative of the value of their third-class passenger traffic,.drawing special attention' to certain gross abuses to" which" these are subjected. He further suggests the introduction of electric fans, which he thinks should be made compulsory within five years ; the use of oil sprinklers to allaydust, and lavatory accommodation in all third-class carriages, which should be :widened. Beyond these important sanitary recommendations no reference is made to the-medical departments of railways, this being, perhaps, a matter beyond the/, province' of his
report. . '':'''' ->-" '" :. - ^ '"'

The Government of India, however, in. the Public Works Department addressed the different railway administrations through the local-governments last year desiring thiit certain rules should be formally agreed to betweerithe.medicarahd sanitary authorities of local governments and tiiose of railways within their areas, for the purpose' of affording such mutual advice, support, and intimation of outbreaks- of epidemics, etc., as may be for the general benfefit. of the' public health and for the prevention of much siekness and
mortality.

While these rules are having the consideration; of our Government the proposition that I would venture'to advance is the necessity lor adequate medical and sanitary'staffs'hot only on our great Indian railways, but also on our mercantile marine, to enable them to cope with modern sanitary 'and medical requirements, the urgent need for which the diagrammaticrepresentationsbelowwill,Ithink,makeobvious;and I trust that the time has now come for our-medical members of Parliament, aided by the General Medical Council, to urge the Government to send out a Special Commissioner and medical expert to inspect and report upon the medical administrations of our mercantile marine and great railways in the interests of public health..
Diagrams representing inequality and inadequacy of Sup.Medl. Staffs on Rys.

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v ;

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: ;

Miles
30002500 2000-

Chief Medical Officer, N.G.S. Railways, India.

OVE vast Imperial commerce and the foreign enterprises which have come into being since the introduction of steam as a motive power, our great mercantile-marine and extensive railway communications, extending in India alone to over 26,000 miles, has resulted, among other things, in rapid intercourse between East and West, which in its turn has gone to bring into prominence certain disadvantages, having regard to the public health of the communities concerned, uituerto remote from one another. Contingencies have an sen necessitating the adoption of special precautionary measures to prevent the conveyance of infection from already infected areas to uninfected areas. Owing partly to the infection being undetectable durino- the latent period m man and the vitality of the virus under prying conditions, climatic and otherwise, the difficulties xpenenced by medical authorities in the framing and adop*nA 1 8 a n i t a r y Preventive regulations have been very great >a tne inconvenience to the general public extremely e 8 e t i m e s of ahZT^ P ani c, the consequence being the >a n le fi ^2 ? ntof such regulations or their irregular adoption Penain areas "pro forma," and the adoption of serum s of Haffkine's antitoxin systematically and on a scale, by the temporary employment of a large superior ar-'d sanitary staff, with the greatest benefit, where tolerated. .... Be necessary last year for the Home Government to India, a special railway expert in administrative m,i Mr T>,omag Robertson, C.V.O., was selected as -jr to inspect and to report on the ad01 railways in India from the commercial and ic aspects, though the administrations of the various ri;^.1?!"1-11? COmpanies in which our Government is urectly interested was not included. 1 text of Mr. Robertson's report was, I believe, in India last May, but the Blue Book to be issued am told, still in the hands of the King's printers. rroman Indian newspaper article on " Indian Rail-

1500 1000 500 _

GIPR EIR MR BNR SIR EBR ;<* Excessive expenditure on superior medical staff. Miles.

NGSR

. . Medical Employes. Administration, Cost Per Mile. Rs.

21.40, 30.0a \

Great Indian Peninsular Railway. East Indian Railway ... Madras Railway... Bengal Najpur Railway South Indian Railway... Eastern Bengal Railway Nizam's State Railway...

2,674 =,358 1,600 1.557 1,350 899 745

10,500 20,300

I5,5
|ooo 8,000 50.18 ;

The democratic idea that every citizen is entitled to the benefit of everything that will' add to human'health and happiness is growing fast. Health and sanitation Acts by the Legislature, medical officers of health, sanitary inspectors, nspections of workshops, etc., have all, in addition to prolonging life and diminishing death, done incalculable service by rousing in the public mind 'the yagne beginnings of a tremendously important -mental;process- of' a dissipation of.