THn,

[OCT., 1949

fe*?'

Staff:-

LATHYRISM IN BIHAR
By S. B. LAL Offlcer-in-charge, Nutrition Scheme, Bihar. Bankipore, Patna LATHYRISM has been reported from the time of Hippocrates. Alention 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 outbreak of lathyrism from Central India. 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 flat country and there are no irrigation facilities, the farmers having to depend entirely on rain for the supply of irrigation water. Darbhanga and Monghyr districts are 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 consisting of the cheapest grains available. Lathyrus sativus is known in these places as ' Khesari '. It is a good hard}^ 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 easy 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. As a rule there is acute scarcity of vegetables and fruits in the villages except for mangoes during the season. Milk and milk products are either not available to the poor or are available only in negligible .quantities. Meat and eggs, because of the high cost, are also very difficult to obtain. The disease started in July. 1947 in the villages of Patna and Monghyr districts while in August 1947 in those of Darbhanga district. All the persons affected were landless labourers and were very poor economical^. They were

1 visiting physician. 2 trained full-time.ayahs to work by shifts. 1 boy. 1 hot, (part-time). The last three on Rs. 40; Pu?. 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 Rs. 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. 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 medical practitioner must inspire enough confidence to this end. There is no doubt that the assistance'of a proper specialist is necessar}*. So, the Government must depute the specialist to visit each centre to help trie general medical practitioner. If the patient feels that he can get comfortable accommodation and at the same time facility for good medical aid i gatea,, these isolation centres will be highly attractive, convenient to the patient and attendants, relieve congestion in the existing sanatoria, isolate the sufferers and check the spread of the disease. The sufferer will get earlier aid, and thereby have a better chance of being cured, and the specialist will have an" opportunity of doing his job more easily. The general medical practitioner will have every thing to be proud of. Most important, there will be a check on the spread of diseases. The next step is to wait for improvement in the economic condition of the country and discovery of specific remedies to combat the disease.

1
3

OCT.,

1949]

LATHYRISM IN BIHAR : LAL

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 PERCENTAGE number Female of Male affected Male Female persons .
!

Patna Monghyr Darbhanga

TOTAL

143 27 49 219

13S 27 46

5
3

96.5 : 100.0 93.9 ; 96.2

3.5 6.1
3.S

. |
i

211

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 II.
TABLE II
PERCENTAGE

Age groups

Male

Female

Male 6.84 3.65 85.83

Female 1.36 2.28

12 to 16 years 18 to 20 years 25 and above

.. ..

is

3 5

188

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

Types of food consumed 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 very 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 onlv 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 nearlv the same. The intake of vitamin A was below the standard laid down by the Nutrition Advisory

TABLE III

Average intake oj calories and types of food in oz. per consumption unit/day {affected families)
Name of district Patna Monghyr Darbhanga ,C e r e a l s
:

puiseg

Leafy Non-leafy \ Fats and ! Fl'esh vegetables vegetables; oils foods i 1.15 0.56 0.59 1.49 0.93 1.61 i 0.33 0.10 0.07 ! 1.06 ! 0.44 0.99

Milk and milk products 1.16 0.17 0.30

Fruits and nuts 0.79 0.60 nil

Condiments Calories ' 1.18 0.71 0.13 3221 2,421 2.904

16.06 1327 12.66 ' 10.74 25.57 ' 329

TABLE IV

Intake of vitamin and percentage of ' Khesari ' in the diet of affected and unaffected families per consumption unit/day .
Families surveyed Patna. Monghyr Darbhansa Affected Unaffected Affected Unaffected Affected Unaffected !
i
i

Percentage of ' Khesari '

. . . .

Vitamin ,

Vitamin Bi,
mg.
32

I.U.
2.834 4,848 2,879 4,012 1,830 4,142

Vitamin C, . . m S. 242 13.6 /: : 37S 102 42A 3.0

. . . i' . 1 . i . !

' ' 74.1 2.0 542 2.5 79.6 3-5

1.8.
1.6

.1.9
2.5

1.6

L70

THE INDIAN MEDICAL GAZETTE

| OCT.. 149

Committee (1944) aneigne same was true for vitamin C as well. State of nutrition In order to assess the state of nutrition, all 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. The lowintake of vitamin A by families of Darbhanga'J district does not reflect the incidence of itsr" deficiency in the children of the place, which'" may be due to the fact that the children whileplaying 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 unaffected families.

TABLE V

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

District

Families surveveci Actual

Boys Girls
TOTAL 43 40 83

Good
!

Fair Percentage j Actual

51. 52.1 103 4G
149

Poor Percentage
34.6 25.5

Percentage ; Actual
14.4 22.3 151 94
245 74 50

PATN'A

Affected

Unaffectf

j Boys i Girls
.TOTAL

23 17
40

18.2

51.3 53.7

47 26

32.6 29.S

124 1S.4 19.2 98 76 176

20.4 22.4

MONGHYR

Affeded

( Boy? ) Girls
TOTAL .

40 30 70 30 20 . 50

45.1 4S.7

79 50 129

36.4 32.1

Unaffected

. Boys ! Girls
TOTAL

90 70 160

50.0 58.2

60 40

29.6 19.9

100 57.1 56.4 84 38 122 58.4 63.1 41 9 50 10.9 1S.6 26.6 25.8

DARBHAXGA

; Affected

\ Girls
TOTAL

Boys

51 26

16.1 17.6

180 S3
263

Unaffected

\ Boys 1 Girls
TOTAL

31 25
56

30.4 18.2

90 85175

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. In a few cases the onset was after an attack of fever. The fever mostly was malaria. The other findings were those of upper motor neuron lesion. Table VI gives the findings of the survev.

OCT.. 1U49J

LATHYRISM IN BIHAR
1ABLE V I

til

Percentage incidence of diseases supposed to be associated with malnutrition

Percentage found to be suffering from District Families ; Total ; ; : number p h r y n 0 _ ! XerophAngular derma thalmia stomatitis
297 ISO 144 93 217 156 180 130 315 147 162 119 S.6 10.4 7.6 13.9 S.7 8.9 7.0 6.9 5.1 4.S 0.7 2.1
7.0 8.8
c.irjpc

Malocchision
5.6 6.5

Total percentage suffering from one or other disease

41.4 2S.3 49.3 28.5
09 ^

PATNA

Affected Unaffected

Boys Girls Bovs

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

14.8 14.7 15.9 18.2 11.7 13.4 10.7 14.5 34 6.8 7.1 2.6

6.2 11.8
S.I

4.S 9.6 5.9 7.1 nilnil 1.9 2.0 nil nil

MONOHTR

Affected

Boys Girls

2.5

23/7 30.2 24.5

Unaffected

j Girls
Bovs Girls Boys Girls

1.5 1.9
22

DARBHANGA

; Affected

?,'.4

16.1 23.1 17.3 12.6

Unaffected

nil nil

Discussion Lathyrus sativus is mostly mixed with Vicia 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 Vicia 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, Vicia sativa, and deficient in vitamin A. Further suggestion that this vitamin may furnish protection against lathyrism 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.). Jacoby (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 i MEU,A>-BY. E. (1930) . . Brit. Med. ,/., i, 677. with lathyrism. Further, hisfindingswith 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 MITKA. 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 XUTRITIOX A D V I S O R Y Report of Sub-Committee on toxic agent of ' Khesari ' exercises its effect. The COMMITTEE (1944). A utrition-al Requirements. Indian Research Fund incidence of B complex deficiency amongst the Association. Xew Deihi. patients were 15.5 per cent, as against 14 per j .SHOUHI, K. L. (1945) . . Indian J. Med. Res., 33, 239. cent reported by Jacoby {loc. cit.). X.. W. H. (1S44). Rambles and Recollections y,o reason could be elicited from the survey of an Indian Official. for the high incidence of the- disease in Hatchard and Sons, London. males. The suggestion put forth by Shourie (loc. cit.) that the high incidence was due to ?XOOK. L. C. (1948) /. Agrie. We^t Australia. 2S, 47. greater intake oi 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 abe 3noan riDebca tas that since the males only work in fields, their calorie requirements, and so their intake of Lathyrus sativus would also increase, has not been borne OUT. INSANITY IN INDIA Summary (From the Indian Medical Gazette. October 1. An outbreak of lathyrism in three districts 1899, Vol. 34, p. 373) of this province has been described. THE following tables, compiled from the 2. Diet surveys of the affected families revealed high consumption of Lathyrus sativus reports upon the Lunatic Asylums of Bengal, Madras and the Punjab, show the relative and low intake of vitamin A. numbers of lunatics in the asvlums at the end 3. The state of nutrition was commensurate or the year 1898 : with the calorie intake. 4. A suggestion based on the field studies Bengal Madras Punjab regarding the cause of the disease has been made. Acknowledgment
I am grateful to my assistant Dr. A. Bose for helping me in collecting and analysing the data. REFERENCES
AYKROYD, W. R..
B.

>..

'i

Idiocy

. .

25 39 626 4 167 3 126.. 2

33 43 453

34

Mania (a) Epileptic (6) Other forms Melancholia (a) Epileptic (b) Other forms (a) Epileptic (6) Other forms Mental stupor General paralysis Delusional insanity N"ot 3ret diagnosed covered.

335

and
G.

Indian ./. Med. Res.. 24, 667.

KRISHNA^,

(1937).
AYKROYD. W. R.. and Ibid.,

43 1 124
0

S2
:

24, 419. 1 Dementia

RAJAGOPAL, K. (1936). BHAGVAT, K. (1946) .. CHOPRA. R. X. (1938) . .

Ibid., 34, S7. The British Encyclopaedia oj Medical Practice, 7, 651. Butterworth and Co., Ltd.. London.
./. Nutrition, 6, 427.

..

4 24 5 1
i

1 %

or re-

33 5S

14 1

13

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

(1933).
HEALTH BULLETIN XO. 23 The Manager of PublicaTOTAL TREATED :.
:

l.OSo

714

55S

#1

(1946). JACOBY, H. (1947)

LEWIS, H. B.. et

"'"" ..
ai

tions, Government of India Press, Delhi. Indian Med. Gaz., 82, 53.
J. Nutrition, 36, 537.

(1948). MCCABRISON, R. (1928). Indian J. Med. Res., 15, 797.

MCCOMBIB"YOUNG, T. C. Ibid., Indian 15, 453.

(1927).
MEGAW, J. W. D., and GUPTA, J. C. (1927). Med. Gaz., 62, 299.

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.