-carch revealed malignant tertian parasites and quinine treats resumed ; and, with the exception of a slight rise

on the ,1 ague on May 4th an<! 7th, no more fever occurred : the improved, and he left hospital on May 18th, the case at tins iving been one of biliary colic complicated by malarial fever. ember 18th. 1902. he returned to hospital, and came under my 1 since 7th in bed. Has passed severa! gall stones since the ich lie brought with him. the largest being about J i n . in The liver dullness extended from the fourth space to 3 in. c costal margin. Spleen not enlarged, well-marked jaundice h pain of a colicky nature requiring morphine. Temperature P to 1020, with profuse perspiration. /er continued, and on December 22nd he coughed up a quanscid 0frothy mucus. Temperature, of a hectic type, continued 103 and 1040 in the evening. The vocal fremitus was slightly cd, but there was only partial loss of resonance at the right diagnosed suppuration in the bile ducts in the liver, and iperation for the purpose of draining the ducts and removing stones. After a consultation vthis was agreed to. On the morne 25U1 he coughed up a small quantity or pus, but in view of the ntioncd above, in which a fatal termination ensued in an of this kind, in spite of the opening tlirough the lung, and ertain knowledge of gall stones having been passed, it was to proceed with the operation as previously arranged. Captain in, I.M.S., kindly helping me. inn.An incision was made in the right linea semilunaris with (3 over the lower edge of the liver. The gall bladder was comliddcn beneath the edge of the liver, but its fundus was reached ued, and a number of small gall stones were extracted. On .sing the finger along the bile ducts beneath the liver, a large gall stones were felt deep under the liver, which could only cached. The wound was now enlarged upwards and downwards, transverse incision made across to the middle line, so as le the lower edge of the greatly enlarged liver to be up. The mass of stones in the right hepatic ducts ow be reached and opened, and with very considerable a mass of large gall stones, some 3 in. in length and over an diameter in places, were removed, some of which were well iu liver substance. As it was quite impossible at such a depth to opening in the duotto the surface, andas the patient was in a -, a glass drainage tube was inserted and gauze carefully packed t and the wound united around the tube. The patient suffered from shock, but rallied somewhat in the afternoon, but was moled by coughing up mucus. At 10 in the evening he was nd coughing up mucus more easily. However, he never fully rom the shock of the prolonged operation and died at 5.30 a.m. ;/The same morning the body was examined. There were :<.>od adhesions around the gauze packing and no trace of leak; charge into the peritoneal cavity. The liver was removed stomach and duodenum and rig-lit lung altogether. Only one U stone in the depth of the liver in the right hepatic duct was Inch was much smaller than some of those removed at the n. so would easily have escaped through the opening made in ;. and would doubtless have escaped through the wound, 1 too deep in the liver to b<? removed at the operation. Behind )C 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, eking abscess had opened posteriorly by the side of the inferior a. and travelled up through the diaphragm and the base of the ig into the inferior bronchi. The common bile duct was dilated, jpeuing into the duodenum was large and free.

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 ets were completely cleared with the exception small stone mentioned, and but for the unfor'pening of the tracking abscess into a bronchus on the 1? arranged for the operation leading to a serious extra the patients strength in coughing up the muco-pus, I } favourable result might reasonably have been hoped ile 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 lavejbeen saved by a still earlier operation, which emphase importance of early diagnosis with a view to very peration. >ve not had . time to search the literature of the w years for cases of this nature, but I think that rate cases in which suppuration in the intrahepatic a ve av d i a d and d an operation ti undertaken d t k with ith .e ?en diagnosed ct object of draining the abscess through opening the -ts are:sufficiently rare to be worth placing on record, e 1 cases are quite, distinct from,.and require totally operative treatment to, the ordinary amoebic tropical

LTHYRISM. By Major A. G. HENDLEY, I.M.S. THE best definition of this affection is Scheube's, which not only sums up in a few words prevalent opinions as to its causation, but at once recalls the nature of a too narrowlyknown disease of importance. He says : " Lathyrism is a disease of the nature of an intoxication with a spastic spinal paralytic course, which is attributable to poisoning with various kinds of the family of Papilionaceae lathyrus (chickpea or common pulse). Dr. Watts, in his Dictionary of the Economic Products of India, says : " Lathyrus, a genus of annual or perennial plant of the natural order Leguminosae, which comprises some 170 species, seven of which are natives of India." The specimens I have here are of the commonest cultivated Indian variety, lathyrus sativus, known in different parts of India under various vernacular names, as khesn dll, tera, lkh, or lkhri. To quote Dr. Watts again: "Lathyrus sativus (jarosse or gesse) is indigenous from the Southern Caucasus to Northern India ; it has spread as a weed of cultivation from its original home, and is now cultivated all over India." In the Central Provinces some 358,000 acres are under lathyrus cultivation ; and it is in these provinces that the disease has of late years become so increasingly prevalent as to call for Government inquiry, which inquiry his been entrusted to Major Andrew Buchanan, I.M.S., who has for the past six months or more been devoting his entire attention to this subject. History. Lathyrism is no newly-discovered affection. Its history dates from very early times, being, according to Huber, alluded to in the Hippocratic writings, where mention is made of the fact that " At Ainos those men and women who continually fed on pulse were attacked by a weakness in the legs which remained permanent." In Don's System of Gardening, again, it is recorded, in describing lathyrus sativus, that : " In several parts of the Continent a white pleasant bread is made from the flour of this pulse, but it produced such dreadful effects in the seventeenth century that the use of it was forbidden by an edict of George, Duke of Wurtemberg, in 1671, which was enforced by two other edicts under his successor Leopold in 1705 and 1714." In Italy and France the disease was also observed during the seventeenth and eighteenth centuries, and in the earlier half of the nineteenth century, large numbers of persons becoming affected in France, British India, and Algiers, attracted apparently some considerable attention. From the years 1857-68, when Dr. James Irvingthen Civil Surgeon of Allahabadcontributed five very interesting and exhaustive papers to the Indian Annals of Medical Science on the subject of an epidemic of lathyrism then prevailing in the North-, West Provinces, down to 1893, when I described in the Indian Medical Gazette a localized outbreak I had met with 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 1896-7, the local conditions artificially produced by the village-landlord m 1893 became general-; the poorer agricultural 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

'70S

**-~j

THYRISM.

native States, gone on spreading ever since, helped by the second severe famine of 1899-1900; 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 recent letter says, " I have seen 190 cases this morning."

other theories, and can only say that the oecurrenpp disease in epidemic form among lathyrus eaters and no others, seenis to me very strong evidence that a IT diet is primarily responsible. The idea that diseased only is injurious is an argument probably borrowed fro analogy of ergotism. I know of no facts to support th Symptoms. That exposure to sun or some local hot wind can h ' ii ife I will now pass on to a description of the symptoms and responsible is at one disproved by the undoubted fact tli 11 mode of onset of the disease. For reasons, given above, it disease has occurred ( (amongst lathyrus eaters) equally r g y s) equally ] will be seen that only the poorest classes are liable to this trously y in India, Italy, y, France,, Algiers, g , and d Wurt^ml Z disease ; those who are forced to subsist on the grain un- countries with vastly dissimilar meteorological condiii'n mixed or diluted only slightly with other grain. All the Also, if exposure to cold cold and and wet wet alone alone could could induce inducellatln-riam affected will be found to belong to this class. They eat it England E l d surely l should hld b f l l of f such h cases. As n'tmrd' be full either ground into flour as bread, cooked as porridge or Manson's suggestion that the affection, like beri-beri mavS boiled with or without oil as lentils, much as we eat haricot a "place disease," one has only to remember that th beanp. Practically all are field labourers, and the wonderful paralysis is incurable, and that removal from the locallt unanimity with which all agree as to the onset of the disease where the person attacked is in no sense beneficial J J is most striking. A man will say, ' I went to sleep perfectly to what the actualwas poison is, and how it acts, that is a matter well and very tired after a day's ploughing or other field work still left for our eminent physiologists and chemists to decid? in the rain (it is always in the rainy season) and awoke in Church has stated the chemical of the grain at the morning to find my legs stiff, weak, trembling, and very water, 10.1; albuminoids, 31.9;composition and fibre, 53.9; on* heavy to lift when I rose to walk." L have never been able 0.9 ; ash, 3.2 ; and has further starch observed that " the oO to-elicit any history of premonitory symptoms.) This weakis a powerful and dangerous cathartic." -, ness and trembling, you will be told,.increased so rapidly expressed Astier says " there is present in the grain a volatile liqnifl " that within ten days progression became difficult, even with alkaloid, probably produced by some proteid ferment, which the aid of sticks. Still the patients have no sense of illness exhibits the toxic action of the seeds, and the action of J and no pain; they have good appetites, sound digestions. which is destroyed by heat." On this volatility and destred/H and natural sleep at night. Both legs are usually affected tion by heat notion has been based much speculation as i&';"S simultaneously, first the calves, then the thighs, and soon possible variations in methods of cooking, explaining flit"? after this all sexual appetite and power was lost. All com- eaprieiousness of the effects of a diet of this grain on difieren t"1 plain bitterly of this. individuals. Scheube says, "Several poisonous alkaloki On examination of any typical case, of some six weeks' have been extracted but further investigations are necessary^ duration, you will find that the gait is very peculiar. Aided also, " that by the administration of preparations made frw with a long two-handed staff walking is possible, the rate of the grain, a disease giving rise to symptoms similar progression being under two miles an hour. The body above lathyrism has been produced in animals." the liips sways from.side to side, whilst the feet, which seem Professor Dunstan, of the Indian Institute, is now working? clogged with invisible weights, are lifted with.evident diffi- at this subject. So far his investigations and experiments oa culty and dragged forward, the toes scratching along or barely animals are inconclusive, but go to show (1) That only certala.* clearing the ground. The leg bearing the weight of the body samples of lathyrus are poisonous ; (2) there are some reason! is bent at the knee and trembles, whilst the advancing leg, to think the poison is contained in the skin or husk of th dragged wearily forward strongly adducted, is planted un- seed, but no fungus has been discovered ; (3) that poultry ax*J steadily directly in front of its fellow, the toes reaching the immune, but that rabbits and guinea-pigs are sometime-*! ground first. In short a kind of paralytic goosestep. The affected. Professor Dunstan also tells me that in Canad general effect is one of laboured unsteadiness, due to great lathyrus is largely grown and freely used as poultry food, weakness. The evident spasm of the thigh adductors ceases probably birds are immune. My own pigeon feeding to be very apparent when the patient reclines on his back, experiments in India were all negative and so support this when the thighs can be separated, usually without resistance, view. 4 to a normal extent. There is no wasting, no loss of muscular There remain two points of interest in connexion with tone, no true tremors, only tremblings of the entire limbs causation of lathyrism, namely, its marked preference / ; when weight is put.oD them. Sensation seems quite un- males and its seasonal incidence, that is, during the rainy affected. The tendon reflexes are much exaggerated, both season. Dr. Irving found that the proportion of females to: knee-jerk and ankle-clonus ; the slightest stimulus starting males attacked was about 1 in 12. Major A. Buchanaa^j the latter phenomenon going for a long time. There is no I.M.S., with a recent very large experience, tells me he find loss of power or undue excitability in bladder or rectum. it 1 in 10. I personally have only seen 3 female cases against v The arms, trunk, head and neck muscles are unaffected. The many hundreds of males. Major Buchanan accepts the con****mind is clear, speech natural, pupils normal and reacting parative immunity of females as an unexplainable fact, naturally to light and accommodation. The urine is often of says that the reason for the seasonal incidence of th dise rather high specific gravity (1030), acid, and contains abundant is very simple, namely, that "he finds that the urates. ouch are the symptoms as I have found them. I am grain pits or granaries are closed in June, and aware that some writers state that digestive disturbances, grain is only issued to labourers in the rains." . i*1 colicky pains, and diarrhoea are usually precursors of the The difficulty in the way of accepting this explanation 1; paralytic state ; and that sensory disturbances such as hyper- that (1) I do not believe the custom he alludes to is genetU'j aesthesia, anaesthesia, and formication, with bladder troubles, that of only eating lathyrus during the rainsit certainlyj such as incontinence and retention of urine, are common. I was not the recent famines ; and (2) the fact l** have never met with a case in my experience of many accordingduring to this idea cases occurring quite early in hie hundreds where the slightest history or evidence of any such must have been caused by a very few days' dietary of tnj complications could be traced. poison ; and this is opposed to all my experience of histonej| given me by patients. I prefer an even simpler solution both difficulties. As long ago as 1858 Dr. Irvine quoted* Etiology. opinion amongst intelligent educated natives As regards the etiology of the disease, it is, I think, prevalent being, that "the lameness produced by eating latbyjus generally conceded now that the paralysis is in some way due really a mixture of palsy and rheumatism," and added 1 to lathyrus poisoning.. Other mam theories of causation are : seem to think that living on this particular grain is the 1. That latbyrus eating has nothing to do with it. disposing cause, and exposure to cold, rain, and damp^eat ' 2. That if it has, it is only diseased grain which is capable of the exciting cause." Tvwr poisonous effects. - -: 3. That exposure to sun or some local hot wind is the true cause. I believe the native idea is the correct one. I Deneve thai 4. That the paralysis is due entirely to cold and damp. lathyrus, whilst it may possibly cause paralysis by i 5. One eminent authority on tropical medicine (Manson') has thrown ordinarily only predisposes to it, that it makes the an out the suggestion that, like alcoholism and probably bert-bcri, the r.?ady or ripe for the attack of paralysis, but that ez disease may be due to the entrance into the body of a toxin'gen orated by to severe wet and cold is required actually to exea te germs-whose habitat is outside the body. ' 6. Lastly, I am quite prepared to hear some champion of parasitism sudden seizure. This seems to me to explain the unv arise and suggest that some organism, so minute as to have hitherto ing history of the sudden unexpected attack during w season only ; for nearly always the attack oc^^Jr^ escaped observation, is really the author of all the mischief. .. In the time at my disposal I cannot fully discuss these and usually thorough wetting whilst ploughing, watching c

i* . h , o r other field work that ordinarily falls to man's lot d not to woman's. To Lheir greater protection from severe nd prolonged exposure alone, I believe, women owe their iomDarative immunity. I have suggested to Major Buchanan that the respective shares which exposure and a lathyrus dietary have in producing the paralysis might well be tested durinethe extensive animal-feeding experiments which are to be carried out at the Bombay Research Laboratory.
L

Satisfactory observations on the morbid anatomy and pathology of the disease are wanting. From the clinical symntoms one would be justified in assuming it to be a form of lateral sclerosis, but in "Watts's Dictionary I find a statement thnt ' Cantarri of Naples has published a number of cases in which he has carefully observed the conditions after death. Jio nllection 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 the lumbar enlargement was found." Allbutt refers to two examinations of horses which had died of lathyrus poisoning. In these the symptoms were apparently mainly those of enrdiac 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." From this he suggests that the nerve mischief may be secondary to the vascular lesions, which would suggest a similarity to ergotism. The prognosis 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 FOR THE PROPER MEDICAL SUPERVISION OF "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., Chief Medical Offleer, N.G.S. Railways, India.

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 WhicK 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 llay-dust, 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 ofTfcailways, this being, perhaps, a matter beyond the; province of his : report. . ''"."' " : V v ' \"j J '" The Government of India, however, in the PubH'c Works Department addressed the different railway administrations through the local governments last year desiring tha certain rules should be formally agreed to between the.medical and sanitary authorities of local governments and th'ose of railways within their areas, for the purpose1 of affording such mutual advice, support, and intimation of outbreaks- of epidemics, etc., as may be for the general benefit of the' public health and for the prevention of much, sikness and mortality. ,'.'' .. \ , "While these rules are having the consideration of our Government the proposition that I would venturero advance is the necessity for adequate medical and sanitary staffs riot 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 diarammatic representations belowwill,I think,make obvious; and 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.

Miles
3000-

OUR 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 2500railway communications, extending in India alone to over 26,000 miles, has resulted, among other things, in rapid in- 2 0 0 0 tercourse between East and West., which in its turn has gone to bring into prominence certain disadvantages, having re- 1500gard to the public health of the communities concerned, hitherto remote from one another. Contingencies have arisen necessitating the adoption of special precautionary 1000 measures to prevent the conveyance of infection from already "ected areas to uninfected areas. 5O0Owing partly to the infection being undetectable during the latent period in man and the vitality of the virus under GIPR EIR MR BNR SIR EBR NGSR varying conditions, climatic and otherwise, the difficulties experienced by medical authorities in the framing and adopI* Excessive expenditure on superior medical staff. .'... BaXL SLr A ru }^ y preventive regulations have been very great, ana the inconvenience to the general public extremely Medical 'Kaome, at these times of panic, the consequence being the Miles. Employs. Administration, Cost Per Mile. aDandonment of such regulations or their irregular adoption m certain area "pro forma," and the adoption of serum Jjjoculations of Haffkine's antitoxin systematically and on a Rs. 31.40 arge scale, by the temporary employment of a large superior Great Indian Peninsular Railway, ',674 0,500 30.0. 30,300 East Indian Railway ... 3,338 nueal aud sanitary staff, with the greatest benefit, where : 6.50 1,600 Madras Railway... 5 a * iterated 35-37 1.557 Bengal Najpur Railway 6 nected' 8.94 essary last year for the Home Government to South Indian Railway1,350 13.500 50.18 99 8,900 ndia a special railway expert in administrative Eastern Bengal Railway te. 8,000 Nizam's State Railway... 745 and Mr. Thomas Robertson, C.V.O., was selected as Z^^i^Daniissioner to inspect and to report on the adThe democratic idea that every citizen is entitled to the "iwwations of railways in India from the commercial and ^nonucaspectB, though the administrations of the various benefit of everything that will add to human-health and ie marine companies in which our Government is happiness is growing fast. Health and sanitation Acts by the ? c l y interested was not included. Legislature, medical officers of health, sanitary inspectora, " ***t Mr. Robertson's report was, I believe, inspections of workshops, etc., have all, in addition to prom india last May, but the Blue Book to be issued longing life and diminishing death, done incalculable service r * ? m ^01*1' 8 t ! n ***the hands of the King's printers. by rousing in the public mind the vague beginnings of a irom an Indian newspaper article on " Indian Rail- tremendously important -mental "procesB of a dissipation" of

26,

'9O3-J

SECTION OF TROPICAL MEDICINE.

TIB

BUI

707

search revealed mnlignsr.t tertian parasites nnd quinine treatLATHYEISM. s resumed; and, with tue exception of a slight rise on the l ague on May 4th an;! 7th, no m'"o fever occurred : the By Major A. G. HENDLEY, I.M.S. improved, and he left h as pi tal on May 18th, the case at this THE best definition of this aflection is Scheube's, which not tving been one of biliary colic complicated by malarial fever, ouiher 18th. 1902. he returned to hospital, and came under n:y only sums up in a few words prevalent opinions as to its I since 7th in bed. Has passed severa! gall stones since the causation, but at once recalls the nature of a too narrowlyich lie brought with him. the largest being about 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 c 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 Papilionaceae lathyrus (chick0 to 1020, with profuse perspiration. pea or common pulse). ,cr continued, and on December 22nd he coughed up a quanDr. Watts, in his Dictionary of tiie Economic Products of scid efrothy mucus. Temperature, of a hectic type, continued 103 and 104e in the evening. The vocal fremitus was slightly India, says : " Lathyrus, a geniis of annual or perennial plant cd. but there was only partial loss of resonance at the right of the natural order Leguminosae, which comprises some 170 diagnosed suppuration in the bile ducts in the liver, and species, seven of which are natives of India." The specimens iperation for the purpose of draining the ducts and removing I have here are of the commonest cultivated Indian variety, stones. After a consultation>this was agTeed to. On the morn- lathyrus sativus, known in different parts of India under e 2sf.l1 he coughed up a small quantity o pus, butin view of the various vernacular names, as khesri dll, tera, lkh. or ntioncd above, in which a fatal termination ensued in an lkhri. To quote Dr. Watts again: "Lathyrus sativus of this kind, in spite of the opening through the lung, and (jaros8e or gesse) is indigenous from the Southern Caucasus to crtain knowledge of gall stones having been passed, it was Northern India ; it has spread as a weed of cultivation from to proceed with the operation as previously arranged. Captain its original home, and is now cultivated all over India." In in, I.M.S.. kindly helping me. ion.An incision was made in the right linea semilunaris with the Central Provinces some 358,000 acres are under lathyrus 1; over the lower edge of the liver. The gall bladder was com- cultivation ; and it is in these provinces that the disease has liddcn beneath the edge of the liver, but its fundus was reached of late years become so increasingly prevalent as to call for led, and a number of small gall stones were extracted. On Government inquiry, which inquiry h i s been entrusted to -ing 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 months or more been devoting his entire attention to this cached. The wound was now enlarged upwards and downwards, subject. transverse incision made across to the middle line, so as History. le the lower edge of the greatly enlarged liver to be Lathyrism is no newly-discovered affection. Its history up. The mass of stones in the right hepatic ducts y be reached 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 " At Ainos those men and women who K: liver substance. As it was quite impossible at such a depth to continually fed on pulse were attacked by a weakness in the opening in the duetto the surface, andas the patient was in a legs which remained permanent." In Don's System of , a gluss drainage tube was inserted and gauze carefully packed Gardening, again, it is recorded, in describing lathyrus : and the- wound united around the tube. The patient suffered sativus, t h a t : " I n several parts of the Continent a white irom shock, but rallied somewhat in the afternoon, but was ublcd by coughing up mucus. At 10 in the evening he was pleasant bread is made from the flour of this pulse, but it nd coughing up mucus more easiiy. However, he never fully produced such dreadful effects in the seventeenth century :om 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 of Wurtemberg, in 1671, which was enforced by two other "Od adhesions around the gauze packing and no trace of leak- edicts under his successor Leopold in 1705 and 1714." In : charge into the peritoneal cavity. The liver was removed Italy and France the disease was also observed during the stomach and duodenum and right lung altogether. Only one seventeenth and eighteenth centuries, and in the earlier half !1 stone in the depth of the liver in the right hepatic duct was of the nineteenth century, large numbers of persons becoming liich was much smaller than some of those removed at the affected in France, British India, and Algiers, attracted 1. so would easily have escaped through the opening made in From the years .. and would doubtless have escaped through the wound, apparently some considerable attention. . too deep in the liver to b<; removed at the operation. Behind 1857-68, when Dr. James Irvingthen Civil Surgeon of e the bile ducts were much dilated and full of pus in a limited Allahabadcontributed five very interesting and exhaustive (if the upper posterior portion of the right lobe of the liver. papers to the Indian Annals of Medical Science on the subject eking abscess liad opened posteriorly by the side of the inferior of an epidemic of lathyrism' then prevailing in the Northa. and travelled up through the diaphragm and the base of the West Provinces, down to 1893, when I described in the g into the inferior bronchi. The common bile duct was dilated, Indian Medical Gazette a localized outbreak I had met with >peuing into the duodenum was large and free. in the Central Provinces, the disease seems to have attracted

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 i.'ts 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 patient's strength in coughing up the muco-pus, I } favourable result might reasonably have been hoped le the conditions revealed post mortem clearly showed thing short of removal of the stones impacted in the duets, and free drainage of the pus-distended intra ducts, could have relieved the symbtoms and averted 1 1 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 emphase importance of early diagnosis with a view to very peration. ve not had time to search the literature of the w years for cases of this nature, but I think that : ate cases in which suppuration in the intrahepatic ave been diagnosed and an operation undertaken with et object of draining the abscess through opening the -ts are sufficiently rare to be worth placing on record, cases are quite, distinct from, and require totally L operative-treatment to, the ordinary amoebic tropical

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 scarcityculminating in the terrible famine of 1896-7, the local conditions artificially produced by the village-landlord in 1893 became general-, the poorer agricultural 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 t h e Central Provinces and adjoining

LATHYEISM. native States, cone on spreading ever since, helped by the second severe foraine 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 recent 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 w 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 bean?. Practically all arefieldlabourers, 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 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, the toes scratching along or barely clearing the ground. The leg bearing the weight 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, to a 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. 8uch 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 expei'ience of many hundreds where the slightest history or evidence of any such complications could be traced. As regards the etiology of the disease, it is, I think, geaerally conceded now that the paralysis is in some way due to lathyrus poisoning.. Other main theories of causation are :
Etiology. Symptoms. other theories, nnd can only say that the occurrence m i disease in epidemic form among eaters a n d4 i g lathyrus y no others seem^ to ^'~| me ^r^ very vt-\r ctmnr * J a_ * *W strong vi/irti-. evidence that ht diet is primariJ responsible. The idea that diseased ^a 1* only is injurious is i an argument t probably probably borrowed^ b o d , analogy of ergotism. I know of no facts to support"h'tP* That exposure to sun or some local hot wind can }>'*\ i" responsible is at one disproved by the undoubted fact th' in disease has occurred (amongst lathyrus eaters) equally < j trously in India, Italy, France, Algiers, and Wurti-inl'^**" countries with vastly dissimilar meteorological condiii"'1^' Also, if exposure to cold and wet alone could induce lathyr ** England surely should be full of such cases. As rei* "rd* Manson's suggestion that the affection, like beri-beri m-ivh? a "place disease," one has only to remember that th paralysis is incurable, and that removal from the localit where the person was attacked is in no sense beneficial A to what the actual poison is, and how it acts, that is a matter still left for our eminent physiologists and chemists to decid? Church has stated the chemical composition of the grain as water, i c i ; albuminoids, 31.9; starch and fibre, 53.9; 0T 0.9; ash, 3.2; and has further observed that "the oO expressed is a powerful and dangerous cathartic." Astier says " there is present in the grain a volatile liquid alkaloid, probably produced by some proteid ferment, which exhibits the toxic action of the seeds, and the action of > which is destroyed by heat." On this volatility and destru ? tion by heat notion has been based much speculation as t possible variations in methods of cooking, explaining A" '" eapriciousness of the effects of a diet of this grain on differ individuals. Scheube says, " Several poisonous alkaloid have been extracted but further investigations are necessary^ also, " that by the administration of preparations made fr the grain, a disease giving rise to symptoms similar to "* lathyrism has been produced in animals." '^f^ Professor Dunstan, of the Indian Institute, is now working' ^ at this subject. So far his investigations and experiments oa.'i animals are inconclusive, but go to show (1) That only certai > r samples of lathyrus are poisonous ; (2) there are some reason'* to think the poison is contained in the skin or husk of the'1.'; seed, but no fungus has been discovered ; (3) that poultry azv.& immune, but that rabbits and guinea-pigs are sometime affected. Professor Dunstan also tells me that in CanadVw. lathyrus is largely grown and freely used as poultry food, S O ?r probably birds are immune. My own pigeon feeding ,'," experiments in India were all negative and so support this view. ', r There remain two points of interest in connexion with the , causation of lathynsm, namely, its marked preference for'A' 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. BuchananJ. " I.M.S., with a recent very large experience, tells me hefind' 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, bot.,_ says that the reason for the seasonal incidence of the disease is very simple, namely, that " he finds that the ordinary*'-, grain pits or granaries are closed in June, and that lathyrtt^ grain is only issued to labourers in the rains." . j*' The difficulty in the way of accepting this explanation i* ;* 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 thnc according to this idea cases occurring quite early in the rain ^fmust have been caused by a very few days' dietary of tne poison ; and this is opposed to all my experience of historie given me by patients. I prefer an even simpler solution < B both difficulties. As long ago as 185S Dr. Irving quoted Uj, prevalent opinion amongst intelligent educated natives being, that "the lameness produced by eating latbyrusi really a mixture of palsy and rheumatism," and added tJ seem to think that Jiving on this particular grain IB the T disposing cause, and exposure to cold, rain, and damp weal. the exciting cause." , . r t-

I believe the native idea is the correct one. I believe lathyrus, whilst it may possibly cause paralysis by i ordinarily only predisposes to it, that it makes the SUDJ r?ady or ripe for the attack of paralysis, but that expos^_. to severe wet and cold is required actually to excite 1 sudden seizure. This seems to me to explain the unj iog history of the sudden unexpected attack during tne season only ; for nearly always the attack occurs a l ^ * .. In the time at my disposal I cannot fully discuss these and usually thorough wetting whilst ploughing, watching cro*

1. Tltat lathyrus eating has nothing to do with it. j . That if it has, it is only diseased grain which is capable of poisonous effects. - \ 3. That exposure to sun 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 (Mansoni has thrown out the suggestion that, like alcoholism and probably bert-beri, the disease may be due to the entrance into the body of a toxin generated 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.

{ 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 Morbid Anatomy and Pathology. further suggests the introduction of electric fans, which he Satisfactory observations on the morbid anatomy and path- thinks should be made compulsory within five years ; the ology of the disease are wanting. From the clinical sym- use of oil sprinklers to allaydust, and lavatory accommodaptoms one would be justified in assuming it to be a form of tion in all third-class carnages, which should be widened. lateral sclerosis, but in "Watts's Dictionary I und a statement Beyond these important sanitary recommendations no tlmt " Cantarri of Naples has published a number of cases in reference is made to the medical departments ofjrailways, which he has carefully observed the conditions after death. this being, perhaps, a matter beyond the; province of his ' .' ' ' ~'\ '" jo nllVction of the spinal cord was discovered. The muscles report. of the lower extremities, especially the abductors, were found The Government of India, however, in the PUDKC Works 1 to have undergone a fatty degeneration, etc.' Scheube men- Department addressed the different railway administrations tions one published necropsy (where death resulted from through the local governments last year desiring that certain malarial cachexia) where "a softening of the spinal cord above rules should be formally agreed to between the mdicaland the lumbar enlargement was found.1' Allbutt refers to two sanitary authorities of local governments and tHose of railexaminations of horses which had died of lathyrus poison- ways within their areas, for the purpose of affording such ing. In these the symptoms were apparently mainly those of mutual advice, support, and intimation of otbreaks- of enrdiac and respiratory oppression, and after death "the mis- epidemics, etc., as may be for the general benefit of the' chief was found mainly,in the cells of the anterior horns of public health and for the prevention of much siekness and ' '. the cord, which were diminished in number and atrophied. mortality. "While these rules are having the consideration of our There was also thrombosis of small arteries, which were also thickened. There was, too, fatty degeneration of the heart and Government the proposition that I would venture' "to advance intrinsic muscles of the larynx." From this he suggests that is the necessity for adequate medical and sanitary -staffs not the nerve mischief may be secondary to the vascular lesions, only on our great Indian railways, but also on our mercantile which would suggest a similarity to ergotism. The prognosis marine, to enable them to cope with modern sanitary and of this disease as regards life is favourable. It does not seem medical requirements, the urgent need for which the diato cause death directly, but the paralysis is incurable. Treat- grammaticrepresentationsbelowwilljlthinkjmakeobvious-and 1 trust that the time has now come for our medical members ment, I believe, is quite futile. of Parliament, aided by the General Medical Council, to urge the Government to send out a Special Commissioner and expert to inspect and report upon the medical A PLEA FOR THE PROPER MEDICAL SUPER- medical administrations of our mercantile marine and great railways VISION OF " REFRESHMENTS " PURVEYED in the interests of public health ON RAILWAYS IN THE TROPICS : Diagrams representing inequality and WITH SPECIAL REFERENCE TO INDIA, AND FOE BETTER LATRINE inadequacy of Sup.Medl. Staffs on Rys. AND LAVATORY ACCOMMODATION FOR THE TRAVELLING INDIAN PUBLIC. Miles
By H. D. MCCULLOCH, M.B., 30002500 2000-

man's lot rom severe ** "prolonged exposure alone, l believe, women owe their mJirative immunity. I have suggested to Major Buchanan that 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 to he carried out at the Bombay Research Laboratory.

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

OUR 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 con-cerned, hitherto remote from one another. Contingencies have arisen 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 during the latent period in man and the vitality of the virus under varying conditions, climatic and otherwise, the difficulties penenced by medical authorities in the framing and adoption of sanitary preventive regulations have been very great, *oa0 the a inconvenience to the general public extremely c? *?^ t these times of panic, the consequence being the abandonment of such regulations or their irregular adoption in certain, areas "pro forma," and the adoption of serum jnocalations of Haffkine's antitoxin systematically and on a uu^e scale, by the temporary employment of a large superior ical and sanitary staff, with the greatest benefit, where was tolerated. 6 T necessary last year for the Home Government to I n d , i a a special railway expert in administrative , and Mr. Thomas Robertson, C.V.O., was selected as inini^Ji9 mmi8 8 i oner to inspect and to report on the ad"*ustrations in India from the commercial and e c of ) railways tnou an1 tn a s p 3 1B g the administrations of the various 1 ir ?- c^ t l" companies in which our Government is S? . y C r e s t e d was not included. e -?* of M r - Robertson's report was, I believe, India last May, but the Blue Book to be issued ^ 1 1 ' 8t ! U i n t h e h a n d s of the King's printers. n d i a n n e w s p a p e r ar ti c le on " Indian Rail-

1500 !000 5OO _

CIPR

i* Excessive expenditure on superior medical staff. Mes. Medical Employs. Administration, Cost Per Mile. Rs. reat Indian Peninsular Railway East Indian Railway Madras Railway ... Bengal Najpur Railway South. Indian Railway Kastern Bengal Railway Nizam's State Railway
3,674 3,358 i,6oo 1.557 20,500 30,300 i*,ooo 15,500 13,500 8,900 8,000 31.40 30.0a 6.50 35-37 8.94 50.18 12.03

u
EIR

MR

BNR

SIR

1
EBR

NGSR

1.35

99 745

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, inspections of workshops, etc., have all, in addition to prolonging life and diminishing death, done incalculable service by rousing in the public xnind the vague beginnings of a tremendously important mental "process of a dissipation of