well. Minchin also noted affection of the bladder. Ruge and his co-workers (1925) and Ranjan (1944) described incontinence of urine and faeces as well as sexual impairment. It has been postulated that the disease is never pro- gressive after a few days or weeks beyond the initial paralysis (Bicknell and Prescott, 1942). Ranjan (1944), however, notes rapid progress of the disease. The published accounts of the reflexes in lathyrism are equally puzzling. Minchin (1940) observed normal cremasteric and abdominal reflexes along with spastic legs and extensor plantar responses. Trabaud and Mouharram (1932) found completely normal reflexes, including the plantar responses, though there was spasticity and clonus of the legs. A common symptom associated with lathyrism is night-blindness according to McCombie Young (1928), and Ranjan (1944) reports marked dimness of vision. Even the diseases which can experimentally be produced in animals by feeding them on certain species of legumes of the genus Lathyrus have also been called lathyrism, although they do not show the characteristic symptoms of the human lathyrism. Geiger et al. (1933) fed rats with a diet consisting of Lathyrus odoratus, the flowering sweet pea (at levels of 80, 50 and 25 per cent of the diet). Characteristic symptoms were lame- ness, paralysis and contracture of the spine and sternum. In other experiments on white rats also fed with a Lathyrus odoratus diet, carried out by Lewis and Esterer (1943), these authors produced a disease which they call lathyrism showing the following symptoms : Incon- tinence, lameness, paralysis of limbs, spinal curvature of the thoracic region. Another nutritional disease by feeding sheep with a certain species of legumes, viz, cull beans, has experimentally been produced by Willman and his co-workers. They call the resulting disease ' The Stiff Lamb Diseasewhich shows the following symptoms : The animal concerned has diffi- culty in walking and rising. It gets tired very soon after walking and tries to lie down whenever permitted to do so. On standing and walking there is disturbance of keeping the balance; later on, inability to rise at all, not even with help. Since the author is working in an area where lathyrism patients are a common sight and since all of them show a uniform symptomatology, it appears advisable to establish first of all a record of the symptoms of this disease, which we regard in this area of Central India as indis- pensable for the diagnosis of lathyrism. Symptoms.?The following trail of symptoms is in our experience found in every lathyrism patient :? 1. Spastic and painful rigidity in the muscles of the lower loin muscles. SYMPTOMS AND TREATMENT extremity, including CAUSE, From this results a typical spastic-ataxic gait, OF LATHYRISM frequently associated with a so-called scissor- Y A SPECIFIC NUTRITIONAL NEUROPATH gait. 2. reflexes in the legs, H. m.d. Exaggerated deep By JACOBY, generally clonus. Chief Physician, Prince of Wales Hospital, Bhopal, 3. The absence of disease-symptoms Bhopal State complete in other parts of the body, especially in the difference Introduction.?There is considerable upper extremity and the head. in the description of symptoms in lathyrism by 1. The flexor and frequently also the different authors. adductor muscles of calf and thigh, particularly Shah (1939) and Minchin (1940) report, the M. gastrocnemius, feel hard and are tender besides of the also involve- spastic paralysis legs, on squeezing. All- these muscles are invariably ment of the arms and sensory impairment as 54 THE INDIAN MEDICAL GAZETTE [Feb., 1947 well developed and never or flabby atrophic. deviation in The patients complain of permanent pain in any direction (Barany's Pointing these muscles which is increased on standing Test). If the is made to and walking. In more advanced cases even the (c) patient walk forwards and sleep is disturbed due to the pains. The backwards with his eyes shut, he will not present the deviation of the so-called examination of passive movements shows per- ' peculiar manent muscle resistance to flexion and extension compass gait' (Krohn, 1938). 2. The reflex are also at the knee- and hip-joints. The degree of this following reactions of lesion. resistance runs parallel to the advancement of significant pyramidal Without excep- tion a is the disease. In very far advanced cases the greatly exaggerated knee-jerk elicited, the resistance is such that it is not possible at all ankle-jerks often being diminished or absent. In some to achieve these movements force. cases, however, also the ankle-jerks are passive by is In this late all such movements are exaggerated. Almost always ankle-clonus stage possible ' present and also of the only by the patients themselves actively, very frequently dancing \ Far cases sudden slowly and with the help of their own hands. patella advanced show?on brisk dorsiflexi'on of the foot to elicit Most characteristic is the of the passive gait patients. ankle-clonus?an reflex The onlooker the as these involuntary complex gets impression though movement of flexion at the patients walk against the obstacle of their own consisting hip-joint and flexion at the knee-joint. Frequently this muscles. They walk with a ' generally slight, flexion reflex' occurs a flexion at the already by gentle apparently voluntary knee-joints, like or of the which is associated or caused a stimulus, deep pressure pinching by foot-drop, skin of the distal of the lower limb. Either in an to for part involuntary attempt compensate i.e. the flexion reflex as well as the the the so-called reflex, latter, resembling Strumpell increased is indicative of Or another of deep reflexes, hyper- phenomenon. way involuntary of So is the is achieved the in irritability pyramidal origin. compensation by swinging leg flexion reflex a feature of the a convex arch instead of the foot prominent lifting (circum- usual flexor contracture (the tendon reflexes duction). The patients seem to walk on their being frequently decreased) and exaggerated toes Another group of who do not only. patients reflexes are an characteristic show the above flexion at the knees will deep equally drag feature of extensor contracture. The latter form the feet on the as soles are ground, though their, is indicative of a less severe lesion than the pasted to it. These patients describe their gait ' flexor contracture (Babinski). Babinski's sign themselves as the \ All scratching ground by stroking the sole along the lateral border these which appear on walking are ' symptoms rather than the median border is as a rule associated as are known to movements, they extensor and signifies a less severe occur in but are not en- pyramidal pyramidal lesions, affection than does an extensor response elicited countered in motor lesions nor extra-pyramidal from the median border as well as from the lateral in the normal individual. These modes of walk- border of the sole 1938). There is elec- rather to the advanced of the (Krohn, ing belong stages no reaction of The senses disease. In the initial the trically degeneration. stages only slight of position and of movement are always and muscle resistance and the bent knees on slightly definitely unimpaired as well as the In cases of all temperature walking prevail. many stages, and touch senses. The Romberg if in of the adductor muscles of sign, positive, whom the spasm is of little significance on account of the above the thigh dominates, the so-called scissor-gait described inco-ordination of muscle movements. results. The walk with crossed patients legs, The reflexes vary : All or some of the the blades of superficial resembling somewhat opened abdominal reflexes as well- as the cremasteric scissors. The movements of the arms, normally reflexes are in less advanced stages normally the of are accompanying gait healthy persons, but are missing in far advanced cases. in and elicitable, always unimpaired lathyrism. Walking This pathological abdominal reflex is generally in more ' advanced stages standing of these associated with the flexion reflex' and the is a kind of patients complicated by peculiar extensor plantar response all belonging to the This ' swaying (ataxia). goes frequently along order of reflexes of spinal automatism' and are with of the muscles of the fibrillary twitchings of involvement. Anyhow, re- lower which in combination with the signs pyramidal extremity, appearance of the previously absent superficial contractures result in mco-ordinated movements. reflexes and of a normal plantar response and This disturbance of inco-ordination of different the disappearance of the 'flexion reflex' are muscle is the cause of this groups certainly among the denoting improvement under of ataxia of signs particular kind lathyrism patients. successful treatment. to cerebellar the It is not due lesions, because 3. There are definitely no abnormal nervous following tests exclude this type of ataxia :? whatsoever in any other part of the ' signs (a) There is 110 decomposition' in the body. Never was any disturbance of sensa- nor of the functions of the sequence of complicated single movements. tion encountered, of the of the sex and of the (fc>) The test of moving the leg and big toe bladder, bowels, away from and back to the examiner's finger as mentality. Examination of the cerebrospinal fluid as to a target, with eyes shut, does not show a pressure, cell count, albumin content and Kahn OF I.ATHYRISM : MCOBY 55 SYMPTOMS AND TREATMENT Feb., 1947] CAUSE, them state that before the occurrence of the no abnormalities. There are also 110first symptoms there was fever with shivering, na fk s^10Ty*s malaria. Dr#*cc? 1(?al filings in urine and blood. Bloodresembling Frequently, this statement normal? Radiologically, lungs andwas confirmed by malaria relapses taking place ?* /u our in the A shanpUr
patients by Rudra and Bhattacharya (1946) in Patna. treatment causes in They found a high serum phosphatase and a consequent re-occurrence of symptoms possible cocarboxylase deficiency in lathyrism and either disease. related these findings to the setiology of the disease. The second stage in our classification of They consider it, however, also possible that the high the more advanced cases serum phosphatase is the effect and not the cause of lathyrism comprises with lathyrism. But, of course, lack of other substances in marked painful muscle spasm and a clearly the diet, apart from vitamins, may be important, as visible spastic ataxic scissor-gait. Muscular suggested by Basu et al. (1937), who found that the fibrillations are These are seeds of which often form the present. patients Lathyrus sativus, staple still in a to with con- food in famine villages, are a very poor source of position walk, ralthough protein, being especially deficient in tryptophane. siderable difficulty and discomfort, either just without or preferably with one or two sticks, The author 1946) has found in this (Jacoby, according to the advancement of the case. area here that the nutritional of a background The treatment of this stage with vast of the is a vitamin B prostigmin proportion population injections does not achieve the same result as complex deficiency. Although symptoms of this in the first stage. The symptoms are only con- are visible in about 14 cent deficiency only per siderably relieved; but it is generally only of our lathyrism the result of the patients, possible to reach an improvement which therapeutic test (see under treatment) suggests resembles the earlier first stage in our classifica- that a latent vitamin B exists complex deficiency tion. Those who were previously able to walk in a far greater It is a hitherto un- proportion. with the described but without a stick, fact that in the obstacles, explained lathyrism villages can under the influence of the prostigmin treat- disease attacks one or two generally only ment walk like untreated fn'st-stage patients, members of a but leaves the others un- family, and those who required the stick are enabled who eat same touched the food and live under to walk without it. the same conditions. Children are affected The third-stage patients are those who are in the same manner as roughly proportion and permanently confined to bed. The muscle but the female sex to a much smaller adults, spasm and contractures are so extreme that as with the male sex. In proportion compared they prevent practically any movement with Shourie's (1945) statistics only about 13 per cent the legs. The pains in the muscles of the lower were females. extremity, of the calves, thighs and loins are Treatment.?This of the present description permanent and severe. These patients have thus curative influence of in prostigmin lathyrism become cripples. At the same time all other is based on the analysis of 50 patients treated functions of the body are unimpaired, the vegeta- with prostigmin. tive as well as the mental functions. The no treatment There has been effective of reflexes are such as we have described under now. how- ' ' lathyrism until Jacoby (1946a), symptoms for the far advanced stages. The ever, discovered that lathyrism responds well prostigmin-injection treatment in this third to prostigmin treatment. This response differs stage achieves little with regard to the crippled in in the different of the disease. degree stages state of these patients, but succeeds in so far The first in our classification stage comprises as the pains almost disappear and the muscle all those patients who can walk with slightly rigidity becomes less. This results sometimes in and some active and bent knees only passive an ability of these patients to leave their bed, muscles as well as with the resistance in their slowly crawling on the floor for short distances. and muscle just noticeable scissor-gait slight These third-stage patients are, of course, not in Their reflexes of pain. deep are, course, greatly a position to work. The patients, however, who exaggerated, the superficial reflexes as a rule belong to the first and second stage, are by the being normal and plantar response extensor, treatment with prostigmin enabled to do almost elicitable from the lateral border of the sole. ' every kind of work. No flexion reflex' is present. In this stage The achievements under prostigmin treatment an clinical cure is achieved apparently complete can in every case and stage be accurately the with through and during treatment pros- checked and even measured in the following in the about 10 tigmin injection; beginning way : The exaggeration of the knee- and ankle- of 2 c.c. are intramuscular injections given jerks becomes less and in early cases practically after which a course of another ten daily, daily normal so that also the clonus may disappear; 1 c.c. follows. injections with only Afterwards, the extensor Babinski response in the early cases injections on alternate days may be sufficient to will equally approach the normal. If in the achieved condition unaltered. If the keep the more advanced stages the superficial reflexes we found treatment is discontinued, invariably were not to be elicited before, they will reappear was ' a re-occurrence of the former symptoms. It in the course of the treatment and the flexor not possible to substitute, either for the short- reflex' disappear. The most accurate evidence term or the long-term treatment, the injections of improvement is the gait, which can be tablets by tablets of prostigmin. The have measured as follows : The patient is asked to proved to 'be ineffective in lathyrism. walk in his usual manner with wetted feet on The required duration of the treatment of the dry floor. The heel-to-heel distance is lathyrism with prostigmin is thus the same as measured with a tape. This distance shows in Myasthenia gravis. Discontinuance of the under prostigmin treatment a marked diminution AND TREATMENT OF LATHYRISM : JACOBY 57 Feb., 1947] CAUSE, SYMPTOMS Two factors have about 3 to 6 inches. Vice versa, if the important induced us to believe in the existence of such a : ejections are the length of background discontinued, steps the nature of food which slowly increases till after about a month firstly, the lathyrism again consume. the original is regained. The symptom patients commonly They live practi- length on teora and dal Few which shows improvement last is the ataxia. It cally only. of them can afford some milk takes about 20 injections before the very rarely and green daily also. As a rule do not eat patients can for instance stand quietly on one vegetable they fish, and fruits. This diet resembles in lcg, or are able to walking immediately on meat, eggs stop and for the diet sudden order. Before the treatment they were quantity quality (except teora) not of those among whom a great able to do so but had to proceed one or two people percentage in this area suffers from the different further in order to their balance, stages? ^eps keep latent and visible?of vitamin B defici- the of ataxia can generally not be complex improvement There is therefore much achieved in late We tried to enhance ency (Jacoby, 1946). stages. likelihood to that the of the effect of the treatment by presume majority prostigmin here also live in a at the same time massage, light lathyrism patients permanent, administering i.e. state of vitamin ?r electric treatment to the lower extremities of although invisible, latent, B lathyrism patients. We did not, however, find complex deficiency. any response to these methods. Secondly, our practical observation at the Vitamins.?Several authors report improve- bedside of lathyrism patients has taught us ment of the disease by the administration of that the response to prostigmin is more certain vitamins. Ranjan advises plenty of immediate and more marked if vitamin B com- vitamin A besides all other vitamins and Ahmad plex treatment precedes the prostigmin treat- (1944) reports relief of pains and regained ment. In a few cases this vitamin treatment ability to walk about freely after parenteral and seemed even indispensable to the usual prostigmin oral administration of vitamin B. Mellanby effect. (1934) classes lathyrism among the deficiency On the strength of these two clinical experi- diseases, since protective foods containing ences of ours we have made it a rule to give to vitamin A and carotene, green vegetables, milk our lathyrism patients first a course of about and eggs can prevent the detrimental effects of 12 vitamin B complex, fortified with 1 c.c. of the toxic agent in the Lathyrus peas. crude liver extract, injections before starting on Strongly against the argument of vitamin prostigmin treatment. deficiency causing the disease is the fact Prevention.?It is the duty of public health that in our experience the administration of authorities in all countries to prevent diseases vitamins in large doses does not improve the rather than to cure them. The of the ' tackling condition to any significant degree. We have disease lathyrism' represents such a public in vitamins A and D tried different batches these health problem to be undertaken by men of in the form of cod-liver oil for a period of two science in unison with the state's administrations. months. We administered the vitamins Bx, B2 It seems to be a tough task, because of its mani- and the vitamin C complex with crude liver fold implications. In any case, science has given route for a daily by oral and parenteral period the lead in this field also by dispersing any of was ever one month. But no response mysticism as to the cause of this disease. To we do not know apparent. On the other hand, put the verdict of science in a nutshell : No of any vitamin deficiency state which does not lathyrism without consumption of Lathyrus. at least to some extent to the therapeutic respond The first task from this scientific of the deficient vitamin alone or in resulting application is of the The combination with the other common vitamins. knowledge enlightenment public. writer has found that the in Another clinical evidence against the view of villagers lathyrism- affected places are alive to the fearful conse- vitamin deficiency being the cause of lathyrism, quences of have is the feature that no visible sign of any such Lathyrus consumption. They been this lesson confronted deficiency occurs in the bulk of our lathyrism taught being daily with the of their brethren who patients. Only about 14 per cent showed sight crippled have consumed teora. The next of the symptoms of vitamin B complex deficiency in task authorities concerned with the of the form of a characteristic glossitis, showing promotion health is a statistical a of the also the so-called inkspots. That is a very small public one; study incidence of now. percentage in view of the high incidence of lathyrism in former years and On the vitamin B deficiency states, which the author initiative of the former Revenue Minister of a (Jacoby, 1946) found in this area. These facts Bhopal State, Sir C. C. Garbett, such was a nutrition show that the cause of lathyristii-is surely not study undertaken by expert a 1945) for the year 1944-45. It deficiency of the above-quoted vitamins as (Shourie, ' occurrence this district as at tried by us therapeutically. This statement, estimated the in least cases '. Since then no further statisti- however, is in no contradiction of the likelihood 1,200 cal data been available and the writer of the presence of a latent vitamin deficiency, have on observations forming the clinical background upon which the depended, therefore, of individ- uals. The writer has to such Lathyrus grain may exercise its toxic effect on attempted gather as from the nervous system. observations originate police officials' in 58 THE INDIAN MEDICAL GAZETTE [Feb., 1947
charge of the concerned. They to Beaumont, G. E. (1942). Medicine. J. and A. Chur- villages point chill Ltd., London. an increase in incidence of there the lathyrism Bicknell, F., and Pres- Vitamins in Medicine. during the year 1946. cott, F. (1942). William Heinemann Ltd., Whatever significance might be given to such London. reports in view of the absence of official data, Geiger, B. J., Steenbock, J. Nutrition, 6, 427. H., and Parsons, H. T. the writer has actually come across and treated (1933). new patients whose disease represents outbreaks Jacoby, H. (1946) .. Antiseptic, 43, 301. in 1946. If this fact of new outbreaks in 1946 Idem (1946a) .. Indian Med. Gaz., 81, 246. The or of an increase in the incidence of Krohn, G. H. M. (1938). Clinical Examination oj lathyrism the Nervous H.K- in is and the System,. general recognized appreciated by Lewis and Co., London. authorities, the third task should be a legislative Lewis, H. B., and Proc. Soc. Exp. Biol, and one. This should not prove too difficult, since Esterer, M. B. (1943). Med., 53, 263. 453. this district is a area. McCombie Young, T. C. Indian J. Med. Res., 16, (Bhopal) grain surplus (1928). The awareness of the to the fearful villagers Mellanby, E. (1934) .. 'Nutrition and Disease.' consequences of teora consumption had appar- Oliver and Boyd, London. ently not the effect of inducing them to leave Minchin, E. L. H. Brit. Med. J., i, 253. teora voluntarily to cattle only instead of using (1940). F. W. .. A Textbook the Practice it for their there- Price, (1941) o{ consumption. They should, oj Medicine. Oxford Uni- fore, be prevented by law from consuming teora versity Press, London. themselves. This ought to be a humanitarian Ranjan, M. P. (1944). Antiseptic, 41, 652. Rubra, M. and 688. duty and should not be governed by any other N., Lancet, i, Bhattacharya, K. P. consideration. Such a step was in fact taken (1946). in November 1945 by the Department Com- Ruge, R., Muhlens, P., Krankheiten und Hygiene missioner of Jubbulpore, banning the sale of and Zur Vertii, M. der Warmen Lander. teora in the Sihora tehsil. (1925). W. Klinkhardt, Leipzig. Shah, S. R. A. (1939). Indian Med. 74, 385. with the of teora con- Gaz., Along legal prohibition Shourie, K. L. (1945) .. Indian J. Med. Res., 33, 239. sumption should go the scientific research with a Trabaub, J., and Mouhar- Rev. Med. Franc., 13, 449. view to investigating a mixture of teora mixed ram (1932). with other grains, i.e. mainly of wheat, in which the proportion of teora is too small to exercise its toxic effect on men. Such research, which the writer had no facilities to carry out, would be of greatest importance in view of the present world food scarcity, because it would assist in overcoming this scarcity by stretching the avail- able food resources with the help of teora, which grows abundantly even on rocky soil in spite of hailstorm, blight, excess of rain, etc. Summary Lathyrism is a specific disease of the pyramidal tract, due to the consumption of teora, a species of the genus Lathyrus, in this area of Central India. A full account of its manifesta- tions and a description of the treatment with prostigmin injections is given. The role, which vitamins, if deficient in the diet, play in the causation and treatment of the disease in men and experimental animals, is discussed. Sugges- tions for the prevention of the disease are made. Acknowledgment The author desires to express his thanks to Sir Colin C. Garbett, former Revenue Minister, Bhopal State, for his keen interest and kind encouragement throughout the work. Thanks are also due to Messrs. Hoffmann- LaRoche, Switzerland, Branch Bombay, for the liberal supply of prostigmin.
REFERENCES Ahmad, S. K. (1944) .. Antiscptic, 41, 514. Basu, K. P., Nath, Indian J. Med. Res., 24, 1027. M. C., Ghani, M. O., and Mukherjee, R. (1937). Basu, Iv. P., Nath, Ibid., 24, 1001. M. C., and Mukhek-
jee, R. (1937). _. j