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TRANSACTIONS OF THE ROYAL SOCIETY OFTROPICAL MEDICINE AND HYGIENE.
Vol. 44. No. 3. December, 1950.
THE LATHYRISM SYNDROME.*
BY
C. GOPALAN, M.D., PH.D.,
Nutrition Research Laboratories, Coonoor, South India.
Lathyrism has been reported as occurring in " epidemic " form in certainparts of India, where lathyrus forms part of the dietary of the population.Thus outbreaks of the disease have been recorded in Central Provinces
(BUCHANAN,
 1902), Rewa
 (ACTON,
 1922 ;
 YOUNG,
 1927), Gilgit
 (MCCARRISON,
1926;
 MACKENZIE,
 1927), United Provinces
 (SCOTT,
 1930), Punjab
 (SHAH,
1939), and Bhopal
 (SHOURIE,
 1945). There has been no report of cases oflathyrism from South India where lathyrus is not consumed.
 MINCHIN
 (1940),however, reported a series of cases of " primary lateral sclerosis " clinicallyindistinguishable from lathyrism, from the Government General Hospital,Madras.The present investigation shows that cases presenting the clinical featuresof lathyrism occur in a sporadic form even in South India. Since, however,South Indian diets do not contain lathyrus, it would seem that lathyrismsyndrome is not solely confined to the lathyrus-eating population.The following report is based on 11 cases investigated by the writer and 50other cases collected from the records of the Government General Hospital.
INCIDENCE.
Economic status.
—The disease was met with among the poorest classes.The cases investigated by the writer had family incomes of less than Rs. 50/-per mensem. The others were cases from the general wards of the hospitalwhere only poor patients are admitted.
Dietary habits.
—All the patients were subsisting on grossly inadequatediets. The dietary consisted mainly of rice gruel with occasional helping ofcheap vegetables ; milk, meat and eggs were rarely, if ever, consumed. Therewas no evidence that lathyrus seeds had ever formed part of the diet of thesepatients.
Age.
—The majority of subjects were young adults. The incidence wasparticularly heavy between the ages of 20 and 40, 41 of the 61 cases belongingto this age period. There were six cases in this series which were below 20years and only four above 50. The youngest patient was a boy of 6 years andthe oldest a man of 59.* I am grateful to Dr. V. N.
 PATWARDHAN,
 Director, Nutrition Research Laboratories,Coonoor, and Sir
 GEORGE MCROBERT
 for their helpful interest in this work.
 
 
THE LATHYRISM SYNDROME
Sex.
—There was a striking preponderance of males over females in theseries, the proportion of males to females being three to one.
Locality.
—The disease was not apparently confined to or predominant inaiy particular portion of the province. The present series included Tamilsand Telugus from different districts.
MFealesmales0-91: 110-19' 3
 
1
TADLE
20-2917
1.
1
 
3(>-39
 
40-49
9
1
1
60-
59
Total.15
THE ONSET.
The onset of the disease was variable. In nine cases, the history obtainedwas that the patient had retired to bed apparently normal, and on waking upfound inability to use his lower limbs. In 21 other cases the onset was sub-acute, the disability progressing to its full-fledged state within 10 to 20 days.In the remaining 19 cases, the disease set in insidiously ; there was graduallyincreasing- weakness and stiffness of the lower limbs, the process being spreadout ever 1 or 2 months. In four cases there was a history of fever of shortduration (4 to 7 days) immediately preceding the attack. Several patients inthis series had had the disease for many years when they were first seen. Therewas no history of remissions and exacerbations of the disorder in these subjects.Eleven patients in the series had suffered from paraesthesias of the lowerextremities immediately preceding, during and for some time after the onsetof the disease. These took the form of tingling, pins and needles, numbness,cramp-like pains and burning sensation in the soles of the feet.
CLINICAL FEATURES.
The presenting complaint was inability to use the lower limbs. Thelimbs were reported to be weak and
 stiff.
 The disability was so great in somepalierts that they were confined to bed. Others managed to get about with theaid of sticks. The patients were markedly ataxic while attempting to stand orwalk and the gait was spastic.On examination, the tone of the muscles of the lower limbs was found tobe considerably increased and their power very much diminished. The limbswere spastic. There was no fibrillation ; wasting was not observed except ina few cases of long duration where there was a moderate degree of wastingpresumably due to disuse. The knee-jerks were exaggerated in all cases andpstellar clonus could be elicited in some cases. The ankle jerks were alsoexaggerated and ankle clonus was frequently present. The plantar responsewas extensor on both sides in all but three cases in which it could not be elicited.
C. GOPALAN
335
„, abdominal reflexes were variable ; in 28 cases they were normal in all•quadrants, in 12 others they were brisk, in 11 cases they were sluggish, in one
SOT
 the other of the upper quadrants and in nine others they were absent in all
¡'quadrants.
fe The deep reflexes in the upper limbs were normal in 52 cases and unusually'"brisk in nine cases. There was no spasticity of the upper limbs in any case.
Çt
 There was a striking absence of sensory changes. Touch, temperature,pressure, pain, position, muscle, joint and vibration sensations were all fullyretained. Patients did not complain of girdle pain and there was no zone ofhyperaesthesia.Sphincteric disturbances were completely absent in 57 cases. Four patients,however, suffered from precipitancy of micturition. The cranial nerves wereall normal. There were no mental changes.No local disease of the spine could be detected on clinical examinationand X-ray of the spine carried out in 19 cases did not reveal any abnormality.
The
 cerebrospinal
 lui
was clear and under normal pressure. There wasno evidence of obstruction to the flow of cerebrospinal fluid. Quickenstedt'ssign was positive in all cases. Myelography carried out in three cases alsorevealed no obstruction. The protein, chloride and sugar content of the fluidwere within normal range in all cases and cells were either few or absent.Lange's test was negative and so were the Wassermann and Kahn reactions.The blood also gave a negative Wassermann reaction.
Haematological examination
—In
 all the 11 cases investigated by the writerthere was hypochromic microcytic anaemia of moderate severity. In 12 othercases in which the results of haematological examination were recorded, therewas also evidence of moderate anaemia of the microcytic hypochromic type.Sternal marrow in all nine cases in which it was examined showed normoblasticreaction.
Fractional gastric
 analysis
 conducted in 13 cases showed normal gastricacidity in three cases, hypochlorhydria in five cases and achlorhydria in fivecases. In two of the latter, the achlorhydria was histamine-fast. (Sternalmarrow was examined in all cases showing achlorhydria and showed normoblasticreaction.)
Clinical signs
 of dietary
 deficiency
 were not recorded in the cases collectedfrom the hospital records. In the cases examined by the writer the state ofnutrition was not worse than that obtaining among other patients in the generalwards of the hospital. None of these cases showed angular stomatitis, glossitisor ocular signs of B complex deficiency. Phrynoderma was not seen in anycase. Night blindness was present in one case. All the cases, however, showedconjunctival discoloration and patchy thickening of subconjunctival tissue.Mosaic dermatosis affecting the anterolateral aspects of the legs was presentin four cases. Two patients who were past 40 years exhibited cataract.
 
THE LATHYRISM SYNDROME
(ABLE
 H.
<-J.
• •• •
 #
• •
••
A.J
*
Reflexes.B.J.
S.J.
*
#
ÍA.R.
pT
1 *3
 
»4
 
«4
*2
•4•4
P.R.Ext.
Ind.
 ¡
Ext.
'"
 i
-•
 
Tone.
 A
Upperlimbs.
«
i
»»
Low,litnbi
••••
 .
••
 
• •
 
••
xnee jerk. A.J. ankle jerk. B.J. biceps jerk. SJ. supinator jerk. A.R. abdomenP.R. plantar reflex. present. •• exaggerated. negative. M. male. F.
 female.
H.C. hypochromic anaemia. Hypo, hypochlorhydria. Achl. achlorhydria. P.M. precipitancy
 of
 i
DISCUSSION.
The
 condition described here is thus a pure upper motor neurone lesion
confined
 to the lower extremities. General nervous diseases like subacute
combined
 degeneration, amyotrophic lateral sclerosis, disseminated sclerosis,
syringomyelia,
 and neurosyphilis on the one hand, and local lesions affecting
the
 spinal cord like
 tumours,
 tuberculous disease of the spine, etc., on the other,
could
 be easily excluded in these cases. Indeed, the condition does not fit in
into
 any of the clinical entities known at present except that it may be classed
jndcr primary lateral sclerosis
 which,
 however,
 is no more than a
 convenient
 label.
The
 disease, however, has several features in common with lathyrism and
is,
 in fa"t, clinically indistinguishable from it. Thus, lathyrism is also charac-
terised
 by spastic paraplegia affecting the lower limbs, normal cerebro-spinalfluid,
 absence
 of sensory changes and absence of involvement of other parts
of
 the body. The age and sex incidence observed in these cases is also in
conformity with that reported
 in
 lathyrism. Thus
 BUCHANAN
 (1902),
 YOUNG
(1926),
 SHAH
 (1939), and
 SHOURIE
 (1945)
 all
 observed that
 the
 majority
 of
cases
 of
 lathyrism
 were in the younger age groups and that males were predomi-
nantly
 affected by the disease. The striking discrepancy, however, was that
none
 of the cases reported here had ever subsisted on lathyrus.
The
 relationship of this syndrome to lathyrism and the role of
 malnutrition
in
 its development require elucidation. It is noteworthy that all the subjects
suffering
 from the disease belonged to the poorest section of the community
 
roipinal fluid.
|
 Lange'sChemistry. ¡ test.
Normal '
M M Ml
Blood.Sternalmarrow.Peripheralpicture.
Normal H.C.
i
W.R. &Kahn.
I M I
spine.Normal
.. 
1
 
analysis.NormalHypo.Achl. (not histamine-fast)NormalHypo.NormalAchl. (histamine-fast)Hypo.Ind. indifferent. *4 present in all four quadrants. *3 present in three quadrants.•2 present in two quadrants. Ab. abrupt. Su. subacute. Gr. gradual.
subsisting on grossly inadequate diets.
 SHOURIE
 (1946) also found that thevictims of lathyrism were the poorest class of people. However, clinical signsof deficiency diseases were lacking and the same was true of lathyrism
 (SHOURIE,
1946).
 MELLANBY
 (1931), from his work on puppies, believed that vitamin Adeficiency was mainly responsible for the development of lathyrism and wasinclined to class lathyrism as a food deficiency disease.
 YOUNG
 (1927) foundnight blindness common in a village affected by lathyrism, and also observedthat the disease did not occur in neighbouring villages where the diet containedas much lathyrus but more vitamin A, fish and meat.
 SHAH
 (1939) reportedgreat improvement in his cases of lathyrism when vitamins A and D weregiven. On the other hand,
 BASU
 and others (1936) pointed out that
 Lathyrussativus,
 which formed the staple food in famine conditions, was a poor sourceof tryptophane.The occurrence of spastic paraplegia in experimental animals fed ondifferent deficient diets has been reported by several workers.
 MELLANBY
(1931) demonstrated lesions in the spinal cord in puppies on a diet deficient invitamin A. Paralysis of the hind limbs and posterior third of the body has beenreported in mice fed on diets deficient in pantothenic acid
 (MORRIS
 and
LIPPINCOTT,
 1941). Spastic paralysis of the hind limbs was observed in rats
(BOAS,
 1927) and dogs on a biotin deficient diet. Degeneration of the lumbarcord has been reported in rats on a vitamin E deficient diet
 (RINGSTED,
 1935),while
 WINTROBE
 and others (1940) demonstrated degeneration of the spinal cordin pigs on a diet deficient in some unknown factor.

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