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2 6 , I9O3-J SECTION OF TR OPIC AL MEDIC INE. I 707search revealed malignant tertian parasites nnd quinine treat-^ resumed ; and, with the exception of a slight rise on the,1 ague .on May 4th an:1. 7th, no more fever occurred : theimproved,, and he left hospital on May iSth, the case at thisiving been one of biliary colic complicated bymalarial fever,ember 18th. 1002. he returned to hospital, and came under myi] since 7tli in bed. Has passed several gall stones since theich he brought with him. the largest being about Jin. in. The liver dullness extended from the fourth space to 3 in.f costal margin . Spleen not enlarged , well-marked jaundic eh pain of a colicky nature requiring morphine. Temperature0 to 102 0, with profuse perspiration .

,er continued, aud on December 2?nd he coughed up a quan-scid irothy mucus. Temp erature, ot a hectic type, continued103 aud 104 in the evening. The vocal fremitus was slightlyicd. but there was only partial loss of resonance at the rightdiagnosed suppuration in the bile ducts in the liver, andoperation for the purpose of draining the ducts and removingstones. After a consultation 4his wasagreed to. On the morn-e 75th he coughed up a small quantity of pus. but in view of theutioned above, in which a fatal termin ation ensued in anof this kind, in spite of the opening through the lung, andcertain knowledge of gall stones having been passed, it wasto proceed with the operation as previously arran ged . Captainin, I.M.S., kindly helping me. . , .inn.An incision was made in the right linea semilunaris with; over the lower edge of the liver. The gall blad der was eoin-iidden beneath the edge of the liver, but its fundus was reachedned, and a number of small gall stones were extra cted. Onsing the finger along the bile ducts beneath the liver, a largegall stones were felt deep und er the liver, which could onlycached. The wound was now enlarged upwards and downwards,transverse incision made across to the middle line, so asle the lower edge of the greatly enlarged liver to beup . The mass of' stones in the right hepatic ductsow be readied and opened, and with very considerable a. mass of large gall stones, some 3 in. in length and over andiameter in places, were removed, some of which were wellK: liver substan ce. As it was quite impossible at such a depth to: opening in the duet to the surface, and as the patient was in a. a glass drainage tube was inserted and gauze carefully packed; and the wound united around the tube. The patient sufferedfrom shock, but rallied .somewhat in the afternoon, but wasmbled bycoughing up mucus. At 10 in the evening he wasud coughing up mucu s more easily. However, he never fullyram the shock of the prolonged operation and died at 5.30 a.m.'//The same morning the body was exam ined. There were:'.iod adhesions around the gauze packine and no trace of leak-ischarge into the peritoneal cavity. The liver was removedstomach and duodenum and right lung altoge ther. Only oneil stone in the depth of the liver in j the right hepatic duct was'Inch was much smalle r tlian some 01" those removed at theii. so would easily have escaped through the opening made in:. and would doubtless have escaped throu gh the wound.1 too deep in the liver to be removed at the operation. Behindic the bile ducts were much dilated and full of pus in a limitedof the upper posterior portion of the right lobe of the liver,eking abscess had opened posteriorly by the side of the inferiora. and travelled up through the diaphragm and the base of theig into the inferior broncJil. The common bile duct was dilated,opening into the duodenum waslarge and free.

is case a correct diagnosis of suppuration in the intra-bile ducts was made very shortly after admission, andration undertaken without any unnecessary delay,eat en largement of the liver and depth of thein its hilum caused unusually great difficulty, yet:cts were completely cleare d' with the exceptionsmall s tone mentione d , and but for the unfor-. "pening of the tracking abscess into a bronchus on thei:: arranged for the operation leading to a serious extrath e p a t i en ts s t r en gth in coughing up the muco-pus, Ii favourable result might reasonably have been hopedi'e the conditions revealed post mortem clearly showedthing 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 avertedil termination of this very deadly affection. In short,case had come under my care a week earlier his lifelave.been saved by a still earlie r opera tion, which e mph a-: ie impor tance of. early diagnosis with a view to veryperation . /ve not had . t i m e , to search the l i terature of the years for cases of th is nature, but I th ink thatate cases in which suppuration in the in trahepaticave been diagnosed and an operation undertaken withnosed and an operation undertaken withct object of drain ing the abscess through opening the-'is are :sum ciently . rare to be worth placing on record,e eases are quit e, disti nct from, and require totallyoUh. i ? V e t r e a t m e n t t o ' t h e ordinary amoebic tropical

LATHYEISM.By Major A. G. HE NDL E Y, I.M.S.TH E best definition of this affection is Scheube's, which notonly sums up in a few words prevalent opinions as to itscausation , but at once recalls the nature of a too narrowly-known disease of impor tance. He says : " Lathyr ism is adisease of then a tu re of an intoxication with a spastic sp inalparalytic course, which is attr ibutable to poisoning withvar ious k inds of the family of Papiiionaceae lathyrus (chick-

pe a or common pulse) .Dr . Wat t s , in his Dictionary of tlie Economic Products ofIndia, says : " Lath y ru s , a genus of annual orperennial p lantof the natural order Zeguminosae, which comprises some 170species, seven of which are natives of India." The specimensI have here are of the commonest cultivated Indian variety,lathyrus sat ivus , known in different parts of India undervar ious vernacular names, as khesari ddll, Uora, lakh, orIdkhori. To quote Dr. Watts ag a in : "L a th y ru s sa t iv u s(jarosse or gesse) is indigenous from th e Southern C aucasus toNo r th ern In d ia ; it has spread as a weed of cultivation fromits original home, and is now cultivated all over India." Inthe Central Provinces some 358,000 acres are under lathyruscult ivation ; and it is in these provinces that the disease hasof late years become so increasingly prevalent as to call forGovernment inquiry , which inquiry his been entrusted toMajor Andrew Buchanan, I .M.S., who has for the past sixm o n t h s or more been devoting his entire at ten tion to th issubject.IListory.Lath y r i sm is no newly-discovered affection. Its his torydates from very early times, being, according to Huber ,al luded to in the Hippocratic writings, where mention ismad e of the fact that "At Ainos those men and women whocontinually fed on pulse were attacked by a weakness in thelegs which remained permanent." In Don's System ofGardening, again , it is recorded, in describing lathyrussa t iv u s , th a t : "In several parts of the Continent a whitepleasant bread is made from the flour of th is pulse, but itprod uce d such dreadful effects in the seventeenth centuryth a t the use of it was forbidden by an edict of George, Dukeof Wurtemberg , in 1671, whi ch was enforced by two otheredicts under his successor Leopold in 1705 and 1714." InI taly and France the disease was also observed duri ng thesev en teen th and eighteenth centuries, and in the earlier halfof the ninete enth century , large numbers of persons becomingaffected in France, British India, and Algiers, attractedappa rently some considerable at ten tion . ir om the years

1857-68, when Dr. James Irvingthen Civil Surgeon ofAllahabadcontributed five very interesting and exhaustivepapers to the Indian Annals ofMedical Science on the subjectof an ep id emic of lathyrism then prevailing in the North-,West Provinces , down to 1893, when I described in theIndian Medical Gazette a localized outbreak I had met within the Central Provinces , the disease seems to have at tractedno notice, save at the h an d s of a fewveterinary surgeons,who noted its effects on catt le , and may in consequence beassu med as practically non-existent. The circumstancesunder which I first made acquaintance with the affectionwere as follows :Towards the end of July, 1893, I came across a village wherequite suddenly some 10 per cent, of themale population haddur ing the previous five or six weeks (that is, since the com-m e n c e m e n t of the rainy season), become paralysed, m ore orless severely, in the lower lim bs. At-that- time I had neverheard.of such an affection as lathyrism, but careful investiga-tion and inquiry into the circumstances of the outbreak soonconvinced me that they owed their condition to poisoningwith lathyrus sat ivus , a pulse on which all the affected, poorhand- to-mouth labourers had largely subsisted for someeighteen months on account of the failure of their moreregular crops, in consequence of which the village landlordhad paid his labourers in kind with the cheapest grain avail-ab len amely , ' l a th y ru s sa t iv u s . For some,:years I saw.n ofurther case of th is d isease; but with years of scarcitycu lmin a t in g in the terrible famine of 1S96-7, the local condi-tions artificially produced by the vil lage- landlord in 1893becam e general-; the poorer agi-icultural labourers were drivento resor t ex tensively to the cheapest foodstuff procurable( la th y ru s ) , and with most disastrous consequences. In theaverage v il lage a dozen or more victims would be found,.,wh i l s t in a famine relief. camp of some 4,000 persons it became easy to pick out on e or two hundre d such cases. ,. The d isease has, in the.Central Provinces.and ^adjoining

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LATHYSISM. IS:KPT-'native States, gone on sp reading ever since, helped by thesecond severe famine of 1S99-1900 ; until at the present timeMajor Buchanan writes to me that he has an incompletecensus of 2,700 cases in one district and 1,400cases in another;and in a reeeni letter says, " I have seen 190 cases thismorning." Symptoms.I will now pass on to a description of the sym ptoms andmode of onset of the disease. For reasons, given above, itwill be seen that only the poorest classes are liable to thisdisease ; those who are forced to subsist on th e grain un-mixed or diluted only slightly with other grain . All theaffected w ill be found to belong to this class. They eat i teith er ground into flour as bread, cooked as porridge, orboiled with or without oil as lentils, much as we eat haricotbeans. Practically all are field labourers, and the wonderfulunanimity with which all agree as to the onset of the diseaseis most striking. A man will say, "I-went to sleep perfectly,well and very tired after a day's ploughing or other field workin the rain (it is always in th e rainy season) and awoke inthe m orning to find my legs stiff, weak, trembling, and veryheavy to lift when I rose to walk.'1 1 have never been ableto elicit any history of premon itory symptoms.) This weak-ness and trembling, you will'be told,.increased so rapidlyth at with in ten days progression became difficult, even withthe aid of sticks . Still the patie nts have no sense of illnessand no pain ; they have good appetites, sound digestions,and natural sleep at.night. .Both legs are usually affectedsimultaneously, first the calves, then the thighs, and soonafter this all sexual ap petite and power was lost. All com-pla in bi tter ly of this . . . . . . . .

On examination of any typical case, of some six weeks'duratio n, you will find that the gait is very peculiar. Aidedwith a long two-handed staff walking is possible, the rate ofprogression being under two miles an hour. The body.abovethe hips sways from.side to side, whilst the feet, which seemclogged with invisible weights, are lifted with.evident diffi-culty and dragged forward, tbe toes scratchingalong or barelyclearing the ground. The leg bearing the wefght of the bodyis bent at the knee and trembles, whilst the advancing leg,dragged wearily forward strongly adducted, is planted un-steadily directly in front of its fellow, the toes reaching theground first. In short a kind of paralytic goosestep. Thegeneral effect is one of laboured unsteadiness, due to g reatweakness. The evident spasm of the thigh adductors ceasesto be very app arent when th e. patient reclines on his back,when the thighs can be separated, usually without resistance,t o a no rmal extent. There is no wasting, no loss of m usculartone, no true tremors, only tremblings of the entire limbswhen w eight is put. on them. Sensation seems quite un-affected. The tendon reflexes are much exaggerated, b othknee-jerk and ankle-clonus ; the slightest stimulus startingthe latter phenomenon going for a long time. There is noloss of power or undue excitability in bladder or rectum.The arms, trun k, head and neck muscles are unaffected. Themind is clear, speech natural, pupils normal and reactingnatu rally to light and accommod ation. The urine is often ofrather high specific gravity (1030), acid, and contains abundanturat es. Such are the symptoms as I have found them. I amaware that some writers state tha t digestive d isturbances,colicky p ains, and diarrhoea are usually precursors of theparalytic state ; and that sensory disturbances such as hyper-aesthesia, anaesthesia, and formication, with bladder troubles,such as incontinence and retention of urine, are common. Ihave never met with a case in my experience of manyhundreds where the slightest history or evidence of any suchcomplications could be traced.

Etiology.As regards the etiology of the disease, it is, I think ,generally conceded now that the paralysis is in some way dueto lathyru s poisoning.. Other mam theories of causation are:1. That lathyrus eating has nothing to do with it. 3. That if it ;has, it is only diseased g rain w hich is capable ofpoison ous effects. . .. 3. That exposure to snn or some local hot wind is the true cause.4. That the paralysis is due entirely to cold and damp.5. One emine nt authority on tropical medicine (Mansonl has thrownout the suggestion that, like alcoholism and probably beri-beri, thedisease maybe due to the entrance into the body of a toxin gene-rated bygerms-whose habitat is outside the body.' -6 . Lastly, I am quite prepa red to hea r some champion of parasitis marise and suggest that some organism, so minute as to have hith erto.escaped observation, is really the author of all the mischief.,. .In the time at my disposal I cannot fully.discuss these and

other theories, .ind can only say that the occurrence f ivdisease in epidemic form among lathyrus eaters and

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SETT- 26, SECTION OF TROPICAL MEDICINE. IHtnuuT, ,

|i flnd prolonge . . .t" comparative imniunl ' 'y- I " a v e suggested to Major Buchanan* j^nt the respective shares which exposure and a ia thyrusdietary have in producing the paralysis might well be tested- during the extensive animal-feeding exp eriments which are t