HANDIGODU SYNDROME
Item
- Title
- HANDIGODU SYNDROME
- extracted text
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RF_DIS_12_SUDHA
_
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HAN DIGO DU
BANGALOP.E-3^ ) * j
SYNDROM^
A Peculiar Orthopaedic Problem
In the State of Karnataka (old Mysore State) in South India a peculiar
orthopaedic problem, hitherto unreported, has come to light in the last two
months. The illness tends to affect the people in the Malnad area of the State
which is situated along the Western Ghats and mostly at an altitude of 2000-3000
feet above sea level with an annual average rainfall of 80-120 inches. This region
is thick in forest wealth and certain areas have classical tropical rain forest. Most
of the people in this region are agricultural labourers and the main products
include rice, arecanut (Areea catechu), sandal wood, timber and in some areas
coffee. The temparature varies from the upper nineties (Farenheit) in summer
to the lower seventies in winter. The humidity is quite high.
The State of Karnataka has an area of about 120,000 sq. miles and its
population according to the latest census in 1971 is about 29 million. As in the
rest of the country about 85% of the population are rural. About 85% of the
population are Hindus. Amongst Hindus there is a group of people who are
referred to as Harijans. They are mainly agricultural labourers performing many
of the manual tasks. Though living in the same village, their living quarters are
separate from those of the main community. They live in fairly clean surround
ings and the source of water supply to their colony is from a well, which is diffe
rent from the main well for the rest of the population. Some of them own cows,
but they tend to sell rather than consume the milk. It is worth emphasizing that
the villages are surrounded by lush vegetation which is hardly few feet from the
residential quarters-of these individuals. None of the villages have an efficient
drainage system, but still the surroundings are kept clean, since the village folk
tend to go into the forest for their excretory activities.
Joint family system is still very much in vogue in the villages. The family
income is made up of that from not only the father, but also other men and
women folk, and sometimes even children.
It is interesting that the same area in Malnad has been of considerable
medical interest in the last two decades because of the discovery of Kyasanur
Forest Disease. This is a haemorrhagic encephalitis caused by the KFD virus,
which is serologically akin to the Russian Spring Summer encephalitic group of
viruses. The main reservoir of the infection are monkeys in the forest, wherein
an epizootic generally tends to precede an epidemic. Transmission to man is by
tick bite and hence KFD virus is an arthropod-borne virus infection. Annually
anywhere from 30-180 or even 200 cases are recorded even today in this area and
in whom KFD virus has been isolated from the blood. This background .infor
mation is felt to be useful in considering the new syndrome.
yW
In India, administratively each State consists of several districts and these
in turn have several taluks. The first cases were reported from Handi
godu Village in Sagar Taluk of Shiinoga District. In January 1975, 4 patients
from Handigodu village were sent to the local hospital stating that they were
unable to walk and within the next week there were about 30 cases, all of them
from the same village. Initially, these were thought to be paralytic in type and
hence a neurologist was asked to take a team and examine these cases. Accord
ingly, after a preliminary study, a team consisting of neurologists and an ortho
paedic surgeon went to Sagar Town (5 miles from Handigpdu Village) and
examined as many cases as possible along with controls. During the course of
the examination, it became obvious that these patients were not suffering from
any primary neurological disorder and that the problem was mainly in the field
of orthopaedics. The clinical and investigatory findings of this illness, which
appears to be rather unique, form the subject of this report. It is suggested that
since such cases do not appear to have been described in the literature before,
this illness may be termed as Handigodu Syndrome after the village of that name
wherein they were reported first.
About 130 cases have been recorded so far from Sagar Taluk alone in the
last 3 months and 20 additional cases from the neighbouring Thirthahalli Taluk
of Shimoga District. An additional 60 cases have been reported in the last six
weeks from the adjoining district of Malnad - viz., Chikkamagalur.
Cases
reported so far are all from the rural population.
This report is based on 45 patients, all of them from Sagar Taluk and who
form the nucleus of the first few cases reported. This study, it must be emphasived, is based only on those admitted to Sagar Hospital and is by no means an
epidemiological study in its strict sense.
For purposes of comparison a group of thirteen controls living in the same
environment as the patients were available for study. The controls could not be
matched for age and sex. However, this draw-back is being rectified, in that
attempts are being made to collect more data to evolve matched controls. Two
controls had a severe degree of anaemia and another one was suffering from
acute bronchitis. The remaining controls had no symptoms or signs of any
disease. It must be emphasized that none of the controls had a clinical picture of
the main disease under consideration. Eight patients (62%) of the controls were
harijans. Seven of the control group had cases of Handigodu Syndrome in
their family : 4 of these were harijans and other 3 non-harijans.
Dietetic History
The staple diet of both the patients and the control group, all of whom
were mainly agricultural labourers and belong to low socio-economic strata of
society (daily per capita income about 20 US cents), was basically the same. Rice
2
was the staple diet which was consumed 2-3 times a day along with tamarind
{Tamanndus indica) soup. Monkey fruit (Artocarpus lakoocha) soup was also
prepared equally by the patients and the control groups. While no detailed
dietary survey was made, available information did not show any significant diffe
rence in the frequency of consumption of pulses, milk and milk products, eggs,
fish, meat or vegetables in the patient population compared to the controls. Red
gram (Cajanus cajan) soup and small bits of dried fish were consumed twice a
week. Green leafy vegetables were eaten only once or twice a month. Eggs or
meat were taken hardly 3 or 4 times an year, and milk and milk products practi
cally never. The diet would thus appear to be grossly deficient in proteins and
calcium in both the groups. The most commonly consumed vegetable was tuber
ordinary yam {Typhonium trilobatum). It is well-known that this product has a
very high cyanide content. However, during preparation this is cut into small
pieces and soaked for a considerable time in water during which process the
cyanide tends to get washed away. Kesari dhal (Lathyrus sativus) was not cons
ciously eaten and even then never formed a staple part of the diet. It must,
however, be stated that considering the wild flora in the region abutting on the
backyard of the house, as it were, one can never be assured of the type of articles
that are consumed in the raw state. It is reported that most of the village folk,
particularly the harijan community, have a habit of consuming illicit country
liquor, which is shared along with women folk and sometime the childrgjWtfcST^
^^
*
It is said that the country liquor is a brew made by fermenting jaggery
sugar) with ammonium sulphate and discarded lead sheets from car ra>teries.
However, reliable information on the frequency of consumption of illjcgjfquor is
notoriously difficult to obtain.
f Q( bangalore-^ > * i.
&
History
This series was made up of 18 males and 27 females (40% and 60% respec
tively). Just under two-thirds of the patients were in the first two decades of life
and just under a quarter were aged below 10 years. The youngest patient was
aged 5 and the oldest 45 years. A note of caution is necessary, particularly with
regard to the older age groups, in that recorded dates of birth are practically
unknown in this group of people, Seventy percent of the patients were Harijans.
Sixty percent were from Handigodu village and another 16% from Adderi
village, harijans from the former and mainly non-harijans from the latter in the
hospital sample. These 45 patients came from 21 families (family means those
who live under the same roof and share a common kitchen), all except six of them
having more than one case per family. History of similar illness in the previous
generations was denied.
The age at onset of symptoms varied from 4-41 years, over three-quarters
being in the first two decades. The duration of symptoms, as reported by the
patients, ranged from 3 weeks to over 4 years. About a quarter and one-fifth of
3
the group had a duration of symptoms varying between six months to one year
and one year to one and half years respectively. Seven patients (16%) gave a
history of fever either at or within one month before the onset of their other
symptoms, which was insidious in 44 of the 45 subjects. The lone exception was
one subject, in whom the peak disability was reached within 48 hours.
The main symptom was pain. It was often referred to as a sudden catch
ing type of pain either in one of the joints of the lower limbs or the back and
which continued to progress in intensity. This type of pain affected the hips
first in 50% of the patients, while in the rest it was mainly the knee joints which
were affected first. Pain in the knees was complained of at some stage or other
of the illness by all the patients in the group, followed by pain in the hips (82%)
ankles (33%) and shoulders (22%). Nine individuals (20%) had low back-ache
and stray individuals complained of pain in the elbows or the wrists. Thirteen
subjects gave a history of swelling of the joints. The knee joints were affected in
all the instances, while in 5 of these, the ankles were also involved. There was
no positive correlation between a history of febrile episode at the onset on the
one hand and a history of swelling of the joints on the other.
Apart from the febrile episode there were no other antecedent symptoms
complained of by the patients.
Physical Examination
The general body build of these patients did not differ significantly from
that of the controls. In general, they were shorter and weighed less compared
to the more affluent sections in this part of the country. However, the age and
sex adjusted heights and weights did not show any significant difference in the
patient group compared to the controls.
Mucocutaneous signs of vitamin
deficiency were an exception rather than the rule (only 3 cases) and were mostly
those of vitamin A deficiency in the form of xerosis of the conjunctivae. Mucocu
taneous signs of vitamin B complex deficiency were present in only one instance.
Anaemia was noted clinically in both the patients and control groups with no
significant difference between themselves ( 2 patients with anaemia in the control
group being excluded for this analysis).
Detailed general and neurological assessment was within normal limits.
The findings on clinical examination were confined essentially to the bones
and joints. Though all patients complained of pain in the joints, clinical exami
nation showed objective evidence of involvement of the joints in only 32 patients
(71%). The most frequent involvement was in the hip joints (30 patients ; 67%),
followed by the knee joints (10 patients ; 22%), and shoulders (3 patients ; 7%);
ankles or wrists were involved in one instance each. Spinal movements were
uniformly normal and painless in all the patients, low backache in some notwith
standing.
4
The findings on examination of the joints were arbitrarily graded as normal,
mild, moderate and severe, the criteria for which were as follows :—
Normal
:
Full range of movements without pain.
Mild
:
75% or more of normal range of movement possible with or without pain
on movement of the joint.
Moderate
:
50 X 75% of normal range of movement possible with or without pain on
movement of the joint, with fixed deformities of joints-
Severe
:
Z_ 50% of normal range of movement with or without pain on movement
of the joint, with fixed deformities of joints.
In general the frequency and severity of involvement of the hip joints were
more compared to the rest, the knee joints coming way behind as second in the
list. There was severe involvement of the hips in 9 instances (20%), but that of
the knees in only 2 patients (4%). Severe involvement of other joints was not
noted in this series. Objective findings in the hip joints were significantly more
frequent when the symptoms were beyond six months in duration. In view of the
small numbers, for purposes of statistical analysis, age at onset was arbitrarily
divided as below 14 years and 14 years and above ; similarly duration of symptoms
were grouped as below 6 months and 6 months and above. Chi square type of
analysis or the ‘t’ test was resorted to throughout and significance expressed at
95% level of confidence.
Eleven out of 45 patients (24%) had definite evidence of swelling of their
joints, 9 of these involving the knee joints and one each the ankle and wrist.
There was no correlation between age at onset, duration of symptoms or fever at
onset on the one hand and the swelling of joints as complained of by the patients
and/or elicited by physical examination on the other. Objective evidence of
spasm of the flexors and adductors of the hip joints and flexors of the knee joints
was noted in 25 (57%), 24 (53%) and 13 (33%) instances respectively. There was
a significant positive correlation between the duration of symptoms and spasm of
the muscles referred to above. Thinning of quadriceps muscles, particularly
vastus medialis, was noted in 12 out of 42 (28.5%) instances. Unfortunately, in
3 instances information on this aspect was not recorded. This thinning was
almost always mild. This could well be a result of disuse since there was no
corresponding demonstrable weakness of the muscle, but there was no correlation
between the presence of objective evidence of involvement of the knee on the one
hand and thinning of the quadriceps on the other. Likewise, there was no corre
lation between the age at onset, duration of symptoms or fever at onset on the one
hand and thinning of the quadriceps on the other.
Fixed deformities were noted in the hip joints in 19 instances (42%) and of
the knees in 2 patients (4%). There was again a significant positive correlation
between the presence of fixed deformities in the hip and the duration of
symptoms.
5
It may be pertinent to point out that though all patients complained of
pain in the knees, objective involvement of the knees was present in only 10
instances (22%). It is very likely that the pain in the knees was more often due
to its being referred pain from the hips.
Investigations
Four patients refused haemotalogical investigations. Non-significant
differences between the patients and the controls included the following: haemo
globin, peripheral eosinophilia, ESR, random blood sugar, blood urea, serum
electrolytes (Na, K, Mg), total serum proteins, total serum Ca, serum inorganic
P and serum alkaline phosphatase. Those instances wherein the values were
beyond the normal range are indicated below.
An attempt was also made to look for any difference in the ranges for
values of various estimations. Haemoglobin of less than 13gms/100ml was
noted in 27% of the patients and 36% of controls - not significant. Though an
absolute eosinophil count could not be carried out, admittedly a rough estimate of
the same was arrived at from the total and differential leucocyte counts. Peripheral
eosinophilia of over 1000 cells per cubic mm was noted in 73% of patients and
38% of controls - not significant. Toxic granules in polymorphonuclear leuco
cytes were significantly more frequent (54% as against 12%) in the controls com
pared to the patients. Erythrocyte sedimentation rate (Westergren method) was
over 20 mm at the end of one hour in 52% of the patients and 60% of controls,
the difference being statistically not significant. Serum electrophoretic fractiona
tion was normal in 75% and 85% of the patient and control groups. The abnor
malities noted in both the groups were very mild and did not show any significant
difference between themselves. Eighty-five per cent of the patients and 60% of
the controls showed hypocalcemia (below 9 mg/lOOml) with no significant diffe
rence within themselves.
Tests of liver function like serum bilurin, Vanden Bergh reaction and
thymol turbidity were normal in all except one patient, who showed evidence of
mild liver dysfunction. These were normal in all the controls. Serum alkaline
phosphatase was above the normal range (5-13 K.A. units) in all the subjects in
the patient and control groups. The values ranged between 16-26 K.A. units in
the patients and 16-25 KA units in the controls.
Urinalysis, available in all showed mild albuminuria in 3 patients, but none
of the controls. Blood VDRL was positive in a dilution of 1 in 8 or above in 3
patients, two of them being husband and wife, but none in controls.
C-reactive protein was positive in 21 out of 41 instances (51%) while the RoseWaaler test, which was available in an equal number, was positive in 14 instances
(35%). C-reactive protein was significantly more frequently positive in those with
6.
peripheial eosinophil count below 1000 than those above. Otherwise, there.was
no correlation amongst the eosinophil count, ESR, C-reactive protein and RoseWaaler test among themselves.
Cerebrospinal fluid was obtained from the lumbar theca in 10 instances
and the findings normal in 9. CSF VDRL was negative in all. One sample was
the result of a traumatic tap. Electrophoretic fractionation of the CSF was done
in 8 instances with completely normal findings. Lumbar puncture was not done
in the controls.
Electrocardiogram was available in 44 patients and all the 13 controls. In
the former group 6 patients, 4 of them aged below 10 years and two aged 12 and
15 years respectively, showed inverted T waves with peaking in Vj through V3 or
even V4 leads associated with ST segment changes, suggestive of a possible
ischemic cardio-myopathy. The EKG was normal in all the 13 controls.
Electromyographic studies, available in 36 patients and 7 controls, were
within normal limits in all. Motor nerve conduction velocity was determined in
34 patients and 7 controls. The findings were in the normal range and were not
significantly different between the two groups.
Radiology
Considering that the patients were admitted in a peripheral hospital with
extremely limited radiological facilities, one could not carry out as complete a
radiological examination as one would have wished. Four patients refused any
type of radiological investigation. In all but one amongst the rest, the following
radiological examinations were carried out:
1.
X-ray of the chest AP or PA view.
2.
X-ray of the pelvis and the hip joints AP view.
3.
X-ray of the lumbar spine AP and lateral views.
4.
X-ray of the knee joints AP and lateral views.
5.
X-ray of the wrists AP view.
One patient allowed only X-ray of the chest, hip, knee and wrist. X-ray of
the shoulders as seen in the chest films were available in 37 instances. Four
patients had X-rays of the ankles, since they had pain referrable to that region.
X-rays of the chest were normal in all but one, who showed evidence of
bronchiectasis in the right lung. X-rays of the bones, especially of the limbs,
tended to show varying degrees of demineralisation of the bones, in some instances
fairly severe, and varying in intensity from one bone to another in the same
individual.
The most characteristic, significant and diagnostic radiological features
were seen in X-rays of the pelvis, wherein the components of the hip joint were
chiefly involved. The changes in the hip joints are described below. Premature
7.
closure, of varying degrees, of the epiphyseal lines of the femoral head, greater
and lesser trochanters was a constant feature in all patients aged below 16 years.
Reduction in cartilage space of the joint, irregularity of the articulating surfaces,
sub-chondral bony sclerosis, cystic areas surrounded by sclerotic bone - these
were seen individually in over three-quarters of the patients. Height of the
femoral head appeared diminished in about 70% of the patients. Other changes,
but less common, were marginal lipping even in young adults, Coxa vara, features
suggestive of epiphyseolysis of varying grades and widening of the symphysis
pubis. Nine patients showed radiological changes akin to Perthe’s disease consi
sting of mushrooming and flattening of the femoral heads. In extreme cases of
hip joint disease, there was complete loss of articular space, destruction of the
normal shape of the femoral head, which in some instances was shifted from its
normal relationship with the acetabulum.
X-rays of the knee joints showed qualitative changes similar to those in
the hips, but of varying intensity. They consisted of varying degrees of prema
ture closure of epiphyseal lines of the bones of the joints in patients below the
age of 16 years and diminution of cartilage space, irregularities of joint surface,
cystic areas in the articulating ends and osteophytosis. Excavations and marginal
sclerosis were seen in the patellae in nearly three-quarters of the cases, while one
patient showed changes in the knee joints akin to Perthe’s disease of the hips.
X-rays of the lumbar spine showed evidence of interference with ossifica
tion of the apophyseal nucleus of the vertebral bodies - platy-spondylia and in
older age groups, marginal lipping. These were noted in nearly three-quarters
of the cases. X-rays of the ankle joints, available in 4, showed flattening of the
body of the talus in two. In the wrists, in addition to varying degrees of dimi
nished articular cartilage space, the other changes were of the nature of osteochondritic lesions, particularly in the lunate bone. The most pronounced feature of
the X-rays of the shoulder was irregularities of the articular surface and cystic
changes, particularly in the head of the humerus. It is interesting that three
subjects showed evidence of diaphyseal aclasis involving either the femur or
humerus or both.
For the purpose of this study, the radiological findings in the joints (spine
excluded) were graded as normal, mild, moderate, severe and gross, the criteria
for which are enumerated below :
Normal
Mild
: None of the below
: Narrowing of joint spaces
Moderate
:
Severe
Gross
Narrowing of joint spaces and minimal bone changes - cystic areas,
sclerosis, osteophytic lipping.
: Gross degree of diminution of joint spaces and/or irregular articular
surfaces and marginal sclerosis-
:
Complete loss of joint space and/or destruction of the articular ends
with or without displacement.
8
Distribution of severity of the radiological lesions in the various joints
are given below :
Normal
Mild
Moderate
Severe
Gross
Total
. ..
Hips
Knees
Ankles
Wrisls
Shoulders
0
6
5
21
9
3
10
18
9
1
1
1
1
1
0
13
11
14
2
0
21
7
7
2
0
41
41
4
40
37
It was uniformly observed that the radiological changes were always well in
advance of the clinical signs and symptoms. Similary, though clinical examination
of the spine was normal, radiological changes of the lumbar vertebrae were fairly
marked.
Three of the controls aged 15, 20 and 26 years, showed certain radiological
changes in the hip joints similar to those observed in the patients. These occurred
in the form of reduction of joint space, irregularity of the articular surface, sub
chondral bony sclerosis, cystic areas, osteophytosis and appearance suggestive of
epiphyseolysis and in one instance akin to Perthe’s disease. Similar changes, but
of lesser degree, were seen in the knee joints in all these 3 instances, who also
showed excavations and marginal sclerosis in the patellae. Appearance of platyspondylia of the lumbar spine was noted in two of these above 3 controls. The
other 10 control subjects did not show any radiological changes similar to those
observed in the various patients. X-ray of the chest in one control showed pneu
monic consolidation.
Activities of Daily Living
The disability of the patients was arbitrarily graded in terms of pain as a
symptom, findings on examination of the joints and activities of daily living. The
last was graded as full, mild, moderate, severe and gross, the criteria for which
are given below :
Full
:
Can walk any distance and do any work to which the patient is normally
accustomed- (N=5)
Mild
:
Walking restricted because of pain, but can walk a shorter distance at
normal pace without support and can squat, get up or bend without help
and freely. (N = ll)
Moderate :
Walking restricted and pace slower, but without support and/or can squat,
get up and bend without support but with difficulty. (N=17)
Severe
Walking restricted and needs support for walking and/or needs help for
squatting, getting up or bending. (N=7)
Gross
:
:
Cannot walk except a few paces, that too with support and/or cannot
stand. (N=5)
9
Disability
Absent
Mild
: None of the below (N = 0)
: Pain present; examination of joints show mild abnormalities ; ADL full
or mild. (N = 17)
Pain present ; moderate abnormalities in the joint on examination ; ADL
mild or moderate. (N = 16)
: Pain present ; severe abnormalities on examination of the joints ; ADL
severe or gross. (N =12)
Moderate :
Severe
In general there was a positive correlation between the degree of involve
ment of ADL and disability on the one hand and duration of symptoms, frequency
and severity of changes on examination of the hip joint, presence of flexor and/or
adductor spasms of the hips and flexor spasm of the knees.
Treatment
Patients whose disability had been rated as mild have been advised analge
sics and physiotherapy to the involved joints along with short-wave diathermyCases coming under the category of moderate disability are being given, in addi
tion, prednisolone in declining doses for a period of six weeks. Since this
therapeutic regime has just been started, it is too early to assess the results.
Cases listed as having severe disability have been chosen for surgical
correction. Indeed four of them have had orthopaedic corrective procedures,
which consisted of release of soft tissue contractures at the hip joints in two
patients, and the flexors released from their attachment. Hip joint capsule was
released from its superior attachment so as to get complete correction of the
flexion at the hip, confirmed by Thomas’ Test on the operating table. When the
hip joint was opened to release the contracture, the opportunity was utilised to
take out specimens of capsule, synovial membrane, articular cartilage, and the
metaphyseal bone along with the deeper cancellous bone for histopathological as
well as virological studies. Incidentally, the gluteus medius muscle was also taken
for biopsy. Subsequent to the operative procedure, these patients were put on
skin traction - to relieve the pain and to retain the correction obtained.
Examination of the exposed hip joint revealed a greyish pale synovial
membrane and glistening white articular cartilage, both on the acetabular side, as
well as on the femoral head. Synovial fluid was thin and clear and was not
significantly increased in quantity.
One patient had biopsy of the structures of the knee joint in addition to
aspiration of the knee joint fluid. The synovial membrane did not appear conges
ted nor was it thickened. The articular cartilage appeared white and glisten
ing. In another patient the periosteum over the lower end of the shaft of the
femur along with a block of bone consisting of the metaphysis, epiphyseal line
10
and pait of the adjoining epiphysis was taken out. These were normal macroscopica ly. Biopsy of the vastus medialis was also carried out in 3 of the 4 cases.
CSF from 4 patients, synovial fluid from the left knee joint in one instance
and biopsy material from cartilage, synovial membrane, femur and its periosteum
along with gluteus medius and vastus medialis from one patient each were
submitted for bacteriological culture for aerobic and anaerobic organisms and
fungi, but with negative results. Culture for M. tuberculosis was also negative.
Sera from 41 patients and all the controls, spinal fluid from 10 patients,
synovial fluid from the left knee joint in one instance and biopsy material includ
ing cartilage, bone, muscle and synovial membrane from 4 subjects have been sent
to Virus Research Centre, Poona, for virological studies with special reference to
arboviruses, and the results awaited. Similarly, the biopsy material from 4
patients who were operated upon have been sent for histopathological examina
tion to the Indian Registry of Pathology, New Delhi, and the results awaited.
Future Work
More controls are in the process of being collected, so as to match them
with the patient population with respect to age and sex. Follow-up evaluation of
these subjects will be carried out as far as possible, but the great limiting factor
is the distance of nearly 220 miles between Sagar Town and Bangalore. More
cases in the severe grade of disability would be submitted for orthopaedic correc
tive procedures, during which process biopsies of the appropriate tissues will be
obtained.
Attempts are being made to examine the cooked food from the patients
and controls for the presence of any toxic products, particularly cyanogens and
nitrile compounds. Samples of urine would be collected from as many patients
and controls as possible and analysed for porphobilinogen, thiocyanates and
nitrile compounds.
Addendum
Since writing up this report, the total series is now made up
of 52 patients and 51 controls matched for age, sex, community and environment.
Three more patients have been operated. Data are being analysed.
National Institute of Mental
Health and Neuro Sciences,
Bangalore-560027.
K. S. MANI
&
H. K. SRINIVASA MURTHY
Fig 2.
Normal hip joints
Fig 3.
Fig 4.
Hip joints - Moderate changes. Note premature closure of the
epiphyseal lines, narrowed joint space and cystic areas with
marginal sclerosis
Hip joints - Severe changes. Note premature closure of the
epiphyseal lines, gross reduction of the joint space and
irregular articulating surfaces
Fig 5.
Hip joints - Severe changes.
Same as in Fig 4 plus widening
of symphysis pubis and marginal osteophytosis at the hip joints
Fig 6.
Hip joints - Gross changes
Note the complete loss of joint
space and deepening of the acetabulae
Fig 7
»
Fig 8.
Mild change - Narrowing of joint space
Fig 9-
Hip joints - Gross changes. As in Fig 6, but in an adult.
Note the gross destruction of the left hip joint with subluxation.
Normal knee joints - AP view
Fig 11.
Normal knee joints - Lateral view
a^o
Fig 10.
Fig 12.
Knee joints - Moderate changes. AP view.
Note premature
closure of the epiphyseal lines, narrowing of the joint space
and cystic areas with marginal sclerosis
Fig 13.
Knee joints - Moderate changes. Lateral view.
Note excavated articular surface of the patellae
Fig 14.
Fig 15.
Knee joints - Severe changes. AP view.
As in Fig 4, but in the knee joints
Knee joints - Severe changes.
Lateral view
J
Fig 16.
Fig 17.
Knee joints - Moderate changes.
As in Fig 12, but in an adult
Knee joints - Moderate changes.
AP view.
Lateral view
Fig 18.
Ankle joints - AP view. Note flattering of the superior
surface of the body of the talus
Fig 19.
Ankle joints - lateral view.
As in Fig 18
Fig 20.
Lumbar Spine - AP view.
bodies with osteophytosis
Fig 21.
Note flattering of the vertebral
Lumbar Spine - Lateral view.
As in Fig 20
Fig 22.
Wrist joints - PA view.
Note increased density of the
lunate bones - osteochondritis-
ICMR Bulletin: Vol.7, No.6, June 1977
HANDIGODU SYNDROME
(Endemic Familial Arthritis)
A disease affecting the joint has been reported in Shimoga
and Chikamagalur districts of Karnataka State for the last
8 years, though the maximum incidence occurred 4-6 years ago.
It has been designated "HANDIGODU SYNDROME", BASAPURA SYNDROME"
and "MYSTERY DISEASE" from time to time. Investigations carried
out earlier by the All India Institute of Mental Health,
Bangalore, in collaboration with the Health Department of
the Government of Karnataka established the fact that th disease
involved the joints and was not a neurological disorder.
In April 1976, preliminary studies were undertaken by
the National Institute of Nutrition, Hyderabad. It was noted
that 8 years earlier there were no reports of this disease;
the disease was seen predominently among harijans and appeared
to have a strong familial tendency; it appeared to have some
relation to dwarfism and rickets and there was close resemblance
to Mseleni joint disease reported from parts of South Africa in
1973.
A detailed epidemiological study was undertaken by a
team of the National Institute of Nutrition, Hyderabad
in November 1976.
DEMOGRAPHIC STUDIES
The disease was found to be confined to a few villages
around the towns of Sagar in Shimoga district and Balehonur
in Chikkamagalur district (parts of the Malnad). Sagar taluk
has a population of around 0.13 million according to the
1971 census. The social caste structure in this area in the
order of population strength, are Deevaru or Idiga, followed
by Brahmins of Havyaka sect, Vokkaligas (with a number of
sub-division), Gowdas, Lingayats and Harijans. The population
figure for scheduled castes and tribes in Sagar taluk was
11,741. Although all the scheduled castes and tribes identified
themselves as either Harijans or Adi Karnatakas, there were
atleast 4 sub-castes among the scheduled tribes in addition to
2
2
several nomadic tribes. Mixing and co-existence of different
sub-caste was rare and marriages almost invariably occurred
within the sub-caste and that too, within a radius of 5-10 km.
resulting in a very high degree of inbreeding.
A house to house study was carried out in 40 villages
of which 34 were affected. In view of the small number
of households in these villages, it was possible to obtain
detailed information on almost all the affected households.
THE DISEASE
Out break:
The disease first appeared. 6-8 years ago, with the
majority of cases developing 4-6 years ago. Very
few cases have been reported in the last two years. It did not
appear to be ineffective in nature, nor was it seasonal or
follow any environmental catastrophe. It was confined
to humans. The onset was gradual, punctuated by pain of moderate
degree in the lower limbs, particularly in the lumbo-sacral
regions, hips and knee joints. Pain was bilateral and of
variable severity, sometimes necessitating immobilisation.
A proportion of cases suffered from crippling flexion deformities
of the knee and hip joints. Involvement of other joints was
rare. The characteristic radiological features were destruction
of articular surfaces of the femur and tibia, osteophytic
lipping of several bones, rarefaction of the bones around the
area of destruction, varying degrees of osteoarthritic changes
in the hip joint and in some.cases cystic changes in the
femoral head.
Subjects of all ages between 6 and 50 years were affected
and there appeared to be no sex prediliction. The disease
per se was not fatal. It was noted that over 85 percent of the
affected subjects belonged to the Harijan community while
the rest belonged to Vokkaliga and Deevaru communities. Not
a single case was found among the brahim community.
. . . .3
3
Familial characters of the disease; In 40 of the 60 affected
households, more than one member vzas affected. A detailed
study revealed the existence of a close social relationship not
only between the affected households of the same village but
also between affected households of different villages. Although
subjects belonging to three different generations suffered from
the disease in some familieis it was significant that in all
of them, the disease made its appearance within a short period
of 1-2 years. Equally significant was the observation that in
many households, the children showed the manifestation first
followed by the parents and on a occassions by the grand parents.
The disease was also seen in both the local inhabitants and their
partners who originally came from other non-affected neighbouring
villages but had subsequently settled down in affected villages.
Relation to achondroplasic dwarfism;
A striking observation
was that in the affected villages in both Sagar and Chikkamagalur
districts, achondroplasic dwarfs were frequently seen. As many
as 22 dwarfs of different ages were encountered during the
survey, the oldest being over 60 years of age. These dwarfs
were seen in villages whose inhabitants were most severely
affected with arthritis, which is clinically a distinct syndrome
not related to any congenital lesion. All the dwarfs were found
to be closely related by birth to members of affected households
and some of them were related to other dwarfs in the same
village and to the dwarfs in the same village and to the dwarfs
in other villages. In a few cases the dwarfs had suffered
from arthritis.
Osteomalacia and ricket-like manifestation in the community; In
the affected households of some villages, a clinical
picture suggestive of osteomalacia was observed. It was
interesting to not that a combination of the joint disease with
either genu varum, genu valgum, rickety rosary or frontal
bossing was seen in many subjects, residing in one of the
villages viz., Basapura.
4
4
A variety of malformations ie., phocomelia, congenital
absence of eye balls, congenitalscoliosis and microcephaly
were observed in young children in the affected areas. Congenital
icthyosis was seen in four adults of the affected households.
AGRICULTURAL PRACTICES IN AFFECTED VILLAGES
Paddy cultivation and tending of plantations are the main
activities of the inhabitants. Crops grown in these villages
include arecanut, pepper, cardamom and coffee. The farmers of
the areas are progressive and have adopted mechanised cultivation
High yielding varieties of paddy have been introduced during
the last decade. These and otheragricultural developments
have madeit necessary for them to go in for extensive use
of fertilizers and pesticides.
The pesticides most widely used were folidol and endrin,
although many others were also used. The paddy fields and
ponds contain a large variety of fish, crabs and frogs.
Following spraying of paddy fields with pesticides, there is
death en masse of the local fauna. Farm labourers usually do
not catch and eat dead fauna from sprayed fields for a period
varying from one day to one week depending on their economic
status. This practice of spraying pesticides on paddy field
is of recent origin - since the last decade.
FOOD HABITS
The staple in these areas is rice. It is supplemented
with dhal, vegetables, and milk and milk products in
the case of economically well off groups. Vokkaliga, Gowda,
and Deevaru communities in addition consume animal foods.
Till about 10 years ago Harijans used to be given one
meal by the land lord in lieu of a part of their wages.
The staple of the Harijans is rice and in addition they
consume large amounts of fish and crabs caught from local
ponds and paddy fields. Consumption of crabs has increased
in recent years because of a tendency to discontinue th<fe
practice of serving food as a part of their wages.
5
5
Although eating of dead fish and crabs following pesticide
spraying has been emphatically denied by the harijans, this
was not found to be correct. After a spraying operation
. the
harijans generally wait for two days before collecting fauna
for food from the sprayed fields. Pesticide spraying of upland
fields however does not prevent them catching fauna from
the lower fields. Eating habits of the poorer Vokkaligas are
essentialJy similar to those of the harijans.
STUDY ON THE NEIGHBOURING NON AFFECTED AREAS
In view of the clustering of the affected villages around
the two major rural towns of Sagar and Balehonnur, it was
considered important to extend these studies to villages
situated at a distance from these towns, beyond the affected
villages. Accordingly the study was carried out in 15
neighbouring villages. In all these villages the 4 communities
were represented but no case of disease had been reported. It
was noted that there was a definite change in the envimment
of these villages as compared to the affected villages. Food
habits were also changed showing increasingly dependency in
milets.
Studies in Sagar town: Members of 53 harijan household residing
in well planned government houses for the last two decades
were studied. Only two affected persons were seen and both had
resided earlier in Handigodu and Kanleypura, two severely
affected villages.
Studies on 166 residents of a Harijan hostel revealed that
only 3 of them had suffered from this disease for a few
years. All three originally came from Handigodu.
CONCLUSIONS
As had been mentioned earlier the affected villagers were
closely interlinked by marriage. Among harijans two subsects
Cheluvagaru and Chennigaru were the main sufferers in “both
districts. Presence of a genetic marker such as achondroplasic
6
6
dwarfism in both the communities suggest the possibility of
a common origin of both these population groups. This is
supported by the short distance (50 km) between the two
affected areas. Historical evidence also favours the
possibility of both groups descending from a single stock.
It is interesting to note that besides Harijans, a
few families belonging to other castes like Deevaru
and Vokkaligas were also affected. Although these affected
families have no links with the harijans in the present
generation, the admixture wth them or inter conversion in
the past cannot be ruled out. This is specially so, because
of the influence about four centuries ago of some social
reformers in this region, who did not believe in caste system
and converted many people belonging to different castes into
a single religion.
In spite of the strong familial tendency epidemiological
studies suggest that the disease, a recent one, has been
precipitated by certain changes in the microecological system.
One striking change over the last decade is the use of high
yielding varieties of paddy with attendant intensive agricultural
practices and the use of large amounts of pesticides. Pond
water being contaminated is a very high risk and the immediate
and direct effect on the fauna after spraying operations has
already been indicated by the wholesale mortality in fishes and
crabs.
The possible hazard due to pesticide residues entering
human food chain have not so far been studied in great depth,
particulary in relation to possible changes in the skeletal
system. However, there are evidences to suggest a role for
chemical toxins to cause bone disease in man due to consuption
of crabs exposed to such chemicals.
The microecological changes that had occurred in the last
decade in this area may be of relevance. There is little
doubt that the application of pesticides in this area has been
significant during the last decade or so . It is also apparant
that crabs and fish are consumed liberally a few days after
'pesticide spraying operations. In view of the published reports
7
7
of the capacity of crabs to accumulate large amount of chemical
toxins suchas DDT and cadmium from the surrounding water, it may
not be unreasonableto suspect that pesticides may'be accumulated
by crabs. In such an event, it is likely that population groups
who consume such crabs are exposed to the risk of ingestion of
pesticide residues through this specific food chain. The effect
of such changes on the health of the poor communities
needs further study.
Incidentally the intensity-
of pesticide use has declined
in the last two years particularly due to the ban on the
use of certain pesticides and the rising cost of pesticides in
general. This does appear to be reflected in the very few
cases recorded in the last two years.
As the communities have been using ten or more varities
of pesticides, the exact chemical nature of each one
of them needs to be understood. The exact role, if any attributable
to pesticides in the aetiology of this disease therefore needs
further study.
•IM
ICMR Bulletin: Vol.7, No.6, June 1977
HANDIGODU SYNDROME
(Endemic Familial Arthritis)
A disease affecting the joint has been reported in Shimoga
and Chikamagalur districts of Karnataka State for the last
8 years, though the maximum incidence occurred 4-6 years ago.
It has been designated "HANDIGODU SYNDROME", BASAPURA SYNDROME"
and "MYSTERY DISEASE" from time to time. Investigations carried .
out earlier by the All India Institute of Mental Health,
Bangalore, in collaboration with the Health Department of
the Government of Karnataka established the fact that th disease
involved the joints and was not a neurological disorder.
In April 1976, preliminary studies were undertaken by
the National Institute of Nutrition, Hyderabad. It was noted
that 8 years earlier there were no reports of this disease;
the disease was seen predominantly among harijans and appeared
to have a strong familial tendency; it appeared to have some
relation to dwarfism and rickets and there was close resemblance
to Mseleni joint disease reported from parts of South Afrca in
1973.
A detailed epidemiological study was undertaken by a
team of the National Institute of Nutrition, Hyderabad
in November 1976.
DEMOGRAPHIC STUDIES
The disease was found to be confined to a few villages
around the towns of Sagar in Shimoga district and Balehonur
in Chikkamagalur district (parts of the Malnad). Sagar taluk
has a population of around 0.13 million according to the
1971 eensus. The social caste structure in this area in the
order of population strength, are Deevaru or Idiga, followed
by Bra'mins of Havyaka sect, Vokkaligas (with a number of
sub-division), Gowdas, Lingayats and Harijans. The population
figure for scheduled castes and tribes in Sagar taluk was
11,741. Although all the scheduled castes and tribes identified
themselves as either Harijans or Adi Karnatakas, there were
atleast 4 sub-castes among the scheduled trbes in addition to
K
2
several nomadic tribes. Mixing and co-existence of different
sub-caste was rare and marriages almost invariably occurred
within the sub-caste and that too, within a radius of 5-10 km.<
resulting in a very high degree of inbreeding.
A house to house study was carried out in 40 villages
of which 34 were affected. In view of the small number
of households in these villages, it was possible to obtain
detailed information on almost all the affected households.
/
THE DISEASE
Out break:
The disease first appeared 6-8 years ago, with the
majority of cases developing 4-6 years ago. Very
few cases have been reported in the last two years. It did not
appear to be ineffective in nature, nor was it seasonal or
follow any environmental catastrophe. It was confined
to humans. The onset was gradual, punctuated by pain of moderate
degree in the lower limbs, particularly in the lumbo-sacral
regions, hips and knee joints. Pain was bilateral and of
variable severity, sometimes necessitating immobilisation.
A proportion of cases suffered from crippling flexion deformities
of the knee and hip joints. Involvement of other joints was
rare. The characteristic, radiological features were destruction
of articular surfaces of the femur and tibia, osteophytic
lipping of several bones, rarefaction of the bones around the
area of destruction, varying degrees of osteoarthritic changes
in the hip joint and in some cases cystic changes in the
femoral head.
Subjects of all ages between 6 and 50 years were affected
and there appeared to be no sex prediliction. The disease
per se was not fatal. It was noted that over 85 percent of the
affected subjects belonged to the Hari{j;an community while
the rest belonged to Vokkaliga and Deevaru communities. Not
a single case was found among the brahim community.
3
3
l
Familial characters of the disease: In 40 of t’ne 60 affected
households, more than one member was affected. A detailed
study revealed the existence of a close social relationship not
only between the affected households of the same village but
also between affected households of different villages. Although
subjects belonging to three different generations suffered from
the disease in some familieis it was significant that in all
of them, the disease made its appearance within a short period
of 1-2 years. Equally significant was the observation that in
many households, the children showed the nanifestation first
followed by the parents and on a occassicns by the grand parents.
The disease was also seen in both the local inhabitants and their
partners who originally came from other non-affected neighbouring
villages but had subsequently settled down in affected villages.
Relation to achondroplasic dwarfism: A striking observation
was that in the affected villages in both Sagar and Chikkamagalur
districts, achondroplasic dwarfs were frequently seen. As many
as 22 dwarfs of different ages were encountered during the
survey, the oldest being over 60 years of age. These dwarfs
were seen in villages whose inhabitant'- were
most severely
affected with arthritis, which is clinically a distinct syndrome
not related to any congenital lesion. All the dwarfs were found
to be closely related by birth to members of affected households
and some of them were related to other dwarfs in the same
village and to the dwarfs in the same village and to the dwarfs
in other villages. In a few cases the dwarfs had suffered
from arthritis.
Osteomalacia and ricket-like Manifestation in the community: In
the affected households of some villages, a clinical
picture suggestive of osteomalacia was observed. It was
interesting to not that a combination of the joint disease with
either' genu varum, genu valgum, rickety rosary or frontal
bossing was seen in many subjects, residing in one of the
villages viz., Basapura.
4
4
A variety of malformations ie., phocomelia, congenital
absence of eye balls, congenitalscoliosis and microcephaly
were observed in young children in the affected areas. Congenital
icthyosis was seen in four adults of the affected households.
AGRICULTURAL PRACTICES IN A FECTED VILLAGES
Paddy cultivation and tending of plantations are the main
activities of the inhabitants. Crops grown in these villages
include arecanut, pepper, cardamom and coffee. The farmers of
the areas are progressive and have adopted ^mechanised cultivation
High yielding varieties of paddy have been/ introduced during
the last decade. These and otheragricultural developments
have madeit necessary for them to go in for extensive use
of fertilizers and pesticides.
The pesticides most widely used were folidol and endrin,
although many others were also used. The paddy fields and
ponds contain a large variety of fish, crabs and frogs.
Following spraying of paddy fields with pesticides, there is
death en masse of the local fauna. Farm labourers usually do
not catch and eat dead fauna from sprayed fields for a period
varying from one day to one week depending on their economic
status. This practice of spraying pesticides on paddy field
is of recent origin - since the last decade.
FOOD HABITS
The staple in these areas is rice. It is supplemented
with dhal, vegetables, and milk and milk products in
the case of economically well off groups. Vokkaliga, Gowda,
and Deevaru communities in addition consume animal foods.
Till about 10 years ago Harijans used to be given one
meal by the land lord in lieu of a part of their v.'ages.
The staple of the Harijans is rice and in audition they
consume large amounts of fish and crabs caught from local
ponds and paddy fields. Consumption of crabs has increased
in recent years because of a tendency to discontinue the
practice of serving food as a part of their wages.
5
5
Although eating of dead fish and crabs following pesticide
spraying has been emphatically denied by the harijans, this
was not found to be correct. After a spraying operation
the
harijans generally wait for two days before collecting fauna
for food from the sprayed fields. Pesticide spraying of upland
fields however' does not prevent them catching fauna from
the lower fields. Eating habits of the poorer Vokkaligas are
essentially similar to those of the harijans.
STUDY ON THE NEIGHBOURING NON AFFECTED AREAS
In view of the clustering of the affected villages around
the two major rural towns of Sagar and Balehonnur, it was
considered important to extend these studies to villages
situated at a distance from these towns, beyond the affected
villages. Accordingly the study was carried out in 15
neighbouring villages. In all these villages the 4 communities
were represented but no case of disease had been reported. It
was noted that there was a definite change in the envimment
of these villages as compared to the affected villages. Food
habits were also changed showing increasingly dependency in
milets.
Studies in Sagar town: Members of 53 harijan household residing
in well planned government houses for the last two decades
were studied. Only two affected persons were seen and both had
resided earlier in Handigodu and Kanleypura, two severely
affected villages.
Studies on 166 residents of a Harijan hostel revealed that
only 3 of them had suffered from this disease for a few
years. All three originally came from Handigodu.
CONCLUSIONS
As had been mentioned earlier the affected villagers were
closely interlinked by marriage. Among harijans two-subsects
Cheluvagaru and Chennigaru were the main sufferers in
both
districts. Presence of a genetic marker such as achondroplasic
6
6
dwarfism in both the communities suggest the possibility of
a common origin of both these population groups. This is
supported by the short distance (50 km) between the two
affected
reas. Historical evidence also favours the
possibility of both groups descending from a single stock.
It is interesting to note that besides Harijans, a
few families'belonging to other castes like Deevaru
and Vokkaligas were also affected. Although these affected
families have no links with the harijans in the present
generation, the admixture wih them or inter conversion in
the past cannot be ruled out. This is specially so, because
of the influence about four centuries ago of some social
reformers in this region, who did not believe in caste system
and converted many people belonging to different castes into
a single religion.
In spite of the strong familial tendency epidemiological
studies suggest that the disease, a recent one, has been
precipitated by certain changes in the microecological system.
One striking change over the last decade is the use of high
yielding varieties of paddy with attendant intensive agricultural
practices and the use of large amounts of pesticides. Pond
water being contaminated is a very high risk and the immediate
and direct effect on the fauna after spraying operations has
already been indicated by the wholesale mortality in fishes and
crabs.
The possible hazard due to pesticide residues entering
human food chain have not so far been studied in great depth,
particulary in relation to possible changes in the skeletal
system. However, there are evidences to suggest a role for
chemical toxins to cause bone disease in man due to corruption
of crabs exposed to such chemicals.
The microecological changes that had occurred in the last
decade in this area may be of relevance. There is little
doubt that the application of pesticides in this area has been
significant during the last decade or so . It is also apparant
that crabs and fish are consumed liberally a few days after
pesticide spraying operations. In view of the published reports
7
7
of the capacity of crabs to accumulate large amount of chemical
toxins suchas DDT and cadmium from the surrounding water, it may
not be unreasonableto suspect that pesticides may be accumulated
by crabs. In such an event, it is likely that population groups
who consume such crabs are exposed to the risk of ingestion of
pesticide residues through this specific food chain. The effect
of such changes on the health of the poor communities
needs further study.
Incidentally the intensity.', of pesticide use has declined
in the last two years particularly due to the ban on the
use of certain pesticides and the rising cost of pesticides in
general. This does ap: ear to be reflected in the very few
cases recorded in the last two years.
As the communities have been using ten or more verities
of pesticides, the exact chemical nature of each one
of them needs to be understood. The exact role, if any attributable
to pesticides in the aetiology of this disease therefore needs
further study.
REPORT OF INVESTIGATION TEAM OF EXPERTS ON HANDIGODU
SYNDROME IN SHIMOGA AND CHIKKAMAGALUR DISTRICTS.
References:1♦ EST(1)CR-502/82-83 from the Principal, B.M.C. Bangalore
dated 23.11.1982
2. 0M.ET.M.C./24/82-83 dated 3.11.82 of D.M.E. Bangalore
MEMBERS OF THE TEAM
1 • Dr Mohamed Nuruddin (Leader of the team), Professor of Medicine
2. Dr Deshikachar, Professor of Surgery
3. Dr M N Shivaprakash, Professor of Orthopaedics
4« Dr Krishna Murthy, Professor of Pathology
5. Dr Parthasarathy, Professor of Radiology
6. Dr P V Aswath, Assistant Professor of P&S Medicine
Accompanied by;
to Handigodu and other villages
1. Dr Gopinath, Assistant District Health & F W Officer, Sagar
2. Dr Lokappa, Medical Officer, Sagar
With para medical staff.
Places visited in Shimoga District
1. Handigodu Village
2. Keladipura
3. Kolisaru
L. Bandagadde
Accompanied by the following at Chikkamagalur
1. Dr Prasanna, District Health & FW Officer, Chickmagalur
Places visited at Chikkamagalur District
1. Kadaba Gadde
2. Hallandur
3. Sangameshwarpet
Patients from the affected areas were seen in the above centres.
At Sagar Taluk If) cases were examined and at Chikkamagalur division
cases were examined.
AGE GROUP : METHODS
Patient age group varied frcm 4-40 years. Most of the affected persons belong
to the age group of 5 - 15 years.
2
Religion & Caste
All the patients belong to Hindu Religion,, Most of the patients belong
to Harijans, Vokkaligas and Edigas.
Detailed clinical examination of each case was done.
An attempt was made to study the Pedigree of each family.
Blood samples were drawn for investigation. Living conditions and the
surrounding area were studied.
History of origin of the disease, their food habits and type of diet
were studied.
Clinical photographs of the pauients were taken.
OBSERVATIONS
1.
Fost of the patients belong to socially economically backward class
2.
Highest incidence of the disease is seen in the age group of 5-15 years.
3.
Sex prediliction is equal
4.
No significant nutritional deficiency was noticed. No gross symptoms
of deficiency was water and fat soluble vitamins seen. No gross protein
deficiency noticed. No calorie malnutrition observed.
5.
Upper part of the body was seen to be normally built than to the lower part.
TABLE 1
Name
Measurement of normal chili:iren aged 10 - 12 years, at Sangameshwarpet
“ *—• — — I. ■ ■ —M —— "W WW , WM «—•
* —• —— —— — — — —
”
Length between
Length between
Height
symp. pubis to foot
crown to symph.
Span
in cms.
pubis.
— — — — —
1. Bagyadeva
12 years
133 cms,,
133 cms
64 cms.
69 cms
2. Satish SC
12 years
129 cms
135 cms
62 cms
67 cms
3. Prasanna
10 years
116 cms
120 cms
59 cms
57 cms
4. BS Sudhakar
10 years
119 cms
120 cms
59 cms
60 cms
3
3
Reasurements of affected children at Sangameshwarpct
Name
Height
in cms
Span
*—
• •—*
Length between
croon tc symph.
p ubis.
Length bttween
symp. pubis to foot
1. Dasavaraja
12 years
122.5 cms
126 cms
55 OT.3
62 cms
2.Nsr3yens
10 years
127.5 cms
135 cms
60 cms
57 cms
3. Thimmaiah
17 years
93.5 cms
105.5 cms 47 cms
57 cms
4. Suresh
*» 14 years
•—
153 cms
75 cms
60 cms
« Patient and Bilateral congenital cataract
*
** Patient is unable to stand. Tibia and fibula tiers bowed. Fibula is almost
by the side of medial side of tibia.
OBSERVATIONS
Genially patients are of short stature. In most of the affected individual
shortness was contributed by the below trunk affection as evidenced by the gross disparit
between Heel to Syrrphysis and Symphysis to crown length.
Span length was found to be abnormal. It is observed that in majority of
the individuals this abnormality ranged from 1-7 cms.
One achondroplastic was also seen. One patient had congenital cataract of both eyes.
The disabilities noticed were involved of Endochondral ossification and gen.ralised
involvement of bones.
These were confinddto the lower limbs and trunk. Particularly the hio joints in
majority of cases and in cw cases other joints were also involved.
The following deformities were observedt
1.
Exaggerated lumbar lardosis
Coxaverun of hip of varying degrees
Genuverum, genuvalgus and genurecurvatum
4. Deformities were noticed in tibia ant! fibula of varying degrees.
No obvious limb length discrepency could be made out.
5. Flexion contractive of hips and knees were seen in few individuals uho were seen
4w—Pew bed ridden for long time
6. In majority of the affected individuals the gait was short shuffing
associated with mild to moderate degree of waddling.
Except in 3 cases who had evidence of mild inflammation of the knee joint.
Others had no signs of active inflammation of the Joints.
2.
3.
4
4
In one case Syndactyle was seen.
No neurological defect was observed.
No mental deficiency was observed.
No evidence of CVS diseases
No evidence of involvement lymphnodes.
PEDIGREE STUDIES
Villagewise details iof the Pedigree studies vzere
tabulated in Table 2.
No. of families in
No. of
families
with history
of consanguineousmarri age
Si
No
No. of
cases
Handigodu
Kaldipura
1
1
1*
2
1
3*
3(1+2)
2.
2
-
1
-
1
-
3.
3
2
2
1
*
1
1
4,
4
2*
2*
*
3
-
3(1+1+1)
5.
5
1
1
-
-
-
6.
6
1
-
-
-
-
7.
7
-
-
1*
-
1
Total
No. of
families
7
8
6
5
8
NO. OF CASES
26
23
23
8
Sangameswar- Kadabapet
gadde
♦Family with history of consanguineous marriage found.
In 4 villages where detailed history of 80 cases were collected
The cases were distributed in 26 families and history of
consanguineous marriage was observed in eight families.
All these families originally belonged to Karkala Area
(Gattada Kelage) and migrated to these places about 2 centuries
back. (Keladi Shivappa Nayaka's time).
5
5
FOOD HABITS
Rice with sambar or rasam without dhal with available vegetables
and roots, like Kesavedantu (Colocasiae), Basale (spinache)
Dantu (amaranth).
Rarely they take non-vegetarian diet once in a year. During
rainy season crabs and fishes are consumed rarely. Some food is
consumed by other people of village.
As it was not the rainy season fish and crab samples were not
collected for examination.
General environmental conditions and housing were quite
satisfactory. Lighting ventilation of the houses were satisfactory.
Water sources were, common both for affected and non affected
persons in the villages.
In many families many persons were affected. Symptoms of this
syndrome were suggestive of a developmental defect as a result
of flexion deformity of hip and knee, upper limbs are normal
in these people.
Majority of the individuals are able to move about for their
routine activity without much of complaint except perhaps that their
efficiency was lower to the extent of disability.
From history narrated by local people and from affected area,
no definite date could be fixed as to when the disease was first
seen. It is likely that this disease appears to be present in the
community since a few generations.
Members of this community are in the habit of consuming illicit
liquors from their teen age in both the sexes. Blood samples collected
showed normal serum calcium levels and in two patients eosinophilia
was present. Anaemia was present in a few cases. Anaemia is of
normocytic hypochromic type. No radiological investigation could
be done.
On the day of our visit to Handigodu village one person who was
suffering from the Handigodu syndrome had died because of pulmonary
tuberculosis as told by the relatives.
6
6
Following are the names of the persons who were subjected to
blood examination.
Si No
Age
Name
Sex
I. HANDIGODU VILLAGE
1.
Griyappa
40
M
2.
Subb emma
34
F
3.
4,
Nagaraj a
13
M
5.
Rama
Ramachandra
5
18
6.
Bharathi
9
M
M
F
7.
Jay a
Nagaraj a
12
10
F
M
Ramachandra
12
M
Varadappa
Rudramma
18
25
18
40
M
8.
9.
10.
11.
12.
13.
Raju
Chandramma
F
M
F
II. KELADIPURA VILLAGE
Manj appa
23
M
F
16.
Pokuramma
Thimmamma
35
45
17.
Chowdamma
35
F
F
18.
19.
20.
Guttiyamma
40
F
21.
22.
23.
24.
14.
15.
25.
P arwar.hamma
12
F
Basamma
35
F
Durgamma
38
F
Nagappa
Ramappa
50
40
M
M
Ramappa
16
M
Chowdamma
18
F
CONCLUSIONS
1. The disease appears to be a herido families disorder affecting
endochnodral ossification.
2. Subsequent crippling appears to be due to super added traume
on a joint which is not mechanically sound.
7
3. The crippling is also due to lack of treatment at the
crucial time of its development.
4. Crippling is appeared to be a preventable condition.
OBSERVATIONS
In these crippled persons their earning capacity is
considerably reduced. Consequently their nutritional status
decreases. They become susceptible tomany other diseases due
to above factors.
RECOMMENDATIONS
1. The individuals who develop the signs of inflammation
of the joints have to be shifted to a hospital under
the care of an orthopaedic surgeon.
2. Immobilisation of the joint, traction,analgesics , steroids and
antibiotics have to be used whenever felt necessary.
3. Deformed joints should be surgically corrected and o
this will increase the earning capacity of the individual
enermously.
4. The persons who underwent corrections of the joints
should be rehabilitated with occupational therapy.
5. Genetic counselling and marriage counselling should be
done to control the disease.
6. Services of social and phylanthropic associations could be
taken for the social upliftment of the community and
rehabilitation of the cases.
7. Chromosomal and genetic studies have to be undertaken.
For the detailed study of cases a selected number of cases
from the affected villages from each group of crippled
and non crippled persons have to be taken. To pin point the
herido familial character of the cisease and to adopt practical
measures in the management and prevention of this disease.
8. In view of the magnitude and endemicity of the problem
and in the interest of long term treatment and in the
prevention of disease it is suggested that a creation of a
special cell headed by an officer with his associated staff.
9. Such rehabilitation centres should be located in a place
where the persons of both the places could be treated similar
to Kyasanur Forest Disease team.
8
10. The team suggests that a detailed survey has to be conducted
in Karkala for detection of cases from where these people
have migrated.
We thank Dr Gopinath, Assistant District Health and Family
Welfare Officer, Dr Lokappa, Dr Prasanna and Dr Begur for thdr
cooperation in conducting the abovesfcudy.
1. Dr Mohammed Nuriddin, Professor of Medicine (Leader of the team)
2. Dr Desikachar, Professor of Surgery
3. Dr M N Shivaprakash, Professor of Orthopaedics
3. Dr Krishna Murthy, Professor of Pathology
5. Dr Parthasarathy, Professor of Radiology
6. Dr PV Aswath, Assistant Professor of P&S Medicine
D/-S 12_- '3
ftoft or irnrr/TOCTor tdm: of tht cc; jviTrrru
e.-p-rrr;-’ tf <-7:^,,,
onipr FT’G',I’T DISTRICTS.
Pofbrerceatl • FDT(1)cr-502/?2-fi3 from the Principal, P.T’.O. Bangalore
dated 23.11.1982
2. m.n.FT.C./24/-2413 dated 3.11.82 of D.M.'-’. Bangalore
C”
■
*</?' "
1. Dr MchaaeS BUruddin (Leader of the term), Professor of Medicine
2. Dr poshikcchar, Professor of Surgery
3. Dr ’’ I: Shivtiprokxsh, Professor' of Orthopaedics
4. Dr Krishna. ISturthy, Professor’ of Pathology
5.
Ft Porthasoratly, Professor of Radiology
5. Dr P V ? swath, Assistant Professor of P&S Medicine
Accompanied by>
to Handigodu and other villages
1. Dr Gqp&oath, Assistant District Health £•. F
Officer, Sagar
2. Dr Lokappa, Medical Officer, Sagar
’’ith para nodical staff.
Places visited- in Shfeo^a District
1, Handi'jcdu Yilla~o
2. Kdlcdipura
3. Folisaru
I • BcndaftTK'de
Acccnnaniad by the frllorin-: at C’-dh'-anaralur
1. Pr Prasanna, District Health ?- F-’ Officer, Chiclarvjalar
Places visito' at Chikbarn-salw’ District
1. Kadaba Gadde
2. Ilallandur
3 • SangunoshvRirpot
Patients fiom the affected areas :;ero sern ir. tho above centres.
At Sagar Tahilc 49 cases were csaninad and at Cliiki.aEiagalur division 46
cases uere o: axined.
GI CjP : M g'CPS
Patient age freup varied frac Lr ~- 40 yoars. Most of the affected persons belbsy;
to the ago croup of 5 - 15 years.
,2
2
Religion & Caste
All the patients belong to Hindu Religion, ("lost of the patients belong
to Harijans, Vokkaligas and Edigas.
Detailed clinical examination of each case was done.
An attempt was made to study the Pedigree of each family.
Blood samples were drawn for investigation. Living conditions and the
surrounding area were studied.
History of origin of the disease, their food habits and type of diet
were studied.
Clinical photographs of the patients were taken.
OBSERVATIONS
1.
Most of the patients belong to socially economically backward class
2.
Highest incidence of the disease is seen in the age group of 5-15 years.
3.
Sex prediliction is equal
4.
No significant nutritional deficiency was noticed. No gross symptoms
of deficiency was water and fat soluble vitamins seen. No gross protein
deficiency noticed. No calorie malnutrition observed.
5.
Upper part of the body was seen to be normally built than to the lower part.
TABLE 1
Measurement of normal children aged 10 - 12 years, at Sangameshwarpet
Length between
symp. |oubis to foot
Height
in cms«
Span
Length between
crown to symph.
pubis.
1. Bagyadeva
12 years
133 cms.
133 cms
64 cms.
69 cms
2. Satish SC
12 years
129 cms
135 cms
62 cms
67 cms
3. Prasanna
10 years
116 cms
120 cms
59 cms
57 cms
4. BS Sudhakar
10 years
119 cms
120 cms
59 cms
60 cms
Name
3
3
Measurements of affected children at Sangameshwarpet
Name
Height
in cms
Span
Length between
crown to symph.
pubis.
Length between
symp. pubis to foot
1. Basavaraja
12 years
122.5 cms
126 cms
55 cms
62 cms
2.Narayana
10 years
127.5 cms
135 cms
60 cms
57 cms
3. Thimrnaiah
■» 17 years
98.5 cms
105.5 cms 47 cms
57 cms
4. Suresh
*■» 14 years
■—
153 cms
60 cms
75 cms
* Patient and Bilateral congenital cataract
** Patient is unable to stand. Tibia and fibula were bowed. Fibula is almost
by the side of medial side of tibia.
OBSERVATIONS
Gencally patients are of short stature. In most of the affected individual
shortness was contributed by the below trunk affection as evidenced by the gross disparit'
between Heel to Symphysis and Symphysis to crown length.
Span length was found to be abnormal. It is observed that in majority of
the individuals this abnortnality ranged from 1-7 cms.
One achondroplastic was also seen. One patient had congenital cataract of both eyes.
The disabilities noticed were involved of Endochondral ossification and generalised
involvement of bones.
These were confinddto the lower limbs and trunk. Particularly the hip joints in
majority of cases and in few cases other joints were also involved.
The following deformities were observed:
Exaggerated lumbar lardosis
Coxaverun of hip of varying degrees
Genuverum, genuvalgus and genurecurvatum
Deformities were noticed in tibia and fibula of varying degrees.
No obvious limb length discrepancy could be made out.
5. Flexion contractive of hips and knees were seen in few individuals who were seen
in—Few bed ridden for long time
6. In majority of the affected individuals the gait was short shuffing
associated with mild to moderate degree of waddling.
Except in 3 cases who had evidence of mild inflammation of the knee joint.
Cfchers had no signs of active inflammation of the joints.
1.
2.
3.
4.
4
4
In one case Syndactyle was seen.
No neurological defect was observed.
No mental deficiency was observed.
No evidence of CVS diseases
No evidence of involvement lymphnodes.
PEDIGREE STUDIES
Villagewise details of the Pedigree studies were
tabulated in Table 2.
SI
No
No. of
cases
No. of families in
Handigodu
Kaldipura
No. of
families
with history
of consanguineousmarri age
S angame swar-■ Kadabapet
gadde
—
1
1
1*
2
1
*
3
3(1+2)
2.
2
-
1
-
1
—
3.
3
2
2
1
1*
1
4.
4
2*
2*
*
3
-
3(1+1+1)
5.
5
1
1
-
-
-
6.
6
1
-
-
-
-
7.
7
-
-
1*
—
1
Total
No. of
families
7
8
6
5
8
NO. OF CASES
26
23
23
8
♦Family with history of consanguineous marriage found.
In 4 villages where detailed history of 80 cases were collected
The cases were distributed in 26 families and history of
consanguineous marriage was observed in eight families.
All these families originally belonged to Karkala Area
(Gattada Kelage) and migrated to these places about 2 centuries
back. (Keladi Shivappa Nayaka’s time).
5
5
FOOD HABITS
Rice with sambar or rasam without dhal with available vegetables
and roots, like Kesavedantu (Colocasiae), Basale (spinache)
Dantu (amaranth).
Rstely they take non-vegetarian diet once in a year. During
rainy season crabs and fishes are consumed rarely. Some food is
consumed by other people of village.
As it was not the rainy season fish and crab samples were not
collected for examination.
General environmental conditions and housing were quite
satisfactory. Lighting ventilation of the houses were satisfactory.
Water sources were common both for affected and non affected
persons in the villages.
In many families many persons were affect'd. Symptoms of this
syndrome were suggestive of a developmental defect as a result
of flexion deformity of hip and knee, upper limbs are normal
in these people.
Majority of the individuals are able to move about for their
routine activity without much of complaint except perhaps that their
efficiency was lower to the extent of disability.
From history narrated by local people and from affected area,
no definite date could be fixed as to when the disease was first
seen. It is likely that this disease appears to be present in the
community since a few generations.
Members of this community are in the habit of consuming illicit
liquors from their teen age in both the sexes. Blood samples collected
showed normal serum calcium levels and in two patients eosihophilia
was present. Anaemia was present in a few cases. Anaemia.is of
normocytic hypochromic type. No radiological investigation could
be done.
On the day of our visit to Handigodu village one person who was
suffering from the Handigodu syndrome had died because of pulmonary
tuberculosis as told by the relatives.
6
Following are the names of the persons who were subjected to
blood examination.
SI No
Age
Name
Sex
I. HANDIGODU VILLAGE
1.
Griyappa
40
M
2.
Subbamma
34
F
3.
4.
Nagaraja
M
5.
Rama
Ramachandra
13
5
18
6.
Bharathi
9
M
F
7.
Jaya
Nagaraja
Ramachandra
12
10
8.
9.
10.
11.
12.
13.
14.
F
12
M
M
18
M
Raju
25
18
F
M
Chandramma
40
F
Varadappa
Rudramma
Manj appa
16.
Pokuramma
Thimmamma
17.
Chowdamma
18.
Guttiyamma
15.
M
II . KELADIPURA VILLAGE
23
'
35
45
M
F
F
35
40
F
F
19.
20.
Parwathamma
12
Basamma
35
F
F
21.
Durgamma
38
F
22.
23.
24.
Nagappa
Ramappa
50
40
M
Ramappa
16
25.
Chowdamma
18
M
M
F
CONCLUSIONS
1. The disease appears to be a herido families disorder affecting
endochnodral ossification.
2. Subsequent crippling appears to be due to super added traume
on a joint which is not mechanically sound.
7
3. The crippling is also due to lack of treatment at the
crucial time of its development.
4. Crip-, ling is appeared to be a preventable condition.
OBSERVATIONS
In these crippled persons their earning capacity is
considerably reduced. Consequently their nutritional status
decreases. They become susceptible tomany other diseases due
to above rectors.
RECOMMENDATIONS
1. The individuals who develop the signs of inflammation
of the joints have to be shifted to a hospital under
the care of an orthopaedic surgeon.
2. Immobilisation of the joint, traction,analgesics, steroids and
antibiotics have to be used whenever felt necessary.
3. Deformed joints should be surgically corrected and o
this will increase the earning capacity of the individual
enermously.
4. The persons who underwent corrections of the joints
should be rehabilitated with occupational therapy.
5. Genetic counselling and marriage counselling should be
done to control the disease.
6. Services of social and phylanthropic associations could be
taken for the social upliftment of the community and
rehabilitation of the cases.
7. Chromosomal and genetic studies have to be undertaken.
For the detailed study of cases a selected number of cases
from the affected villages from each group of crippled
and non crippled persons have to be taken. To pin point the
herido familial character of the
isease and to adopt practical
measures in the management and prevention of this disease.
S. In view of the magnitude and endemicity of the problem
and in the interest of long term treatment and in the
prevention of disease it is suggested that a creation of a
special cell headed by an officer with his associated staff.
9. Such rehabilitation centres should be located in a place
where the persons of both the plac s could be treated similar
to Kyasanur For st Disease team.
.
...
...
.
.
.
...8
8
10. The team suggests that a detailed survey has to be conducted
in Karkala for detection of cases from where these people
have migrated.
We thank Dr Gopinath, Assistant District Health and Family
Welfare Officer, Dr Lokappa, Dr Prasanna and Dr Begur for thdr
cooperation in conducting the abovestudy.
1. Dr Mohammed Nuriddin, Professor of Medicine (Leader of the team)
2. Dr Desikachar, Professor of Surgery
3. Dr M N Shivaprakash, Professor of Orthopaedics
3. Dr Krishna Murthy, Professor of Pathology
5. Dr Parthasarathy, Professor of Radiology
6. Dr PV Aswath, Assistant Professor of P&S Medicine
ku?-a
Di s
I -a- ‘I-
Karnataka Medical Journal, Vol.XLVIII, pp.103-107, April-June, 1983
HANDIGODU SYNDROME - A MYSTERIOUS DISEASE
P V Aswath
*
and M K Sudarshan
**
Introduction
In January 1975, 4 patients from Handigodu village in
Karnataka were examined at the local hospital for the complaint
of inability to walk. In the next week there were about 30 similar
cases from the same village. Initially it was thought to be a
neurological disorder. However, soon a team of specialists
who examined, these cases identified the disease to be an
orthopaedic problem and ruled out any primary neurological
involvement. The disease was labelled as "Handigodu syndrome"
named after the village Handigodu from where the cases were reported
first-'-. Following this many investigations have been conducted
on this disease. But unfortunately the aetiological factor(s)
responsible are yet to be identified. An approximate estimate has
been made that more than 600 cases are affected by this disease.
Though the disease has been reported about 8 years back, public
feel that nothing substantial has been made to contain the problem,
2, 3
as the disease permanently cripples the individuals.
. These
incapacitated individuals who are invariably from a lower class,
became a socio-economic burden not only to their families but
also to the community.
A profile of the disease has been presented in brief and
a few suggestions have been made.
Topography
The disease has been reported from a few villages (only)
around the towns of Sagar in Shimoga district and Balehonnur
in Chikmagalur district (parts of Malnad area) ofKarnataka State.
*
Assistant Professor of Preventive and Social Medicine,
Bangalore Medical College, Bangalore.
** Assistant Professor of Community Medicine, Kempegowda Institute
of Medical Sciences, Bangalore 4
2
The affected region is predominantly an agricultural area
and has no industries. These villages are situated along the
Western ghats and mostly at an altitude of 2000-3000 feet above
sea level. The annual rainfall is about 80-120 inches. The region
is thick in forest wealth and certain areas have a classical
tropical forest. The temperature ranges from upper nineties in
summer to lower seventies (Faranheit) in winter. The relative
humidity is quite high.
Demography
The population of Chikmagalur district and Shimoga district
4
is about 0.9 million and 1.6 million respectively . The
caste wise dominance in the area is idigas, brahmins, vokkaligas,
5
lingayats and harijans in that order.
Because of the stringent
social mores, marriages take place within the same sub-caste and
that too within
a radius of 5-10 kms resulting in high degree
of inbreeding. About 76% of the population is rural and 86%
'Hindus'. The literary rate is about 43%. The estimated crude
birth rate and the crude death rate are 29.2 and 12.0 respectively
(Karnataka State figures). The infant mortality rate is 83.3
and the projected expectation of life at birth by sex in Karnataka
is 61.4 years for males and 59.4 years for females.
Environmental sanitation
It is observed that there is a fairly clean surroundings
around the affected households in these villages. The
houses are mostly kucha with thatched roofing, though a few
houses are pucca with tiled roofing. The source of drinking water
is well. There is no drainage system and the villagers go to the
adjacent forest for their excretory functions.
Agricultural activities
Most of the people in the area are land cultivators and
their chief agricultural produces include rice, arecanut,
pepper, cardamom and coffee. The farmers are progressive and have
3
3
mechanised cultivation. Following the introduction of high yielding
varieties of paddy, since last decade there is a wide scale use
of pesticides. The paddy fields and adjacent ponds contain a
large variety of fish, crabs and frogs. However, following pesticiie
spraying of paddy fields, there is large scale death of local
fauna. Farm labourers, particularly the poor harijans and
vokkaligas though deny eating this dead fauna, it has been
found to be not true. And consumption of crabs and fish has increased
in recent years because of the tendency of discontinuing the
practice of serving food (as a part of their wages) to these
land labourers by their landlords.
Dietary practices
Rice forms the staple diet and is consumed. 2-3 times a day
along with tamarind soup. Though a detailed dietary history
has not been elicited, it has been found that green leafy vegetables
are consumed once or twice a month. Egg/meat are taken hardly
3-4 times a year and milk and milk products practically never. The
tuber ordinary yam (which is known to have a high cyanide content)
however, is soaked in water, washed (removes cyanide), cooked and
consumed. Another interesting feature is the consumption of
illicit country licjuor, even by some of the women and children.
However, as the wild flora in the area is abutting on the backyard
of the houses, there is a suspicion about the type(s) of articles
consumed in raw states.
The Disease (fig.1)
The disease per se is not fatal and is confined to humans.
ICMR
as early as in 1976 conducted an house to house survey
in 40 villages and found 34 villages to be affected. Subsequently
many teams have investigated the disease. But it appears that
an exact estimate of the number of cases affected is not available.
The first investigating team reports that there was no history of
similar illness in the previous generations. But a recent investigation
team observes that this disease appears to be present in the community
since a few generations.6 it has also made a study of family
pre
... .4
4
pedigree in some cases and after observing a high frequency
of consanguineous marriages in these cases, the disease is now
suspected to be herido-familial. It is significant that in some
households members of the three generations were affected almost
at the same time. In many cases children suffered earlier and more
7
severely than the elders of the household . However, it appears
that one of the drawbacks of these studies is the non—inclusion
of adequate and appropriate controls and absence of sampling
methods.
The disease has been found to affect people in the age
group of 5-64 years. Infants and preschool children appear
to have been spared. However, the disease is reported to have a
higher predeliction towards younger age group (5-15 years). Most
of the patients are from the socioeconomically backward classes
(mostly harijans and a few vokkaligas and idigas) and not a
single case has been reported from the brahmin community. No
significant nutritional dificiencies are seen. The disease
appears to be neither infectious nor contagious.
The onset is insidious, associated with pain and swelling
of joints, particularly of the lower limbs. The frequently
affected joints are hips and knees. In some cases, due to severity
there is crippling flexion deformities and disuse muscular atrophy
The characteristic radiological picture is destruction of articular
surfaces of femur and tibia, osteophytic lipping of many bones,
rarefaction of the bones around the area of destruction, varying
degrees of osteoarthritic changes in the hip joint and sometimes
with cystic changes in the femoral head. The disease is suspected
to be affecting endochondral ossification. The subsequent crippling
is thought to be due to superadded trauma on a joint which is
not mechanically sound. It is opined that this crippling is
preventable as it is due to lack of treatment at the crucial time
ofits development.
5
5
In one of the surveys, 22 dwarfs were encountered among
1000 harijans studied in the affected villages. It was found
that all the dwarfs were inter-related, in addition, they were
7
free from the disease except for three dwarfs. Osteomalacia and
rickets like manifestations have been frequently encountered in
this area. A variety of congenital malformations such as
phocomelia, congenital absence of eye ball with rudementary
palpebral fissure, microcephaly, congenital scoliosis and
o
icthyosis have beenobserved in the affected population.
A team of investigators who recently investigated the disease
in April 1983, suspect the disease as an autoimmmune reaction
akin to rheumatoid arthritis or the auto-immune reaction being
9
triggered of by the KFD viral infection prevalentin the region.'
The disease has been identified tobe similar to Kashinbeck
syndrome (Urov1s disease) reported among Siberians, which
is presumed to be due to consumption of cereals contaminated
with the fungus fusarium sporotrichiella. The disease also has
a striking resemblance with Mseleni joint disease in South
Africa, which is thought to be due to an unidentified environmental
factor.
Investigation
The haemotological investigations done include haemoglobin,
ESR, peripheral Eosinophilia, random blood sugar, blood urea,
serum electrolytes (Na K Mg), total serum proteins, total
serum calcium, serum inorganic prosphorous and alkaline phosphatase.
The other investigations done include tests of liver function
like serum bilirubbin, vanden bergh reaction and thymol turbidity
urine analysis, rose waaler test, C-reactive protein, CSF
examination, ECG, EKG and electromyography. The results of these
investigations have failed to throw light on the disease.
6
o
CONCLUSION
This crippling disease appears to be primarily an
orthopaedic problem mostly affecting the poor lower socio
economic ethnic f group, with a tendency for familial segre
gation. Apparently industrial effluents have no role in the
genesis of this disease as there are no industries in this
area.
Though the pathological process of the disease appears to
have been studied, the aetiological factor(s) responsible
for the same are still at large. The disease is thought to be
herido familial following an history of high frequency of
consanguineous marriages in the affected families. It is also
suspected to be nutritional, suspected factors include (a)
illicit country liquor, (b) pesticides (concentrated) in
crabs and fishes consumed by the affected people, (c) unidentified
food article consumed in raw state from the adjacent thick
forest.
Lastly, it is to be noted that a striking observation of
a number of achondroplasic dwarfs in the affected area has
been made. It should also be remembered that this area
is known for the occurrence of Kyasanur Forest Disease (KFD).
Suggestions
In the light of the above observations, few suggestions
are made for future work on the disease:
a.
There is an urgent need for an immediate establishment of
a special research cum service cell at a suitable place
(preferably at Sagar Town) to carry out further
investigations and to provide therapeutic and preventive
services. The cell should be staffed by an Epidemiologist?
Orthopaedic Surgeon(s), Radiologist, Genetic Specialist,
Physiotherapist(s), other ancillary and field staff with
adequate clinical and independent transport facilities.
7
7
b.
The immediate task is to identify all the cases and
mapping of the disease. Those persons in whom the disease
is still in early stages, should be provided with
physiotherapy and the required treatment facilities at
the centre,
c.
The persons who are already permanently crippled have
to be rehabilitated vocationally to help them to earn
their livelihood. It is also desirable that the
Government should provide a suitable compensation to
these individuals,
d.
As one of the investigation teams has observed the disease
to be associated with consanguineous marriages, the
‘at risk1 population in the area must be properly
educated in this regard. The people should also be
advised against the consumption of crabs and fish
from the paddy fields.
e.
There is scope for a detailed field epidemiological
investigation of this mysterious disease.
Acknowledqement
The authors are thankful to Dr A N Armugam, Professor
and Head of the Department of Community Medicine,
Kempegowda Institute of Medical Sciences, for his valuable
suggestions and help.
References
1.
K S Mani and H K Srinivasa Murthy (1974):
Handigodu syndrome—A peculiar orthopaedic problem.
National Institute of Mental Health and Neuro Sciences,
Bangalore 560027.
2.
Deccan Herald (1983): Handigodu disease,
March 1, 75, MG Road, Bangalore-1.
3.
Ibid: Deadly disease leaves 600 crippled, April 25.
4.
Directorate of Health and Family Welfare (1982),
Health and Family Welfare Services—Karnataka,
Year Book 1980-81, Bangalore-9.
5.
Indian Council of Medical Research (1977): Handigodu
Syndrome (Endemic familial arthriti s), Research
Information Bulletin, Vol.7, No.6, Nevi Delhi.
6.
Mohammed Nuruddin, Desikachar, Shivaprakash,
Krishnamurthy, Parthasarathy and Aswath (1983) Report
of investigation team of experts on Handigodu
Syndrome in Shimoga and Chickmagalur Districts,
Directorate of Health and Family Welfare Services,
Bangalore-9.
7.
Krishnamachari and Bhat (1978), Endemic familial
arthritis of Malnad—An outbreak in Southern India,
Trop, Geogr. Med., 30, 33-37.
8.
Bhat and Krishnamachari (1977): Endemic familial
o
arthritis of Malnad—An epidemiological study. Indian
J. Med. Res. 66, 5,777-786.
9.
Hande, H S Venkatarangan, Mruthyunjayanna and Shivananda
(1983): Report of the expert team submitted to the
Director of Medical Education, Bangalore 9.
JD/i)
if.
Karnataka Medical Journal, Vol.XLVIH, pp.103-107, April-June, 1983
HANDIGODU SYNDROME - A MYSTERIOUS DISEASE
P V Aswath
*
and M K Sudarshan
**
Introduction
In January 1975, 4 patients from Handigodu village in
Karnataka were examined at the local hospital for the complaint
of inability to walk. In the next week there were about 30 similar
cases from the same village. Initially it was thought to be a
neurological disorder. However, soon a team of specialists
who examined these cases identified the disease to be an
orthopaedic problem and ruled out any primary neurological
involvement. The disease was labelled as "Handigodu syndrome"
named after the village Handigodu from where the cases were reported
firstFollowing this many investigations have been conducted
on this disease. But unfortunately the aetiological factor(s)
responsible are yet to be identified. An approximate estimate has
been made that more than 600 cases are affected by this disease.
Though the disease has been reported about 8 years back, public
feel that nothing substantial has been made to contain-the problem,
2, 3
as the disease permanently cripples the individuals.
. These
incapacitated individuals who are invariably from a lower class,
became a socio-economic burden not only to their families but
also to the community.
A profile of the disease has been presented in brief and
a few suggestions have been made.
Topography
The disease has been reported from a few villages (only)
around the towns of Sagar in Shimoga district and Balehonnur
in Chikmagalur district (parts of Malnad area) ofKarnataka State.
*• Assistant Professor of Preventive and Social Medicine,
Bangalore Medical College, Bangalore.
** Assistant Professor of Community Medicine, Kempegowda Institute
of Medical Sciences, Bangalore 4
2
The affected region is predominantly an agricultural area
and has no industries. These villages are situated along the
Western ghats and mostly at an altitude of 2000-3000 feet above
sea level. The annual rainfall is about 80-120 inches. The region
is thick in forest wealth and certain areas have a classical
tropical forest. The temperature ranges from upper nineties in
summer to lower seventies (Faranheit) in winter. The relative
humidity is quite high.
Demography
The population of Chikmagalur district and Shimoga district
4
is about 0.9 million and 1.6 million respectively . The
caste wise dominance in the area is idigas, brahmins, vokkaligas,
5
lingayats and harijans in that order.
Because of the stringent
social mores, marriages take place within the same sub-caste and
that too within
a radius of 5-10 kms resulting in high degree
of inbreeding. About 76% of the population is rural and 86%
'Hindus'. The literary rate is about 43%. The estimated crude
birth rate and the crude death rate are 29.2 and 12.0 respectively
(Karnataka State figures). The infant mortality rate is 83.3
and the projected expectation of life at birth by sex in Karnataka
is 61.4 years for males and 59.4 years for females.
Environmental sanitation
It is observed that there is a fairly clean surroundings
around the affected households in these villages. The
houses are mostly kucha with thatched roofing, though a few
houses are pucca with tiled roofing. The source of drinking water
is well. There is no drainage system and the villagers go to the
adjacent forest for their excretory functions.
Agricultural activities
Most of the people in the area are land cultivators and
their chief agricultural produce^ include rice, arecanut,
pepper, cardamom and coffee. The farmers are progressive and have
3
3
mechanised cultivation. Following the introduction of high yielding
varieties of paddy, since last decade there is a wide scale use
of pesticides. The paddy fields and adjacent ponds contain a
large variety of fish, crabs and frogs. However, following pesticiie
spraying of paddy fields, there is large scale death of local
fauna. Farm labourers, particularly the poor harijans and
vokkaligas though deny eating this dead fauna, it has been
found to be not true. And consumption of crabs and fish has increased
in recent years because of the tendency of discontinuing the
practice of serving food (as a part of their wages) to these
land labourers by their landlords.
Dietary practices
Rice forms the staple diet and is consumed 2-3 times a day
along with tamarind soup. Though a detailed dietary history
has not been elicited, it has been found that green leafy vegetables
are consumed once or twice a month. Egg/meat are taken hardly
3-4 times a year and milk and milk products practically never. The
tuber ordinary yam (which is known to have a high cyanide antent)
however, is soaked in water, washed (removes cyanide), cooked and
consumed. Another inter sting feature is the consumption of
illicit country liquor, even by some of the women and children.
However, as the wild flora in the area is abutting on the backyard
of the houses, there is a suspicion about the type(s) of articles
consumed in raw states.
The Disease (fig.1)
The disease per se is not fatal and is confined to humans.
ICMR as early as in 1976 conducted an house to house survey
in 40 villages and found 34 villages to be affected. Subsequently
many teams have investigated the disease. But it appears that
an exact estimate of the number of cases affected is not available.
The first investigating team reports that there was no history of
similar illness in the previous generations. But a recent investigation
team observes that this disease appears to be present in the community
since a few generations.
pre
it has also made a study of family
4
4
pedigree in some cases and after observing a high frequency
of consanguineous marriages in these cases, the disease is now
suspected to be her&do-familial. It is significant that in some
households members of the three generations were affected almost
at the same time. In many cases children suffered earlier and more
7
severely than the elders of the household . However, it appears
that one of the drawbacks of these studies is the non-inclusion
of adequate and appropriate controls and absence of sampling
methods.
The disease has been found to affect people in the age
group of 5-64 years. Infants and preschool children appear
to have been spared. However, the disease is reported to have a
higher predeliction towards younger age group (5-15 years). Most
of the patients are from the socioeconomically backward classes
(mostly harijans and a few vokkaligas and idigas) and not a
single case has been reported from the brahmin community. No
significant nutritional dificiencies are seen. The disease
appears to be neither infectious nor contagious.
The onset is insidious, associated with pain and swelling
of joints, particularly of the lower limbs. The frequently
affected joints are hips and knees. In some cases, due to severity
there is crippling flexion deformities and disuse muscular atrophy
The characteristic radiological picture is destruction of articular
surfaces of femur and tibia, osteophytic lipping of many bones,
rarefaction of the bones around the area of destruction, varying
degrees of osteoarthritic changes in the hip joint and sometimes
with cystic changes in the femoral head. The disease is suspected
to be affecting endochondral ossification. The subsequent crippling
is thought to be due to superadded trauma on a joint which is
not mechanically soujid. It is opined that this crippling is
preventable as it is due to lack of treatment at the crucial time
ofits development.
5
5
In one of the surveys, 22 dwarfs were encountered among
1000 harijans studied in the affected villages. It was found
that all the dwarfs were inter-related, in addition, they were
7
free from the disease except for three dwarfs. Osteomalacia and
rickets like manifestations have been frequently encountered in
this area. A variety of congenital malformations such as
phocomelia, congenital absence of eye ball with rudementary
palpebral fissure, microcephaly, congenital scoliosis and
.icthyosis have beenobserved in the affected population. 8
A team of investigators who recently investigated the disease
in April 1983, suspect the disease as an autoimmmune reaction
akin to rheumatoid arthritis or the auto-immune reaction being
triggered of by the KFD viral infection prevalentin the region.
The disease has been identified tobe similar to Kashinbeck
syndrome (Urov1s disease) reported among Siberians, which
is presumed to be due to consumption of cereals contaminated
with the fungus fusarium sporotrichiella. The disease also has
a striking resemblance with Mseleni joint disease in South
Africa, which is thought to be due to an unidentified environmental
factor.
Investigation
The haemotological investigations done include haemoglobin,
ESR, peripheral Eosinophilia, random blood sugar, blood urea,
serum electrolytes (Na K Mg), total serum proteins, total
serum calcium, serum inorganic prosphorous and alkaline phosphatase.
The other investigations done include tests of liver function
like serum bilirubbin, vanden bergh reaction and thymol turbidity
urine analysis, rose waaler test, C-r active protein, CSF
examination, ECG, EKG and electromyography. The results of these
investigations have failed to throw light on the disease.
.6
6
CONCLUSION
This crippling disease appears to be primarily an
orthopaedic problem mostly affecting the poor lower socio
economic ethnic f group, with a tendency for familial segre
gation. Apparently industrial effluents have no role in the
genesis of this disease as there are no industries in this
area.
Though the pathological process of the disease appears to
have been studied, the aetiological factor(s) responsible
for the same are still at large. The disease is thought to be
herido familial following an history of high frequency of
consanguineous marriages in the affected families. It is also
suspected to be nutritional, suspected factors include (a)
illicit country liquor,
(b) pesticides (concentrated) in
crabs and fishes consumed by the affected people,
(c) unidentified
food article consumed in raw state from the adjacent thick
forest.
Lastly, it is to be noted that a striking observation of
a number of achondroplasic dwarfs in the affected area has
been made. It should also be remembered that this area
is known for the occurrence of Kyasanur Forest Disease (KFD).
Suggestions
In the light of the above observations, few suggestions
are made for future work on the diseases
a.
There is an urgent need for an immediate establishment of
a special research cum service cell at a suitable place
(preferably at Sagar Town) to carry out further
investigations and to provide therapeutic and preventive
services. The cell should be staffed by an Epidemiologist^
Orthopaedic Surgeon(s), Radiologist, Genetic Specialist,
Physiotherapist(s), other ancillary and field staff with
adequate clinical and independent transport facilities.
7
7
b.
The immediate task is to identify all the cases and
mapping of the disease. Those persons in whom the disease
is still in early stages, should be provided with
physiotherapy and the required treatment facilities at
the centre.
c.
The persons who are already permanently crippled have
to be rehabilitated vocationally to help them to earn
their livelihood. It is also desirable that the
Government should provide a suitable compensation to
these individuals.
d.
As one of the investigation teams has observed the disease
to be associated with consanguineous marriages, the
'at risk' population in the area must be properly
educated in this regard. The people should also be
advised against the consumption of crabs and fish
from the paddy fields.
e.
There is scope'for a detailed field epidemiological
investigation of this mysterious disease.
Acknowledqement
The authors are thankful to Dr A N Armugam, Professor
and Head of the Department of Community Medicine,
Kempegowda Institute of Medical Sciences, for his valuable
suggestions and help.
References
1.
K S Mani and H K Srinivasa Murthy (1974):
Handigodu syndrome—A peculiar orthopaedic problem,
National Institute of Mental Health and Neuro Sciences,
Bangalore 560027.
2.
Deccan Herald (1983); Handigodu disease,
March 1, 75, MG Road, Bangalore-1.
3.
Ibid: Deadly disease leaves 600 crippled, April 25.
4.
Directorate of Health and Family Welfare (1982),
Health and Family Welfare Services—Karnataka,
Year Book 1980-81, Bangalore-9.
5.
Indian Council of Medical Research (1977): Handigodu
Syndrome (Endemic familial arthritis), Research
Information Bulletin, Vol.7, No.6, New Delhi.
6.
Mohammed Nuruddin, Desikachar, Shivaprakash,
Krishnamurthy, Parthasarathy and Aswath (1983) Report
of investigation team of experts on Handigodu
Syndrome in Shimoga and Chickmagalur Districts,
Directorate of Health and Family Welfare Services,
Bangalore-9.
7.
Krishnamachari and Bhat (1978), Endemic familial
arthritis of Malnad—An outbreak in Southern India,
Trop, Geogr. Med., 30, 33-37.
8.
Bhat and Krishnamachari (1977): Endemic familial
arthritis of Malnad—An epidemiological study. Indian
J. Med. Res. 66, 5,777-786.
9.
Hande, H S Venkatarangan, Mruthyunjayanna and Shivananda
(1983): Report of the expert team submitted to the
Director of Medical Education, Bangalore 9.
T>(8
SUNDAY....
herald
April 10- 1988
to the disease and claims that
the disease is restricted to those
who eat non-vegetarian foocj The
disease is not contagious and it is
not noticed among children
below six years, according to the
survey which covered
Handigodu, Bandagadde,
Haregoppa. Keladipura,
Lingadahalh, Karehonda,
Kalascpet, Bommatthi, Bclcyur,
Balcgody and 27 other affected
villages. Studies are under way
to determine if the disease is
Castes are most susceptible to
the disease. While the population hereditary.
of Channangi in 37 affected
MEDICAL survey which
villages of Sagar Taluk is 2,227.
- covered 45 villages in Sagar,
there were 186 cases of the
Sorab, Hosanagar and Siddapur
Handigodu syndrome among this taluks reveals that there arc
sub-sect The tally for the
eight cases of the disease among
Cheluvadi which has a
men in the age group of 0 to
population of 354 is 87 cases.
nine years. 52 cases among men
1’he population and disease ratio between 10 and 18 years and 97
among other communities as per cases among men above 19 years.
the survey is: Vokkaliga:
Similarly, there were eight
1118-35, Uppar 236-4 and Idiga: cases among women in the age
2731-11. The survey says that
group of 0 to nine years, 39
the Ramakshatriya and Achari
cases among women above 19
communities are also vulnerable years. In all, 45 villages reported
5
Disease that seeks out
SCs in Handigodu
a wry smile: “1 am not sure of
Pain in the limb joints is the
initial symptom of the disease.
In all there are about 500 such The victims later find it difficult
to move their limbs and this
crippled people in Handigodu
leads to bow-legs and further
ana 36 other villages of Sagar
deformities. The disease strikes
Taluk who arc affected by the
during
all parts of the year and
Handigodu syndrome, a
at least four fresh cases are
mysterious disease named after
reported annually, the doctors
the village, located five km off
say.
Sagar, in which it occurred first
in 1975. Some four cases were
Mr. Chandrashekhar, who has
reported then. The village itself
conducted a socio-economic
has got its name due to the
survey of the victims for the
sticky character of the soil. An
ICMR project, says that
adjoining village where the soil
Cheluvadi and Channangi, two
structure is loose, is called
sub-sects among the Scheduled
byj^.C. Gundu Rao passing it.”
TJ F.R voice is hoarse. She is
1 1 clad in coarse clothes. The
wrinkles on her frail face
probably cannot outnumber the
trials in her life.
As 60-year-old Maramma toils
with her feeble hands to peel
raw areca fruits, she replies to
questions with a contempt that
serves only to conceal her
helplessness and sorrow in life.
Maramma has deformed legs,
the effect of the Handigodu
A
Handigodu has not wiped out his smile.
364 cases and the doctors this
year are still examining 11
doubtful cases, the survey
reveals. The doctors have also
classified 127 cases of mild
deformity, 113 moderate
deformity cases and 36 cases of
severe deformity. Whereas the
deformity on knee joints needs
corrective surgeries like genu
valgus and genu varus, the one
on hip joints calls for bilateral
Harijan women affected by Handigodu returning from work.
These people were earlier very TAR K. Venkata Rao. a private
much opposed to medical
U medical practitioner, has
treatment since they firmly
arranged a donation of Rs. 200
believed that this disease was
per operation case through the
due to the wrath of family
Sai Samiti of Bangalore.
deities like Chowdy and Bhoota.
The doctors feel more help
They used to throw away
should be forthcoming from both
medicines given since they
the Government and voluntary
agencies since the severe
thought that wearing amulets
deformity among some patients
was the only panacea to their
needs more than one surgical
illness. Now. the social workers
and para-medical personnel have, operation. This means that the
patients and the relatives looking
adductor tenotomy.
to some extent eradicated these
after them have to stay in
superstitions.
Even
then,
many
Dr. H.K Srinivasa Murthy,
patients are reluctant to undergo hospital for months together.
orthopaedic surgeon of
Most patients cannot afford to
operations since staying in the
Bangalore, visits Sagar every
for one month after the stay so long forgoing their
second Saturday and Sunday of hospital
operation and a minimum of six earnings, the doctors say.
each month to perform
months’ physiotherapy will affect
Both the Zilla Parishads of
operations on the victims. Both
daily earnings. Their
Shimoga and Chikmagalur
the operation and post-operative their
reluctance
is
all
the
more
districts where the disease
treatment arc free as far as
understandable if the patient
prevails should make joint efforts
patients are concerned. The
happens
to
be
the
bread-winner
to secure aid from the Centre,
doctors and the social worker say of his family.
the Indian Red Cross Society
that it is not possible for them to
and even external agencies to
motivate over two victims at a
Dr. Srinivasa Murthy has
help the victims, feels Mr.
time to undergo operations
conducted 25 operations so far
during Dr. Murthy’s visit. The
including six repeat cases. Manja Chandrashekhar. His efforts in
securing medical treatment for
villagers who are scared of
and other victims who have
the victims have won accolades
operations are reluctant to come undergone operations say that
from many. He also suggests
to hospital though the ICMR
the surgery has helped improve
authorities provide a vehicle at
their limb movement but there is that the Government should start
their door-step.
|
Continued on page 8
no total relief from pain.
syndrome, a strannc disease
in parts of Shimoga
'•strict. inc malady which has
Brcvaibng
killed her two sons, Rumnppa
and Nujznraj, has also afflicted
Nagaraj s wife Neclavva. h has
not spared Nagaraj’s children
. (Maramma’s grandchildren),
Manja (15) and Rama (10).
Maramma’s daughter Subbamma
(26) who has also fallen a victim
to the scourge, has been unable
to marry. Maramma’s husband
Fakcerappa died a natural death
long back. Thus her woes arc
endless.
With her emaciated hands and
crippled legs. Maramma cannot
sit for more than two hours to
peel areca and thus she can earn
Measures
needed
THE weaving centre at
B Handigodu must be
re-activated at once to
ease
the
desperate
plight of the Handigodu
victims. Other steps that
would contribute to the
containment of the dis
ease would be —
Q Shimoga Zilla Parishad
must ensure that the
weaving centre at Hand
igodu resumes its work
and admits new batches
of victims for training.
©
Government and
other agencies should
raise resources to supply
handloom to the trained
victims.
<3 Establishment
of a
residential
workshop
with an intake of 300 is
desirable.
Sulngodu.
The disease amicling the
villagers is being studied by two
teams of the Indian Council of
Medical Research (ICMR)). The
study under the guidance of
Prof. S.P.S. Tiotia of the
Lalalajpath Roy Memorial
Medical College, Meerut and
Dr. S.S. Agarwala of the Sanjay
Gandhi Memorial Medical
College, Lucknow, is aimed at
identifying the cause of the
disease and recommending
remedies. The threc-year
research project ends after the
ICMR teams submit their final
report.
The disease is prevalent in
Anandapura, Kasaba, Talaguppa
and Avinahalli hoblics and
Bharangi and Karur. The other
two hoblics of the taluk are free
from the disease. Handigodu
syndrome cases arc also reported
from two villages of Sorab
Taluk, three villages of
Hosanagar Taluk and one village
of Siddapur Taluk of Uttara
Kannada District, according to
field staff of the ICMR Project.
The staff this year have noticed
the occurrence of the disease in
Devangi and Untoor villages of
Tirthahalli Taluk. In all 21 cases
were reported from these two
villages till February this year.
The doctors who confirm the
prevalence of the disease in parts
of Chikmagalur District,
however, deny its occurrence in
Indi Taluk of Bijapur District.
The ICMR personnel who
visited Indi Taluk recently, did
not find any positive proof of the
disease, the doctors in Sagar say.
State Government has
THEsanctioned
a monthly
pension of Rs. 50 to 211 victims
so far under its welfare
programme for the handicapped.
The pension applications of some
more
victims are being
O Both
Shimoga
and
processed.
Chikmagalur Zilla Pa1 he authorities have also set
rishads
should
join
up a weavers’ training centre in
hands to demand aid
the
village as part of their
from the Centre and
rehabilitation programme. Both
other external agencies.
Dr. H. Srinivas, who is in charge
O Deployment of a field of the ICMR project and social
staff headed by an As
worker H.M. Chandrashekhar
sistant Surgeon to be in feel that training the victims in
charge of the Handigodu weaving is ideal since it involves
disease cases exclusi
a lot of exercise for the limbs.
vely. Construction of a This can be a good substitute for
physiotherapy which the victims
separate ward with a
require regularly.
besjkrength of 10.
But the centre which has
trained two batches offering a
only Rs. two a day which is
monthly stipend of Rs. 200 per
hardly enough to keep the pot
individual is yet to admit the
boiling in a house of so many
third batch. The trained victims
crippled members. There arc also have not got any handloom
days when she is too tired to
either to become self-reliant. The
come to work. Asked how she
absence of a meaningful
will survive those days, she says
rehabilitation programme has
bluntly: “We have learnt to
forced the victims to rely on the
starve when there is no income.” job of peeling raw areca nuts.
Nagaraj (18). another crippled Each victim thus engaged will
person in the village, is
get 60 paise for peeling the areca
arduously managing to get
in a particular local measure,
around with the help of a
Gidna. Hence their daily
tricycle. H.G. Manjappa (18)
earnings arc too meagre to buy
who is lucky to have his
enough food to combat
deformity cured substantially
malnutrition which some doctors
through surgery, is braving the
believe is one of the causes for
SSLC examination and says with the disease.
- Media
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