given slowly and sulphapowders were given. He made some improvement after 24 hours but died on the fourth day. 12 th December, 1948.?Called to see a Mohammedan male child, 4 years of age,_ in village Gholapara, on the other side of the river on the 4th day of his illness. History of fever with convulsions and vomiting and the starting child becoming unconscious soon afterwards. As usual in medical practice out here, he had been given a quinine injection and some mixture was tried to be forced down the throat, but with
glucose
feeds could be
diazine
no
SPORADIC
CASES OF ENCEPHALITIS
IN RURAL BENGAL By M. L. KUNDU,
m.b., f.r.f.p.s., l.m.
Nabadwip The following case notes suggest that cases of Encephalitis lethargica occur occasionally in the area including the town of Nabadwip and its adjoining villages in both the districts of Nadia and Burdwan. 9th January, 1949.?The patient, M. M., age 21 years, of A^illage Singhaguri near Sumudragarh,
district Burdwan, came to
healthy young cultivator, Nabadwip. About noon purchase something in the bazar after straw, when he was, according to bya
sell straw in
he went to selling the standers, seized with convulsions and fell down on the road-side. The convulsions persisted for two hours, after which he became unconscious. He lay there throughout the night. His people arrived the next morning on search, found him on the road-side drain" and brought -him to my consultation room at about 9 a.m.
Pulse was 68 per minute, regular and of normal volume but slightly increased tension, respiration 16 per minute, and temperature in axilla 101 ?F. Face was flushed and there was contraction of the pupils' on both sides. He resisted attempts to open his mouth but there was no froth nor any sign of injury anywhere. The body was relaxed and there was no Kernig's sign of exaggeration of reflexes or stiffness of the neck. There was no enlargement of the liver spleen. There were some rales and rhonchi in the chest but no dullness anywhere and the heart sounds were normal. There was no smell of any drug in the mouth and the bladder was empty. Blood : no malaria parasites; W.B.C. 15,000 per c.mm., poly 82 per cent, L.M. 1 per cent, S.M. 16 per cent, eosinophils 1 per cent. Spinal fluid came under pressure but it was perfectly clear. He was given 4-hourly injections of soluseptasine intramuscularly and glucose 12-^- per cent 50 cc. twice a day. Orally no medicine could be administered in the beginning, but later on *
Will the social workers kindly attend to the next lying unattended by a drain ??Editor, I.M.G.
case
success.
The child was in a state of constant spasm. Pulse 100 per minute, temperature by rectum 101.8?F. No enlargement of the liver or spleen, abdomen and eyes sunken, pupils moderately No stiffness of the neck or Kernig's dilated. sign present. No adventitious sound in the heart On lumbar puncture, clear fluid came or lungs. under pressure and after removal of about 10 cc. the convulsions stopped. An injection of camphor-in-oil was given and rectal feeding with glucose advised, and also glucose intramuscularly. Patient showed some improvement on the next day and could swallow some fluids but started having convulsions the following day. As no one was procurable to do another lumbar puncture, this therapeutic help could not be given and the child died after 3 days. 10th October, 1948.?A Mohammedan male child in Nabadwip Mussalmanpara, aged about a year, reported to have developed fever a week ago and treated as a case of typhoid. Began to get convulsions from the 4th day of the fever and became completely unconscious on the 5th. day. Seen on the 7th day of the illness. Child in a semi-comatose condition, slight stiffness of the
neck, temperature 100?F., pulse 140, respiration 20 per minute, abdomen sunken, Kernig's sign present. Blood examined showed no M.P., leucocyte count 13,000 per c.mm., poly 72 per cent, lympho 5 per cent, S.M. 21 per cent, eosino 1 per cent. Pupils moderately dilated on both sides. Rectal feeds were given and bromides by mouth and injections of camphor-in-oil, and on the 8th day the child showed some improvement, with convulsions diminished. As sulphadiazine by mouth and soluseptasine made little improvement, lumbar puncture was proposed but the
child's father refused it. On consultation with another practitioner, streptomycin was started and even after 3 days there was no improvement and the child became opisthotonos. A lumbar puncture under chloroform now brought out clear fluid without much pressure and it did not improve the condition. The child eventually died on the 15th day. 14th August, 1948.?Hindu male, 20 years, at Nabadwip Poramatola, was seen in consultation with another practitioner on the 3rd day of the disease, with history of high fever ranging between 103 to 104?F. and the patient having
THE INDIAN MEDICAL GAZETTE
292
convulsions and gradually getting comatose. Quinine intramuscularly had been given already and repeated without any benefit. On examination the extremities were cold, and patient lethargic. Pulse 140, temperature by rectum 107?F., respiration 30, no adventitious sounds in the heart and lungs, no stiffness of the neck, Kernig's sign absent. Blood examined, no M.P., leucocytes 14,500 per c.mm., poly 73 per cent, S.M. 24 per cent, L.M. 3 per cent, eosino 2 per cent. Was put on wet pack and later ice enema. Glucose given intravenously and cartazol injections repeated every 4 hours. At night another medical man was called without notice, who gave another quinine injection and the patient died very soon afterwards. Pupils were contracted equally. 21 st May, 1948.?A Hindu female child, 2 years, at Nabadwip Ramsitapara, seen in consultation with another medical man on the 3rd day of the illness. History of high fever and convulsions, unabated with usual treatment, with purgative, sponging and bromides. Pulse 158, respiration 34, abdomen sunken, pupils moderately dilated, temperature 102?F. by rectum, Kernig's doubtful, slight retraction of neck, no adventitious sounds in heart or lungs. Quinine already given by injection. Lumbar puncture showed clear fluid under pressure and convulsion stopped after this. No treatment was of any avail and the child died after two days. Blood examination revealed moderate leucocytosis and no malaria parasite. Comments The picture of this series of cases confronts with a disease which is characterized by fever and convulsions or coma followed by the signs of meningitis, like retraction of neck, Kernig's sign being either absent or present in a doubtful manner. The disease proved fatal in 3 to 15 days. Injection of quinine, soluthiazole or streptomycin did not make any impression and in fact injection of quinine made them worse than before and proved fatal in one case. It had the common character of the spinal fluid being ijnder pressure and removal of it stopped the convulsions. The fluid was absolutely clear and showed no increase in the cellular elements. Blood showed in every case moderate leucocytosis with increase of polymorphs but not to the extent we get in cases of cerebrospinal, pneumococcal or influenzal meningitis. There was no rash or any evidence of exanthematous condition to group it with virus diseases like typhus, measles or any septicajmic conditions. Further elucidation could have been made of its nature, if there was a possibility of doing a spinal fluid or blood culture, both of which are not possible in this town at present. us
From facts gathered from the rural practitioners during the last 4 years of my stay in this province, I have been told often by them that these are cases of malignant malaria and that
[July,
1949
they do not hesitate at all to give in such cases quinine intramuscularly without making any attempt to take a blood slide and have it
examined beforehand. Of course, out in the it will be a counsel of perfection to have a blood examination done, as not even 5 per cent of our rural population can afford either the cost of it or the means of taking blood slides to towns where a microscopical examination could be done. On the top of it very few medical men can take proper blood films for the purpose and the quacks that abound have no qualms on their conscience about the need of a diagnosis. In our town, however, where there are several medical men trained in laboratory work or at least possessing a microscope, it should not be impossible to have a couple of slides taken before quinine is pushed by injections, and it seems that the fear of missing a case of malignant malaria is always predominant in our minds so that we do not think of other possibilities.
villages
I am presenting a disease, probably of
dismal array of a subtle virus nature, unamenable to our present armamentarium of antibiotics and certainly of fairly wide distribution in our town and villages, which requires a diagnosis. The nearest approach to my mind is that these are cases of Encephalitis lethargica, though they do not conform to the classical description. But it is well known that the signs and symptoms vary very much in different localities.
glucose
feeds could be
diazine
no
SPORADIC
CASES OF ENCEPHALITIS
IN RURAL BENGAL By M. L. KUNDU,
m.b., f.r.f.p.s., l.m.
Nabadwip The following case notes suggest that cases of Encephalitis lethargica occur occasionally in the area including the town of Nabadwip and its adjoining villages in both the districts of Nadia and Burdwan. 9th January, 1949.?The patient, M. M., age 21 years, of A^illage Singhaguri near Sumudragarh,
district Burdwan, came to
healthy young cultivator, Nabadwip. About noon purchase something in the bazar after straw, when he was, according to bya
sell straw in
he went to selling the standers, seized with convulsions and fell down on the road-side. The convulsions persisted for two hours, after which he became unconscious. He lay there throughout the night. His people arrived the next morning on search, found him on the road-side drain" and brought -him to my consultation room at about 9 a.m.
Pulse was 68 per minute, regular and of normal volume but slightly increased tension, respiration 16 per minute, and temperature in axilla 101 ?F. Face was flushed and there was contraction of the pupils' on both sides. He resisted attempts to open his mouth but there was no froth nor any sign of injury anywhere. The body was relaxed and there was no Kernig's sign of exaggeration of reflexes or stiffness of the neck. There was no enlargement of the liver spleen. There were some rales and rhonchi in the chest but no dullness anywhere and the heart sounds were normal. There was no smell of any drug in the mouth and the bladder was empty. Blood : no malaria parasites; W.B.C. 15,000 per c.mm., poly 82 per cent, L.M. 1 per cent, S.M. 16 per cent, eosinophils 1 per cent. Spinal fluid came under pressure but it was perfectly clear. He was given 4-hourly injections of soluseptasine intramuscularly and glucose 12-^- per cent 50 cc. twice a day. Orally no medicine could be administered in the beginning, but later on *
Will the social workers kindly attend to the next lying unattended by a drain ??Editor, I.M.G.
case
success.
The child was in a state of constant spasm. Pulse 100 per minute, temperature by rectum 101.8?F. No enlargement of the liver or spleen, abdomen and eyes sunken, pupils moderately No stiffness of the neck or Kernig's dilated. sign present. No adventitious sound in the heart On lumbar puncture, clear fluid came or lungs. under pressure and after removal of about 10 cc. the convulsions stopped. An injection of camphor-in-oil was given and rectal feeding with glucose advised, and also glucose intramuscularly. Patient showed some improvement on the next day and could swallow some fluids but started having convulsions the following day. As no one was procurable to do another lumbar puncture, this therapeutic help could not be given and the child died after 3 days. 10th October, 1948.?A Mohammedan male child in Nabadwip Mussalmanpara, aged about a year, reported to have developed fever a week ago and treated as a case of typhoid. Began to get convulsions from the 4th day of the fever and became completely unconscious on the 5th. day. Seen on the 7th day of the illness. Child in a semi-comatose condition, slight stiffness of the
neck, temperature 100?F., pulse 140, respiration 20 per minute, abdomen sunken, Kernig's sign present. Blood examined showed no M.P., leucocyte count 13,000 per c.mm., poly 72 per cent, lympho 5 per cent, S.M. 21 per cent, eosino 1 per cent. Pupils moderately dilated on both sides. Rectal feeds were given and bromides by mouth and injections of camphor-in-oil, and on the 8th day the child showed some improvement, with convulsions diminished. As sulphadiazine by mouth and soluseptasine made little improvement, lumbar puncture was proposed but the
child's father refused it. On consultation with another practitioner, streptomycin was started and even after 3 days there was no improvement and the child became opisthotonos. A lumbar puncture under chloroform now brought out clear fluid without much pressure and it did not improve the condition. The child eventually died on the 15th day. 14th August, 1948.?Hindu male, 20 years, at Nabadwip Poramatola, was seen in consultation with another practitioner on the 3rd day of the disease, with history of high fever ranging between 103 to 104?F. and the patient having
THE INDIAN MEDICAL GAZETTE
292
convulsions and gradually getting comatose. Quinine intramuscularly had been given already and repeated without any benefit. On examination the extremities were cold, and patient lethargic. Pulse 140, temperature by rectum 107?F., respiration 30, no adventitious sounds in the heart and lungs, no stiffness of the neck, Kernig's sign absent. Blood examined, no M.P., leucocytes 14,500 per c.mm., poly 73 per cent, S.M. 24 per cent, L.M. 3 per cent, eosino 2 per cent. Was put on wet pack and later ice enema. Glucose given intravenously and cartazol injections repeated every 4 hours. At night another medical man was called without notice, who gave another quinine injection and the patient died very soon afterwards. Pupils were contracted equally. 21 st May, 1948.?A Hindu female child, 2 years, at Nabadwip Ramsitapara, seen in consultation with another medical man on the 3rd day of the illness. History of high fever and convulsions, unabated with usual treatment, with purgative, sponging and bromides. Pulse 158, respiration 34, abdomen sunken, pupils moderately dilated, temperature 102?F. by rectum, Kernig's doubtful, slight retraction of neck, no adventitious sounds in heart or lungs. Quinine already given by injection. Lumbar puncture showed clear fluid under pressure and convulsion stopped after this. No treatment was of any avail and the child died after two days. Blood examination revealed moderate leucocytosis and no malaria parasite. Comments The picture of this series of cases confronts with a disease which is characterized by fever and convulsions or coma followed by the signs of meningitis, like retraction of neck, Kernig's sign being either absent or present in a doubtful manner. The disease proved fatal in 3 to 15 days. Injection of quinine, soluthiazole or streptomycin did not make any impression and in fact injection of quinine made them worse than before and proved fatal in one case. It had the common character of the spinal fluid being ijnder pressure and removal of it stopped the convulsions. The fluid was absolutely clear and showed no increase in the cellular elements. Blood showed in every case moderate leucocytosis with increase of polymorphs but not to the extent we get in cases of cerebrospinal, pneumococcal or influenzal meningitis. There was no rash or any evidence of exanthematous condition to group it with virus diseases like typhus, measles or any septicajmic conditions. Further elucidation could have been made of its nature, if there was a possibility of doing a spinal fluid or blood culture, both of which are not possible in this town at present. us
From facts gathered from the rural practitioners during the last 4 years of my stay in this province, I have been told often by them that these are cases of malignant malaria and that
[July,
1949
they do not hesitate at all to give in such cases quinine intramuscularly without making any attempt to take a blood slide and have it
examined beforehand. Of course, out in the it will be a counsel of perfection to have a blood examination done, as not even 5 per cent of our rural population can afford either the cost of it or the means of taking blood slides to towns where a microscopical examination could be done. On the top of it very few medical men can take proper blood films for the purpose and the quacks that abound have no qualms on their conscience about the need of a diagnosis. In our town, however, where there are several medical men trained in laboratory work or at least possessing a microscope, it should not be impossible to have a couple of slides taken before quinine is pushed by injections, and it seems that the fear of missing a case of malignant malaria is always predominant in our minds so that we do not think of other possibilities.
villages
I am presenting a disease, probably of
dismal array of a subtle virus nature, unamenable to our present armamentarium of antibiotics and certainly of fairly wide distribution in our town and villages, which requires a diagnosis. The nearest approach to my mind is that these are cases of Encephalitis lethargica, though they do not conform to the classical description. But it is well known that the signs and symptoms vary very much in different localities.
