FIGHTING AN ENEMY – A STORY FROM SURATGARH, RAJASTHAN

 Indian Armed Forces train and conduct Military Exercises in Suratgarh region of  Rajasthan with a sense of ‘excitement’ induced by the preparation to confront the enemy. The attack by an ‘invisible’ enemy is manifested by the medical symptom of mental excitement.      

SURATGARH, RAJASTHAN – THE LAND OF RIG VEDA:      

Suratgarh is in Sri Ganganagar District of Rajasthan. Around 3,000 B.C., Suratgarh is believed to be a lush green pasture land due to the presence of Sarasvati River which is repeatedly mentioned in Rig Veda and is described as “Ambi ta mey, Nadi ta mey, Devi ta mey, Sarasvati” meaning that River Sarasvati is Best Mother, Best River, and Best Goddess.      

Fighting the Enemy – The Excitement at Suratgarh:      

Suratgarh is of strategic importance. I visited and camped in this area several times during the period from 1976 to 1978. It was not a picnic. My visits were mostly related to military training and exercises that would prepare me to fight the enemy in a battle. Battle preparation always induces a sense of excitement. Apart from the body, the mind would be put on an alert to accept the challenge and confront the enemy. I never missed that feeling on any day that I spent in Suratgarh. During 1977, I camped at Suratgarh for three months where the First Armored Division opened a ‘Desert Driving School’ to impart training to military drivers. The sandy desert terrain poses a challenge to the man aswell as the machine. The driving lessons were imparted by instructors from Army Service Corps which provides provisions(rations) and transportation in the conduct of military operations. We established a very small camp in tents on the Suratgarh-Sri Ganganagar Road. I set up a very modest Medical Inspection Room in a bunker to provide medical services to trainees at our School. I had posted a sign on the road near our School to encourage others to visit my Medical Inspection Room if they needed any help. I had always liked the idea of preparing for the battle. The success in actual war depends upon the skills a person acquires while training for the battle. I thought that it was important that I must learn to drive and operate all types of vehicles that Indian Army would use in the desert terrain. Like all other trainees at the School, I drove a 3- ton Lorry, the basic workhorse of Indian Army. I successfully finished my training and was issued a Military Driver’s License. Apart from 3- ton Lorry, I also operated all other vehicles like Jeep, Jonga, and 1- ton trucks. The driving tracks included regular surface roads and plenty of cross-country driving over sand dunes and desert terrain. It was exciting to face the challenge and be prepared.      

Fighting an Invisible Enemy – A Challenge to Human Existence:      

Fighting a visible, external enemy is easier rather than fighting an ‘invisible’ enemy. The Rhabdovirus that causes the fatal disease of RABIES is one such invisible enemy. The virus has a characteristic ‘bullet’ shape. It is described as a neurotropic virus as it chiefly attacks the central nervous tissues and causes brain inflammation. While a person is alive, the infection is always diagnosed on clinical grounds.

After death, the evidence for this infection is demonstrated by the presence of microscopic, the oxyphilic inclusion bodies called the ‘Negri Bodies’ found in the cytoplasm of the brain nerve cells. 

The disease once manifested, has no cure and the mortality is 100 percent. The disease was eradicated in Britain and Australia, but is still prevalent in India. Rabies is primarily a disease of a variety of animals( the Canidae tribe) and man is secondarily infected. In India, furious canine rabies causes most cases of the disease in man. The virus also attacks the salivary glands and the virus is present in the saliva of the infected animal.

For man, the immediate source of infection is essentially the rabid domestic, street, or pet, dogs, and cats. The infection could also spread from wild animals like Jackals and Foxes. The virus is transmitted to man either by the bite of an infected animal or by contact through the mucous membranes or breaks in the skin such as cuts, abrasions, and open injuries that get licked by the animal.The virus cannot enter the body without some trauma to the skin or mucosa. However, the virus can gain entry if it contacts intact conjunctiva of the eyes. Transmission by ‘droplets’ has also been demonstrated. Once within the body, the virus travels using nervous tissues and attacks the brain. Depending upon the site of entry into the body, the disease can manifest itself in about 10 to 90 days.      

HYDROPHOBIA – THE FEAR OF WATER: THE CHARACTERISTIC FEATURE OF RABIES:      

During the very initial phase of infection which may last from 1 to 10 days, the disease is manifested as increasing restlessness, excitement, anxiety, and irritability.

Although rabies has a fairly long incubation period—from the time of the infected bite to the time a person develops symptoms—once the virus impacts the brain it replicates quickly and efficiently.  It particularly impacts the limbic system, the part of our brain which controls our emotional and behavioral life (and helps us to form memories).

A person who has rabies will become very fearful, highly agitated and often violent.  That’s because the brain is now infected, and the brain’s ability to do its job has been overtaken by the spreading infection.

From the brain, the rabies virus travels to a person’s salivary glands where it reproduces itself at astonishing rates.  A person with rabies develops the inability to swallow while simultaneously developing an extreme need to drink. 

Working at cross purposes—the need to drink and the inability to swallow—leads to a condition called hydrophobia (“fear of water”).  Doctors who treat rabies-infected people see extremely thirsty people pushing away glasses of water.  Patients become fearful of drinking because their inability to swallow causes choking.

After the initial period of 1 to 10 days, the symptoms and signs of Hydrophobia appear in the man. This is a characteristic feature of the disease only in man and does not occur in dogs or other animals. The fearful manifestation of Hydrophobia includes violent contractions of the diaphragm and other respiratory muscles if the individual attempts to drink water. The muscles of throat go into spasm and the victim would be unable to drink water despite extreme thirst. The sight of water or even the sound of water may precipitate these very distressing spasms and attacks of panic.Man has no natural immunity against the infection. Anti-Rabic Vaccine treatment is useful during the incubation period. The Vaccine treatment has no value if the Rabies Virus reaches the brain. Once the symptoms of the infection appear, no treatment is possible. Rabies is prevalent in India, but the incidence is very low in the Indian Armed forces. We had 59 reported cases of Rabies from 1944 to 1964, about 3 cases per year. There have been cases of Rabies transmitted by corneal grafts taken from people who had died of undiagnosed Rabies.      

THE INVISIBLE ENEMY’S ATTACK IN SURATGARH:      

While I was attending to patients at my Medical Inspection Room at the Desert Driving School, a Non-Commissioned Officer (NCO) came to our Camp to seek my assistance. He belonged to the Corps of Electrical & Mechanical Engineers (EME). He being a member of the SIKH religious community could be immediately identified by the turban that he wore and his beard. He was well-groomed and was in proper military attire and had very good physical stature and appearance. His Unit sent a small detachment to Suratgarh area in preparation for some training event. They were camping nearby. His Unit was not directly affiliated to First Armored Division which had set up the Driving School. During that time, Suratgarh had only a Primary Healthcare Clinic.  I was the only Army Medical Officer providing services to military personnel stationed in that area. As he walked in, I could see that he was excited and I immediately assured him that he should have no apprehension to seek my services and the Unit affiliations are of no consequence and he should totally feel free to discuss his medical problems with me. He had a very brief medical history. For some unknown reason, he was feeling restless, excited , and becoming anxious about his restlessness. He had no headache, no fever, and no other problems. He was apparently performing all his tasks very well and had no quarrels or arguments with his colleagues. I could easily see his attitude and military bearing. He was displaying a very disciplined behavior, a respectful attitude while coping with a serious and troubling condition. I could immediately rule out the possibility of overt or occult ‘Malingering’. He was a NCO who spent several years in military service, he was very well-adjusted to his military life and had no particular problems with superiors or colleagues of his Unit. I spent time to fully medically examine him and evaluating his general condition and exploring the reasons for this sudden onset of mental restlessness in an adult who had no prior medical problems. He was not disgruntled, cynical or bitter. He was speaking and answering all of my questions in a very coherent manner. He was not expressing any bizarre ideas or thoughts. He was not hallucinating, not deluded or demented. His personal habits were good and he did not consume alcohol or any other mood altering drugs. He was not any medications. He was not experiencing a ‘STRESS’ disorder and appeared to be having good stress resistance. He had no pressing domestic concerns or problems. I could not discover any physical factors like Heat or infections like Malaria or metabolic disorders like diabetes which may explain his condition. Through careful interrogation, I could exclude Psychiatric illness or disorder. After spending some time, I could not still come to any conclusion and I was unwilling to send him away with some symptomatic treatment to relieve his anxiety.      

MEDICAL COMFORTS  AND  MEDICAL DIAGNOSIS:      

Unlike in civil medical practice, the army medical practice gives attention to the individual and not exclusively to the disease. At Medical Inspection Rooms, we very often provide ‘Medical Comforts’, to all people who visit us, as needed. The Medical Inspection Room is entitled to draw rations like sugar, tea leaves, and milk powder and very often we serve hot, and refreshing tea while people wait at the Clinic. Suratgarh is an extremely hot place. I was drawing blocks of ice to keep my Clinic cool as there was no electricity or air conditioning. I was also serving chilled water to all visitors and consistently encouraged everyone to consume more fluids.      

After my initial, inconclusive evaluation of my patient, I wanted to provide him some ‘Medical Comfort’ and offered him a glass of chilled water as it was already very hot. He declined my offer and showed no interest to drink water. He was not being rude or impolite. He was too excited and was not in a mood to relax. But, that very simple act of offering water as ‘Medical Comfort’ and his refusal made me to contemplate about his condition. It suddenly occurred to me that I could be dealing with a case of Rabies. He had no symptoms or signs that could be identified as ‘Hydrophobia’. He had no such concerns or problems at that time. However, I decided to fully explore that possibility. I again started my interrogation to find out if he had contact with any animal. He never had pet animals. He was never bitten by any animal. He was never licked by any animal. I carefully examined his skin and could not discover any cuts, abrasions, open wounds or healed injuries. His skin was intact and it would not be possible for Rabies Virus to enter his body through his unbroken skin. I had no other options left and I was not able to exclude the possibility of Rabies infection as the cause of his medical complaints of restlessness and anxiety. I had no choice other than acting upon my suspicion even though I fully trusted his statements about never being licked or bitten by any animal.      

THE ROAD JOURNEY FROM SURATGARH TO ABOHAR, PUNJAB:      

I made a decision to medically evacuate my patient to a military medical facility located about 95 Kilometres away at ABOHAR, Punjab. We made no such prior plans to evacuate patients from the Desert Driving School to Abohar. I had to make that decision on my own keeping the best interests of my patient in my mind. I also decided to transport the patient myself and to drive the 1 – ton truck ambulance. I wanted to assume the full responsibility for taking the military vehicle to Abohar. As we were getting ready for this road journey, I checked and found that I had only 2 ampoules of Injection Chlorpromazine hydrochloride (LARGACTIL), a drug of choice to alleviate anxiety. It can tranquillize the patient without impairing his consciousness. Largactil has a marked sedating effect without causing stupor. However, I had only two ampoules in my Clinic. I quickly ran to Suratgarh Primary Healthcare Centre and met the doctor there to get some additional ampoules of Largactil. He had none in his dispensary. So, I prepared my patient for the road journey after administering the medicine that I had and none for the duration of the journey. The road was in a very bad shape with pot holes. My patient could not be fully sedated with the dose I administered. While I was driving the ambulance, I kept the partition glass window open to check on the patient. Two of my medical assistants were with the patient, and the ambulance driver was in the co-passenger seat in the front. The bumpy ride caused a bit of stress and my patient was constantly shouting from behind asking me to slow down and sometimes he was directing me to speed up. I was happy to hear his voice and finding that his condition was still stable without any worsening of symptoms. By the time we entered the Hospital at Abohar, it was already dark. I contacted the Duty Medical Officer who  immediately sent word to the Surgeon to evaluate the patient. The Surgeon carefully examined him and there were no clinical grounds to diagnose Rabies at that hour. The possibility was there. In any case, the patient needed Hospital admission simply on account of his extremely excited condition. I gave the postal address of my Unit and obtained an assurance from the Surgeon that he would communicate to me the Medical Diagnosis of my patient. After that assurance, the patient was duly handed over, I left Abohar and returned to Suratgarh. A few days after this trip, my three months of stay at Suratgarh concluded and I returned to my Unit where I assumed the duties of Unit Adjutant. I received that unfortunate Medical Diagnosis in the mail. The Surgeon wrote to me stating that the Medical Diagnosis of Rabies was confirmed after conducting an autopsy and the demonstration of ‘Negri Bodies’ in the brain nerve cells.      

BHAJA GOVINDAM:      

The human body is very vulnerable and could be attacked in several manners. In this particular patient, the deadly virus  might have gained its entry into his body through the conjunctiva of his eyes. The saliva, the droplets carrying the Virus from an infected animal like a Jackal or Fox could have entered his eyes while the animal was in his vicinity but escaped from being noticed by him. We camp outdoors and sometimes fail to notice an imminent threat. I would suggest to all of my readers to use protective goggles while camping outdoors and introduce its use on a regular basis while conducting military exercises and training in areas where infected animals could be present. After taking all these precautions, we still need the help, the help of our LORD, the help that a sweet name like GOVINDA could offer to protect and defend our human existence.      

Dr. R. Rudra Narasimham,     

Kurnool Medical College, Kurnool, A.P., India.,     

M.B.B.S., Class of April 1970.