"Ghasa" is a term from the dialect of Western Rajasthan which is used to describe various non-proprietary medications and traditional household remedies. The name originates from !he Hindi word "Ghisna" which means to "rub" or to "Grind". The usual form available is in the form of a cake which is . ground to a paste and the child is made to lick small amount of it. Ghasa administration to infants and neonates has been a practice in this region for years together. Elderlies in the family cite a variety of indications for its use including irritability, diarrhea, common cold, ill-health and as a build-up tonic.

We have encountered many patients at our institution presenting with respiratory distress, deranged sensorium and abdominal distension, who had no contributing factor in their history and physical examination to explain their morbid state except a history of excessive Ghasa administration. A prospective study was therefore undertaken over a period of six months to evaluate various clinical presentation of toxicity of Ghasa and correlate these with presence of toxic substances on pharmacological analysis (if detected). A total of 32 cases were enrolled. There were 22 male and 10 female babies in our study group (M:F ratio 2.2:1) with 37.5% cases each being from the age group of <1 month and 1-12 months and remaining 25% were in the age group of 1-3 years. Only patients with a definite history of Ghasa administration in the past 3 days and showing evidence of intoxication were included. A careful physical examination, historical details and laboratory evaluation was performed to rule out any other clinical condition like sepsis, dyselectrolytemia, other intoxications and infectious illness accounting for the patients' symptomatology. Only after such exclusion was the child enrolled. Gastric aspirate was collected in all patients and stomach wash undertaken with potassium permanganate solution. Representative samples of incriminated "Ghasa" or gastric aspirates were sent by courier to Department of Pharmacology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai for pharmacological analysis.

Mothers gave Ghasa to their children and their motivators were grand parents, relatives, quacks, others (friends and relatives) and self in 50%,12%, 7%, 6% and 25%, respectively. Of the 16 grand parents who motivated the patients' mothers to give Ghasa, 4 were regular users of opium themselves. Reasons cited for administration of Ghasa were diarrhea and in- digestion; irritability; social customs and for constipation in 51%, 41%, 16% and 8%, respectively (figures not mutually exclusive). Symptoms observed in these cases were un- consciousness (75%); difficulty in breathing (68%), convulsions (37%), bluish discoloration (31 %) and abdominal distension in 18% cases (not mutually exclusive). Pin point pupils was the most striking sign noted in 75% cases.

Twenty four of the 32 patients had de- ranged sensorium with coma of Grades I, II, III and IV seen in 28%, 21 %,6% and 18%, respectively. Abdominal distension with diminished bowel sounds was present in 18.7% cases. Respiratory manifestations were ob- served in 87% cases with shallow respiration in 18 cases and apnea or gasping breathing in the remaining 10 cases.

Stomach wash with KMn04 solution (1:5000) revealed instant discoloration in 87.5%. While those showing no change in color of KMn04 solution were managed symptomatically, others were subjected to repetitive stomach wash. Since the clinical picture mimicked opium poisoning, naloxone was given intravenously to all these patients keeping a close watch on their respiratory status and pupillary reaction. While 10 patients responded to a single dose of naloxone, 18 cases needed multiple dosages. Of these 18, four responded and six required IPPV support besides antagonist. A total of 8 patients ex" pired (despite IPPV support) from respiratory failure and persistent apnea. One expired patient showed pulmonary hemorrhage and another had intra cranial hemorrhage Grade II (both neonates). Pharmacological analysis of 8 representative samples revealed only traces of cannabis but could not detect even small amounts of opium.

It is concluded that administration of such traditional household remedy is not always safe and in fact may be life threatening. Ghasa intoxication mimics opium poisoning clinically and the patients respond to measures similar to those used in opium intoxication. However, the offending substance was not detected by the laboratory analysis techniques available to us. Though traces of cannabis were seen, the symptomatology or signs showed no features of cannabis poisoning. Thus one should avoid giving Ghuttis and non proprietary formulations since nothing is known about their composition.
 

Pramod Sharma,
B.D. Gupta,
Nilima Kshirsagar,
K.K. Meena,
Vivek Arora,
Girish Sharma,
Department of Pediatrics,
Umaid Hospital,
Dr. S.N. Medical College, Jodhpur, India.
and Department of Pharmacology,
Seth G.S. Medical College and
K.E.M., Hospital, Mumbai, India.