SCARLATINA IN INDIA. By Alexander Garden, M.D., Civil Surgeon, Saharunpore. The numerous communications published during the last twelve months in the Indian Alcdical Gazette and in the Lancet leave no room for doubting that scarlatina lias fairly taken its place amongst the diseases incident to Europeans in India, though evidence ia still wanting of its occurrence amongst the native population. Ttiat its introduction, at any rate in the epidemic form, is of comparatively recent date, is evidenced by the absence of all
Mat 1,
SCARLATINA IN INDIA.?BY A. GARDEN.
1872.]
mention of it in standard works on the diseases of India such as Martin's and Moorhead's, and by the generally accepted belief in its non-existence in India. That this belief arose from any want of knowledge or power of observation on the part of the numerous talented surgeons who have practised in India for long periods without seeing or hearing of a case of scarlatina I cannot allow, any more than there was anything special in the training and qualifications of those surgeons in whose practice the 14 cases happened during the nine years, 1860 to 1868 inclusive, which are quoted by Mr. Bradshaw from the array
It would, of course, be rash to assert that whatever occurred until recent years, but if they did they must have been few and far between, and so mild as not to have attracted attention. Even now, when year by year it seems to be becoming more and more common, but a medical blue-books. no
cases
comparatively
in India have had any experience of evidence on the of the disease, unless, indeed, subject remains unpublished. In proof of this, I would refer to the small number of medical
men
a mass
replies
from the practitioners in Calcutta,
published
in the Indian
Medical Gazette. It seems to me
highly probable that this almost, if not entire, immunity of people in India formerly from scarlatina depended greatly on the inability of the germs of the disease to retain their vitality during the long voyage round the Cape, during which the great heat of the tropics was twice passed through, the climate of India also not being congenial to their growth and spread. In this hypothesis, no count is taken of its possibly arising de novo, which I think we must admit not unfrequently occurs,
the cases, however, being mild in their nature, and most
occurring singly. The chief outbreaks have been amongst European ti-oops, and in those cases we may fairly suspect importation of the germs, and this seems in some of the cases to be undoubted. Thus, in the outbreak at Sealkote in H. M.'s 58th Eegiment, related by Dr. Lundy in the Indian Medical Gazette, the disease made its appearance soon after the arrival of a draught of recruits from England. In the Lancet of August 5th, 1871, Surgeon Chappell relates an outbreak at Kirkee, exactly similar in its circumstances. He relates, however, another case in which often
he considers the disease to have arisen de novo, as no chance of contagion could be traced. The patient, a lady, lived a full mile from the part of the station in which the other cases had occurred, but with the evidence we have of its communication at the hands of the laundresses in England, there need be no difficulty in
imagining a similar method of communication in India. In outbreaks, such as those at Simla, and in II. M.'s 1-12th at Poona, no such origin could be traced. It is a fair conclusion, I think, to suppose that the shorter voyage from England now undergone by troops has had much to do with the greater frequency of the disease during the past few years, and we may also anticipate the time when it shall have gained a complete footing in the country, and become common amongst the native population, as in my experience measles and hooping cough are becoming more and more every year. Largely as importation acts as the cause, there are many cases in which no such origin can be traced, and in which we must allow the probability of the disease having arisen de novo. There need be no difficulty in this, for every disease, however infectious, must have had its commencement at some time or other. In this class I would place the two cases which occurred in my own practice formerly, and one of which I published as a case of erythema scarlatiniforme," but which, with the more extended evidence now at command, I am quite ready to admit to have been genuine cases of mild scarlatina, and possibly also the outbreak in a family in this station, in which four out of five children were attacked, a short history of which I am about to give I will not enter into details, as they would occupy too other
"
much space. On August on
account of
loth, 1871, diarrhoea,
I
was
and
asked to
prolapsus
see
Harriet R., aged 2,
ani connected with teeth-
105
-
ing. The mother casually mentioned that the child had had prickly heat, and that the skin was peeling off in flakes. On examination, I found marked desquamation of the trunk. I could get no history at all from the mother, as she thought it was nothing but prickly heat. No soreness of the throat had been noticed, but I found the fauces deadly injected. The desquamation followed the usual course. Three weeks after, an abscess formed in the external meatus of the right ear. Bridget R., aged 8 years, was taken ill on the 16th, suddenly, with fever and sore throat. Within thirty-sixhours the scarlatinous rash appeared, first on the chest, and gradually extended to the back, abdomen, limbs and face. The throat symptoms were most marked; the redness of the fauces, pharynx and tousils being decidedly those of scarlatina. The tonsils were much enlarged, and the glands at the angles of the jaw were hard and painful. For twelve hours, the gums were red and swollen. The strawberry tongue was also marked. There was mild delirium on the third and fourth days. On the sixth day brawny desquamation
commenced, and this process passed through the usual On made
no
course.
occasion could I find albumen in the urine.
She
good recovery. Helen R., aged 7, was quite well on the morning of the 23rd August. In the evening she complained of sore throat. I found punctated redness of the pharynx, fances, tonsils and soft palate. The tonsils were considerably enlarged. The glands at the angles of the jaws were hard and painful; the strawberry tongue was marked. The rash was very slightly developed, and hardly appeared on the face at all. Desquamation commenced on the sixth day, and passed through its usual course. The fever was very slight; the axillary temperature never rising above 100?. She made a good and rapid recovery. Robert R., aged 9, was taken ill on the 14th September, 1871, suddenly, with rigors, followed by fever. The rash appeared within twelve hours, hist in the chest; the fever followed the a
The throat symptoms were more marked than in On the 3rd day, there was mild delicases. rium; desquamation occurred as in the other cases. No albuHe made a good recovery. men could be detected in his urine. usual course.
any of the other
That these were marked cases of scarlatina,, there can be no doubt. Cases of rotheln they certainly were not, though the rash in all first appeared in the trunk. In none of cases were there catarrhal symptoms. From the patients I made the most careful enquiries as to the chance of the disease having been communicated to the children from elsewhere, but not one iota of evidence could I gain. They have had no communication with people from other stations whatever, nor had they received clothes or any articles of furniture, so that there are grounds for supposing that it may have originated afresh. No other cases occurred, and on the most careful enquiry I could hear of of
throat amongst the servants of this, or of the Had as perfect isolation as possible not been insisted on, the disease most probably would have spread. Though isolation, as regards the whole family, was possible, so as to guard other families as much as possible from contagion, in the bungalow itself this was impossible, nor did it seem to be of much importance to me, as it had not been attempted when I no
cases
sore
neighbouring
saw
families.
the first case, and the whole
gether. December, 1871.
family
had
been
living
to-
Mat 1,
SCARLATINA IN INDIA.?BY A. GARDEN.
1872.]
mention of it in standard works on the diseases of India such as Martin's and Moorhead's, and by the generally accepted belief in its non-existence in India. That this belief arose from any want of knowledge or power of observation on the part of the numerous talented surgeons who have practised in India for long periods without seeing or hearing of a case of scarlatina I cannot allow, any more than there was anything special in the training and qualifications of those surgeons in whose practice the 14 cases happened during the nine years, 1860 to 1868 inclusive, which are quoted by Mr. Bradshaw from the array
It would, of course, be rash to assert that whatever occurred until recent years, but if they did they must have been few and far between, and so mild as not to have attracted attention. Even now, when year by year it seems to be becoming more and more common, but a medical blue-books. no
cases
comparatively
in India have had any experience of evidence on the of the disease, unless, indeed, subject remains unpublished. In proof of this, I would refer to the small number of medical
men
a mass
replies
from the practitioners in Calcutta,
published
in the Indian
Medical Gazette. It seems to me
highly probable that this almost, if not entire, immunity of people in India formerly from scarlatina depended greatly on the inability of the germs of the disease to retain their vitality during the long voyage round the Cape, during which the great heat of the tropics was twice passed through, the climate of India also not being congenial to their growth and spread. In this hypothesis, no count is taken of its possibly arising de novo, which I think we must admit not unfrequently occurs,
the cases, however, being mild in their nature, and most
occurring singly. The chief outbreaks have been amongst European ti-oops, and in those cases we may fairly suspect importation of the germs, and this seems in some of the cases to be undoubted. Thus, in the outbreak at Sealkote in H. M.'s 58th Eegiment, related by Dr. Lundy in the Indian Medical Gazette, the disease made its appearance soon after the arrival of a draught of recruits from England. In the Lancet of August 5th, 1871, Surgeon Chappell relates an outbreak at Kirkee, exactly similar in its circumstances. He relates, however, another case in which often
he considers the disease to have arisen de novo, as no chance of contagion could be traced. The patient, a lady, lived a full mile from the part of the station in which the other cases had occurred, but with the evidence we have of its communication at the hands of the laundresses in England, there need be no difficulty in
imagining a similar method of communication in India. In outbreaks, such as those at Simla, and in II. M.'s 1-12th at Poona, no such origin could be traced. It is a fair conclusion, I think, to suppose that the shorter voyage from England now undergone by troops has had much to do with the greater frequency of the disease during the past few years, and we may also anticipate the time when it shall have gained a complete footing in the country, and become common amongst the native population, as in my experience measles and hooping cough are becoming more and more every year. Largely as importation acts as the cause, there are many cases in which no such origin can be traced, and in which we must allow the probability of the disease having arisen de novo. There need be no difficulty in this, for every disease, however infectious, must have had its commencement at some time or other. In this class I would place the two cases which occurred in my own practice formerly, and one of which I published as a case of erythema scarlatiniforme," but which, with the more extended evidence now at command, I am quite ready to admit to have been genuine cases of mild scarlatina, and possibly also the outbreak in a family in this station, in which four out of five children were attacked, a short history of which I am about to give I will not enter into details, as they would occupy too other
"
much space. On August on
account of
loth, 1871, diarrhoea,
I
was
and
asked to
prolapsus
see
Harriet R., aged 2,
ani connected with teeth-
105
-
ing. The mother casually mentioned that the child had had prickly heat, and that the skin was peeling off in flakes. On examination, I found marked desquamation of the trunk. I could get no history at all from the mother, as she thought it was nothing but prickly heat. No soreness of the throat had been noticed, but I found the fauces deadly injected. The desquamation followed the usual course. Three weeks after, an abscess formed in the external meatus of the right ear. Bridget R., aged 8 years, was taken ill on the 16th, suddenly, with fever and sore throat. Within thirty-sixhours the scarlatinous rash appeared, first on the chest, and gradually extended to the back, abdomen, limbs and face. The throat symptoms were most marked; the redness of the fauces, pharynx and tousils being decidedly those of scarlatina. The tonsils were much enlarged, and the glands at the angles of the jaw were hard and painful. For twelve hours, the gums were red and swollen. The strawberry tongue was also marked. There was mild delirium on the third and fourth days. On the sixth day brawny desquamation
commenced, and this process passed through the usual On made
no
course.
occasion could I find albumen in the urine.
She
good recovery. Helen R., aged 7, was quite well on the morning of the 23rd August. In the evening she complained of sore throat. I found punctated redness of the pharynx, fances, tonsils and soft palate. The tonsils were considerably enlarged. The glands at the angles of the jaws were hard and painful; the strawberry tongue was marked. The rash was very slightly developed, and hardly appeared on the face at all. Desquamation commenced on the sixth day, and passed through its usual course. The fever was very slight; the axillary temperature never rising above 100?. She made a good and rapid recovery. Robert R., aged 9, was taken ill on the 14th September, 1871, suddenly, with rigors, followed by fever. The rash appeared within twelve hours, hist in the chest; the fever followed the a
The throat symptoms were more marked than in On the 3rd day, there was mild delicases. rium; desquamation occurred as in the other cases. No albuHe made a good recovery. men could be detected in his urine. usual course.
any of the other
That these were marked cases of scarlatina,, there can be no doubt. Cases of rotheln they certainly were not, though the rash in all first appeared in the trunk. In none of cases were there catarrhal symptoms. From the patients I made the most careful enquiries as to the chance of the disease having been communicated to the children from elsewhere, but not one iota of evidence could I gain. They have had no communication with people from other stations whatever, nor had they received clothes or any articles of furniture, so that there are grounds for supposing that it may have originated afresh. No other cases occurred, and on the most careful enquiry I could hear of of
throat amongst the servants of this, or of the Had as perfect isolation as possible not been insisted on, the disease most probably would have spread. Though isolation, as regards the whole family, was possible, so as to guard other families as much as possible from contagion, in the bungalow itself this was impossible, nor did it seem to be of much importance to me, as it had not been attempted when I no
cases
sore
neighbouring
saw
families.
the first case, and the whole
gether. December, 1871.
family
had
been
living
to-
