It used to be stated that the predisposition to infection was less in children, more in adults, and the rule laid down was that the bread-winners of the family are first struck down, then the children, but this does not coincide with the more recent experiences, see p. 404.

Males are a little more liable to die from typhus than females. The cause probably mainly is the greater muscular development. Typhus fever is a fever in which there is disintegration of muscle and poisoning of the system from the products; hence it is an old observation that patients with strong muscular development bear typhus ill, and that the mortality is greater among such. Besides this males on the whole are more intemperate than females, and are more liable to kidney complications; intemperance in itself predisposes.

(302) Seasonal Prevalence.

The prevalence of typhus is a little influenced by season. Buchan and Mitchell's1 curve shows that typhus is above the average from January to the beginning of May, and, with the exception of the hot season of July, in which it is very slightly above, it is slightly below the average from the middle of May to the end of September; it rises decidedly in the first week of October, and decreases in the middle of December to again rise towards the end of the same month. They, however, rightly remark that "it is a curve which calls for clearer definition from future observations, though it has two maxima, the larger in the early months of the year, and the smaller in the height of summer." The mortality curve of Buchan and Mitchell does not altogether agree with the admissions into the London Fever Hospital in the different months of the year; thus the 18,268 cases admitted from 1848-1870 were distributed through the months as follows:

1 Journal of the Scottish Meteorological Society, July 1874-75.

D D

The general fact that it is more prevalent in cold, less prevalent in mild, weather, has been explained by saying that in the cold months of the year the poor shut their windows and therefore the ventilation being less typhus spreads easier, a very feasible explanation, if the December and July portions of Buchan and Mitchell's curve can be explained away; otherwise not so.

(303) Race.

It is not known whether typhus irrespective of personal habit and general environment attacks one race rather than the other, the broad fact that in England typhus is more especially disastrous among the Irish is incontestable, but it is among the Irish that there has been most overcrowding and poverty, a sufficient cause of greater prevalence. In the years 1848-67 there were admitted into the London Fever Hospital:

1 in every 135 of the Irish inhabitants of London.

English.
Scotch.

foreigners resident in London.

showing a considerable incidence on the Irish race.

(304) Prevalence of Typhus in 1886.

In 1886 the Medical Department of the Local Government Board1 made a special inquiry as to the existence of typhus in the country, and Mr. Spear, to whom was entrusted the investigation, made a most instructive report. For one reason or other 67 districts came under suspicion; in most of these where fever was found it proved to be the ordinary enteric fever of the country, but in no less than 17 important centres of population typhus was found existing; for example, at Leeds 56 cases in 33 families were reported between October 26th, 1886, and 28th of January, 1887, nearly all occurring among the Irish, in a locality in which the people were poor and ill-housed. "Unrecognised cases among

children had occurred in this infected area before the date assigned to the earliest reported case."

At Middlesborough a localised outbreak of typhus occurred in

1 Sixteenth Annual Report of the Local Government Board (Supplement). of Medical Officer for 1886.

Report

the latter half of 1886, at least eighteen cases and four deaths being notified between August 11th and December 4th. The early cases seem to have been mistaken for "scarlatina." In Hartlepool a town in which the poorer quarters are so crowded together as to render impossible free areation, and the houses described by Mr. Spear, in many cases "so ill-ventilated, damp, and in such bad repair as to be unfit for habitation "-typhus broke out in 1886; the first cases were certainly unrecognised, and were confused with "typhoid," there were 141 known cases, but owing to defects in the administration of Hartlepool at that date only 58 cases were removed to hospital. The same report gives details of typhus outbreaks in Oldham, Maryport, Sunderland, Liverpool, and other places, and Mr. Spear concludes as follows: "The circumstances related above will show how difficult it has been found in the majority of cases to learn the actual origin of an outbreak of typhus. The frequency with which the early cases are mild in character so as to pass unrecognised, and the constancy with which they appear under circumstances of destitution and squalor, may suggest the possibility of the germination or growth under such conditions of a morbific agent possessed of potential capacity, thereafter progressively developing infectiveness and specificity— a theory which, in relation to apparently simple sore throat and diphtheria, has been brought under notice by Dr. Thorne. I have not found, however, that early, apparently initial, cases among adults are exceptionally mild. It seems that this characteristic of early cases is marked because of the frequency with which children are the first to suffer, and they, although it is somewhat paradoxical considering their greater susceptibility to infection, exhibit first to last during the progress of an epidemic singular immunity from severe and fatal attack. Moreover, although the disease amongst children is comparatively benign, it exhibits, so far as my experience goes, marked specific characters. The characteristic measly eruption is commonly distinguishable, and nervous and nutritive disturbances as shown, for example, by subsequent though transient deafness, and the falling off of the hair, which we should not expect to follow an ordinary febrile attack, are of extremely frequent occurrence." The report next lays stress on the frequency of failure to recognise the early cases, and the lamentable results. "In Leeds, Hartlepool, Carlisle,

Middlesborough, Oldham, Newcastle-on-Tyne, and Flint the disease gained a footing through the neglect of unrecognised cases, and in Liverpool this is the common experience with respect to constantly recurring localised outbreaks." . The comparative inac

tivity of the typhus of recent years-its slowness of extension-is, it would appear, mainly attributable to the comparative absence of distress; for, although much harassing poverty has prevailed of late, that form of it has happily been exceptional which amounts to absolute want. That the inherent potency of the infection remains the same may be inferred from the fact that under the more fixed and comparable conditions its behaviour does not vary; it will still spread with great frequency to the well fed and well housed, as, for example, to hospital nurses, when such persons are much exposed to its influence; and again, its fatality amongst adults is maintained, On the other hand, the belief indicated above is supported by observing its constant predilection for the most indigent of the population, by noticing the manner in which it will single out the most distressed and squalid households, and then spread to all the various members." 1

(305) The Nazareth House Outbreak.

The outbreak of typhus at Nazareth House in 1882-3 is particularly instructive to medical officers of health, for it is a good example of the mild form which modern typhus may assume and the necessity of the accurate diagnosis of the febrile ailments of children. Nazareth House is a home in Hammersmith for the succour of the aged poor and destitute children. Its population in 1883 was 53 sisters of charity, 133 old persons, male and female, and 175 children. On October 8th a visit was made by the uncle of one of the children, accompanied by a little child, who had recently recovered from "some illness." The illness of this child, as investigated by Mr. Spear, was probably undiagnosed typhus. The uncle lived in a very bad cellar-dwelling in Hammersmith, he looked himself ill. On the 22nd of October the child E. L., which had been visited, sickened of a feverish disorder, which was thought to be "influenza," the sister who nursed her remembered a measly rash, the child's hair subsequently fell off leaving the 1 The most recent recorded outbreak of typhus is one which occurred in Sheffield in 1890, and is described by Dr. Thomson. Public Health, vol. iii. p. 17.

head almost bald; five weeks after E. L.'s attack, when the latter had been down in the class room for about a fortnight a second child, C. O., was taken ill. Then a child who had sat at C. O.'s bedside reading to her was stricken, so "the disease continued to spread, until on the 9th of January, 1883, eight cases had occurred, all of them, with the exception of the first case, being very slight it appears, so that the disease was still looked upon as "influenza." On January 9th Christmas day was kept; the children had a Christmas tree and a dramatic performance, and in the evening a large party of friends from the outside, as well as the inmates, including the convalescent children, were assembled in the "Community" Hall. Two priests played much with the children on January 9th, and they both afterwards passed through an attack of fever, which was regarded at the time by different medical attendants as typhoid, but which there is great probability was typhus. One sickened exactly fourteen days after the day of the party; the other had been ailing for some days, and the commencement of his attack is not well determined. On the 9th of January two children were poorly at Nazareth House, and one was confined to bed, and on the following day two sickened. One of these last suffered from a lung complication, and died on January 23rd. She was eighteen years of age, and her death was certified as from “influenza, congestion, and convulsions." Meanwhile other cases occurred, so that on February 2nd seven more children were ill. The medical attendant now suspected typhus fever, precautions as to the admission of strangers were prescribed, and a few days later, on February 6th, when a sister who had been nursing the children was attacked, pretty complete isolation measures were adopted.1

In all the cases were thirty-one in number. The disease was actually three months prevailing in a mild form before it was recognised, the home itself was neither dirty nor overcrowded, and the sanitary arrangements and regulations were reported by Mr. Spear to be excellent.

(306) The Isolation and Prevention of Typhus.

The prevention of typhus is in theory of the simplest :-given good ventilation and ample cubic space typhus disappears. Since

1 Report of the Medical Officer to the Local Government Board for 1883. Mr. Spear's report upon an outbreak of typhus fever at Nazareth House, Hammersmith.