the severe application of the Artisans and Labourers' Dwellings Acts in the parishes of St. Giles and St. Marylebone, and the construction of improved dwellings, typhus has become extinct in those parishes. The improvements in Liverpool have also markedly reduced the disease, and probably in a few years typhus will almost disappear from the mortality records of that city. An outbreak of typhus demands the immediate personal investigation and attention of the health officer. There should be a house-to-house and room-to-room inspection of the affected area, and cases of overcrowding should be rigidly dealt with. Handbills distributed among the people, insisting upon the almost certain prevention of the malady by the windows of sleeping rooms being open at night, may also do good. In such bills it should be specially pointed out that typhus is not so much a children's as an adult's disease, and that therefore individual effort in the way of cleanliness, aeration, and sobriety is the more essential. In dealing with Irish populations the hearty co-operation of the priest will make the work of the health officer easier, and should always be obtained if possible. Every case of illness, no matter under what name it is called, should be investigated by the health officer in the affected area. In the first few cases of typhus the diagnosis must be well established; but if the outbreak seems to be likely to attain any dimensions, it is not wise to wait for the eruption, but given an adult with headache, high fever, and prostration, he should be removed at once.

The danger of infection to the medical men and nurses of hospitals in which typhus is treated, as well as to laundresses who wash typhus-infected linen, is considerable: the records of the London Fever Hospital give lamentable evidence of this. No doubt some of the exposure might be rendered less dangerous; for instance, if a constant current of air could be established in a typhus ward it should not be difficult for nurses and doctors to do all that is necessary in the way of attention and examination on the windward side. Auscultation is specially dangerous, the more so if the clothes are turned down and the physician immediately puts his ear to the usual short stethoscope. It is to be recommended that the chest to be examined remain exposed for some minutes previously to the air, and that the long flexible stethoscope be always used. Nurses should be preferably selected above thirty

five years of age; they should be sufficient in number so as not to be fatigued, and be carefully instructed as to the danger of breathing too closely the emanations from the patient. The most ample ventilation should be enforced, and the greatest cubic space possible is a necessity in the treatment of typhus patients. It is not known whether the excreta from bowels and kidneys are infectious or not, but it is prudent to consider them so, and, as in typhoid fever, to receive them in disinfecting solutions.

The ordinary disinfection and aeration of rooms from which typhus patients have been removed is sufficient, for however virulent the typhus poison in its concentrated state may be, there is ample proof of its easy destruction. Fumigation with sulphur or chlorine and afterwards submitting bedding and other things to a heat above the temperature of boiling water for a few hours, will perfectly disinfect.

Experience derived from Liverpool and other places show the necessity of having "houses of refuge" provided, in which those persons who have been, so to speak, soaking in a typhus atmosphere, although not themselves suffering from the disease, can be purified and have their clothes disinfected.

CHAPTER XXVII.

MICRO-PARASITIC DISEASES AFFECTING THE NERVOUS SYSTEM.—

RABIES. TETANUS.-WHOOPING COUGH.

(307) Rabies.

To this group belong rabies, tetanus, and whooping cough.

It is unnecessary to treat of rabies in this work, for it is more a matter of veterinary police. It is obvious that, so far as danger to man is concerned, a malady that is implanted only by direct inoculation by the bite of an animal (usually a dog) can be practically suppressed by a general muzzling order throughout the kingdom, carried out with the greatest severity and uniformity for two months. If this were done it is not likely that the order would have to be repeated for several years. This however requires a special Act of Parliament, the present law allowing each county authority to make their own regulations, hence neither uniformity of repression nor permanent good has followed; the unmuzzled rabid dogs of a county not under order biting the muzzled dogs of another.

The beautiful researches of M. Pasteur, showing that the microbe is primarily localized in the nervous system, and that it is possible to attenuate the virus and to perform a protective inoculation even after the bite, are matters of notoriety.

TETANUS.

(308) Researches on the Bacteriology of Tetanus.

Tetanus is a disease caused by a micro-parasite; the microparasite most frequently enters the body by means of a wound.

It is only within the last few years that the true nature of tetanus has been manifested; the following is a brief notice of the more important researches:

Carle and Rattone1 were the first to produce typical tetanus in the rabbit. They inoculated an emulsion of the sciatic nerve from a person who had died of tetanus; infection of a second animal with the sciatic nerve of the first produced the same result, but inoculations of the blood were fruitless.

Nicolaier, under the direction of Flugge, introduced garden earth subcutaneously into rabbits, guinea-pigs, and mice; clonic spasms of the affected limb were produced, and in the course of twenty-four hours this was followed by general tetanus. At the seat of inoculation fine bristle-shaped bacilli were found; these were often swollen at one end. If the garden earth was previously sterilized by heating it to 110°, then no effect followed; artificial cultures were not pathogenic. Winiwarter3 repeated and confirmed these results.

Rosenbach was the first who discovered the bacillus in man. He injected under the skin of guinea-pigs and rabbits pieces of tissue taken from the boundary-line between the sound and gangrenous parts of the thigh of a man dying of tetanus; tetanus was produced in the animals, and it was propagated through a series of animals by inoculation of matters taken from near the inoculated place. The bacillus was recognized in the neighbourhood of the inoculation, but not in the rest of the organs.

4

Brieger separated a ptomaine from an impure culture of the bacillus; he called this substance tetanin, because it produced, even if injected in minute quantity, tetanus in animals. He separated the same substance from the amputated arm of a tetanic subject.

Bonome in three cases of traumatic tetanus propagated the malady from matter taken from the neighbourhood of the wounds, and recognized the bacillus; his inoculations of the blood, the spinal marrow, and the nervous tissues were negative. He found

1 Carle e Rattone, "Studio experimentale sull' eziologia del tetano," Giornale della R. Acad. di Med. di Torino, 1884, 3.

2 Nicolaier, Deutsche med. Wochenschrift, 1884, 2.

3 Winiwarter, Allgemeine chirurg. Pathologie u. Therapie, 1817, 13te auflage.

4 Brieger, Berlin. klin. Wochenschrift, 1887, 15, 17; 1888, 17.

5 Bonome, Giornale della R. Acad. di Med. di Torino, 1886. Archiv par. la Scienza Med. 1888, xii. 4.

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that the bacillus when in the spore state was not destroyed at a temperature of 100°. He made the instructive observation that at the storming of the church in Bajaido, out of seventy wounded, nine died of tetanus, and in three he recognized the specific bacillus. He experimented with limestone dust taken from the ruins; this inoculated into wounds produced tetanus in animals, and he found in the pus taken from the inoculated part the bacillus. The researches of Giordano,1 Ferrari,2 and Hochsinger are also to be mentioned, from all of which the conclusion may be drawn that traumatic tetanus has usually some connection with the contamination of wounds by earth. This connection was specially clear in some cases observed by Beumer. One of these cases was that of a man, aged thirty-one, who was attacked with tetanus after a wound by a splinter when playing at skittles, and it was found that small splinters of wood taken from the skittle alley produced tetanus when inserted beneath the skin of animals. In a second case, recorded by the same observer, a boy running barefoot wounded his foot by a stone, and tetanus followed; small stones taken from the same place introduced into wounds in animals produced tetanus.

In a later series of experiments, Beumer excised little bits of tissue from the neighbourhood of the umbilicus of infants dying from tetanus neonatorum, and inoculated these bits of tissue into animals and produced tetanus.

Beumer also proved, through a highly exact series of researches, that the tetanus-producing bacillus was very widely distributed in the superficial layers of various kinds of soil, on the foul surface of streets, and in the dust of dwellings. He also showed that a wound when actively granulating was not very susceptible of taking the infection.

One

Several cases are on record in which tetanus seems to have been conveyed by the hands or instruments of the surgeon. of the most striking of these is related by Langer, in which the horses castrated by the same écraseur died of tetanus, but after boiling the instrument in oil no others died or were affected from its use.

1 Giordano, Giornale dell. Acad. di Med. di Torino, 1887, 3, 4.

2 Ferrari, Italien. Chirurg. Congress, Genua, April, 1887.

3 Hochsinger, Centralblatt f. Bacteriol. 1887, ii. 2, 3.

4 Beumer, Berlin, klin. Wochenschrift, 1887, 30, 31.