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rash and notify it as scarlet fever. She was removed to hospital on February 28th, and died on
March 8th. The diagnosis of scarlet fever was not confirmed, but typhus was suspected,
though the evidence of its existence (viz., " so very faint a rash that a positive diagnosis was out
of the question ") as stated by the medical superintendent was very slight, and the post-mortem
showed only pneumonia.
Cases 1 and 2 seem to have been sporadic and accidental, since beyond the fact that
Case 1 occurred in the neighbourhood of Case 3, there seems no other ground for suggestion of
a connection between them and the subsequent cases.
Case 4 was a little girl of nine years; she fell ill on March 3rd, nine days after the last.
Her residence was about three quarters of a mile from Cases 1 and 3, and the only thing in
common between her and the last was that they attended the same school, which was situated
about midway between their homes. Case 3 was at school during the early stage of her attack,
for the teacher described her as " sitting shivering by the fire, and vomiting once, or twice."
They were not in the same class, but had opportunities of meeting out of class hours in the playground
and class rooms.
Case 5 is not so clear ; she fell ill five days after the last, viz., on March 8th. She was
married, and lived in a small street just round the corner—certainly not more than 50 yardsfrom
Case 4. This latter occurred in an annexe to a beer-house, with which it communicated
directly, where Case 5 frequently went for beer. Her children went to a different school than the
last two cases, and situated in a different direction, but do not seem to have been personally
acquainted with Case 4, though owing to the proximity of their respective houses I do not see
how they could have failed to play with one another occasionally in the street, without necessarily
knowing one another's names. The onset of the illness in this case was so close, in point of
time, to that of Case 4, that unless a very short incubation period is assumed it seems difficult
to establish a direct connection.
Cases 6 and 7 were sisters, and Case 8 a brother of Case 3, and arose from her by direct
contagion, 20 days after her removal to hospital, proving that Case 3 was typhus.
Case 9 was brother to the last three, and was infected directly by them after an
incubation period of about a fortnight.
Case 10 was a very well-marked typical one, but presents great difficulties as to its origin ;
she fell ill on March 29th, nine days after Cases 6, 7, and 8, and 20 days after Case 5. It
occurred in one of the best residential houses in the Borough. Her friends were well-to-do.
The patient assisted her mother in house work, had not been visiting anywhere the previous
month, and had only occasionally gone in the street, and then not in the immediate neighbourhood
of the previous cases. The house is in the main read, and about a quarter of a mile from
Warford Place, where Cases 3, 6, 7, and 8 occurred. Her father and brothers, however, have a
wood yard at the back of but not communicating directly with Warford Place, and her sister,
who had had influenza a couple of weeks before she developed typhus, and was attended by the
medical man who notified the latter, did office work in this yard. I was informed that none of
the inhabitants of 14, Warford Place had worked in this wood yard during the last 10 years, and
that the sister who worked in the office did not come in contact with the hands, except when
paying them once a week through a small window.
Case 11 occurred on March 31st. In this case children from the same house and family
attended the Paradise Street school, in connection with which were Cases 3,5,6 and 7. An
illness in a young brother of this patient, which occurred between March 16th and 21st, may
possibly have been the connecting link between this and the other cases which attended the
school.
Case 12 occurred on April Ist in a street in the same neighbourhood, but the only
traceable connection with previous ones was that a sister and young brother attended the
Paradise Street school, there being in addition a history of the young brother having been ill on
or about March 6th with diarrhoea.
The remaining cases require no special comment, since they were all infected directly by the
cases mentioned above. In all the seventeen cases, with the exception of 1, 2, 5 and 10, the
only meeting-place common to all where they might have acquired infection was the St. Joseph's
Schools, Paradise Street. Of the thirteen cases which had this school in common, eleven were
scholars, and the remaining cases, 11 and 12 in the table, though they did not attend the school,
had brothers or sisters who did, and in both cases there was a history of some indefinite illness
among these scholars previous to the case of typhus. It is hard to ascertain the nature of the
illnesses in the members of the families of 10, 11 and 12, which preceded the typhus; but in
one case at least, that of S. R., at. eight years, brother to Case 11, the illness was described as
febricula, and was of sufficient duration to be compatible with an anomalous attack of typhus.
He was sent to the Infirmary, and the Medical Superintendent, who had seen a good deal of
typhus in Ireland, stated that he had no symptoms suggesting this complaint. It is just
possible that as our knowledge of infectious diseases becomes fuller, these indefinite illnesses in
families which precede the case of typhus may be classed as " latent " or " masked " typhus, in
which the virus after " passage " through one or more human beings becomes more virulent, or
getting into more favourable soil culminates in a typical attack of typhus fever.
That similar mild cases occur in other infectious diseases has been shown in the case of
diphtheria by the late Sir Thome Thorne in the Milroy Lectures for 1891; by Koch in his
description of the suppression of endemic typhoid in a group of German villages in the district
of Trier; and more recently in the case of scarlet fever by Caziot, who describes an outbreak of
19 cases in a school, which originated in the so-called " latent "or " masked" cases. The
mildness of typhus in children, coupled with the not infrequent absence of or poor development
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