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of the rash, has long been known, and from one or two of the cases I saw, I can quite understand
the disease being overlooked when not associated with more typical cases.
In no other way does it seem possible to account for cases appearing suddenly where
there were no previous ones, unless an extraordinary vitality of the virus in houses and clothes
is assumed. As regards the general surroundings of the patients, in the Cases 1, 2, and 10, the
people were clean, in comfortable circumstances and not overcrowded, and in the absence of an
outbreak one would not have thought of looking for typhus.
In the remaining cases, though the people were poor, they were by no means destitute.
One or two families were dirty, but taken on the average they were by no means the worst in the
Borough ; and employing as a standard of cubic space the figures of the bye-laws for houses let
in lodgings, viz., 400 cubic ft. living and sleeping, and 300 for sleeping only, and half these
figures for children, they were not over-crowded.
Coming to the question of diagnosis, the cases with the exception of the first three and
last were examined by me prior to removal to the M.A.B. hospitals. Here the diagnosis was
confirmed with the one exception mentioned (Case 3). Among the diagnostic points common to
the large majority of the cases, I may mention : (1) The sudden onset; (2) the late appearance
and character of the rash ; the sudden rise of temperature to the maximum in those cases where
it could be observed, and (4) the dulling of the faculties.
1. Sudden onset. —Almost every patient was quite decided as to the day of onset of the
disease, and some went even so far as to state the hour of the day on which it occurred ; one
stating she left work for dinner, and was attacked during the interval; and another that she took
ill just as she was putting on her hat to go out. Murchison draws attention to this characteristic.
2. Late appearance and character of rash. —This generally made its appearance from the
fifth to the seventh day of disease, and usually appeared as small roseolous spots on the trunk
and extensor aspects of the limbs. They were not elevated at first, but occasionally became so
later, and though fading at first on pressure, very soon became permanent and often petechial.
As this roseolous rash became marked, it was nearly always accompanied by subcuticular
mottling, giving a brownish sunburnt appearance to the skin. In addition to the petechia which
appeared as the result of the gradual charge in the roseolous spots, there were frequently other
petechia present, which appeared early and independently of tbe roseolous rash, and were very
often indistinguishable from flea bites. These latter are said to be easily recognised by the puncture
in the centre and the light-red areola around, but this criterion applies only to the early stage,
since when old they lose these characters and resemble closely the petechise of small-pox or
typhus. The latter can, however, generally be distinguished by their want of uniformity in size
when a sufficient number are closely examined, when a certain percentage will often be found larger
and somewhat deeper seated than flea-bites. Other considerations which go to show that in many
cases we had not to do with flea-bites but petechise, are that they were seen on many of the
patients whose habits and surroundings were perfectly clean, and also that in one family where
three children were lying ill together in one bed, the two elder were covered with petechise,
whereas the baby had less than half-a-dozen altogether. Had flea-bites been so numerous as the
appearance of the elder members suggested, I think it highly improbable that a baby with a
tender skin should be immune.
I have gone into this symptom somewhat fully, since the medical practitioners and myself
found it a very practical difficulty, and a feature of diagnosis on which opinion differed very
much.
The amount and visibility of the rash differed greatly in different cases. In one case, No.
6, the child above mentioned, the rash seemed to be absent except for those half-dozen petechæ.
She was in the same bed as her elder brother and sister, who had typical attacks of typhus, and
was in the same stage as they were. The child looked ill, had a temperature of 102°, furred
tongue, etc., and but for the surrounding circumstances I don't doubt that the case would have
been undiagnosed, and put down to some complaint of childhood. I never realised before how
easy it is for this disease to be kept going among young children, in the same manner as
happened in the outbreak in Nazareth House, recorded in the Public Health Text-books.
3. The sudden rise of temperature to the maximum.—ln those cases where they were under
observation from the first, such as contacts, the temperature rose very rapidly, within fortyeight
hours to 102°, 104°, or higher. In this respect they differed markedly from enteric.
4. The dulling of the faculties. —This is always looked upon as a very important symptom,
but in one case at least it appeared to be absent throughout the disease ; she was mother of patients
3,6, 7 and 8, and was otherwise typical. In a majority of the cases it was very marked, and was
accompanied by deafness. Suffusion of the conjunctivae was common, but some did not show
this.
Having seen several cases of typhus in Belfast and Dublin, I had no hesitation in arriving
at a diagnosis in the majority of the cases, though as a whole they did not seem so severe or
typical as the cases one sees in Ireland. This is, however, probably to be explained by the fact
that the circumstances of the patients in Ireland as regards overcrowding, want of good food, and
general poverty are worse than in London, and render attacks not only more severe on the
individual, but more liable to spread through a community.
There seemed to be only one feature in the course of the illnesses which was not strictly
followed in these cases, and that was the occurrence of a crisis from the twelfth to the fourteenth
day.
Of the seventeen cases eleven fell by lysis, which generally lasted two or three clays, and
occurred in or about the time the crisis might be expected. Two had a fairly typical crisis. There
were four deaths, which occurred on the 9th, 11th, 11th, and 16th day of the disease. Although I
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