CHAPTER XII.

SPECIAL ZYMOTICS.

Continued Fevers.-Three kinds of Continued Fevers.-Relation of Fevers to each other.-Typhus.-Typhus caused by Overcrowding.— Outbreak of Fever at Carlisle.-Black Assizes.-Period of incubation of Typhus. - Communicability of Typhus.—Enteric Fever.-Origin of Enteric Fever from Fæcal Contamination.-Examples.-Enteric Fever and Milk.-Contagion of Enteric Fever.-Relapsing Fever.—Relation of Relapsing Fever to Famine.-Cholera and Diarrhoea. Their relation to Enteric Fever.—Cholera and Water Supply.—Diphtheria, Croup, and Pythogenic Pneumonia.—Their Cause.-Erysipelatous Diseases and Hospital Plagues.—Puerperal Fever.-Healthy Hospitals.—Exanthemata. Scarlatina.-Relation between Scarlatina and Slaughter-houses.— Measles. On the relation of Measles to Fungi.-Small-pox.Vaccination.-Relative mortality of Vaccinated and Unvaccinated.— Re-vaccination.-The Beneficial Effects of Re-vaccination.

We shall now proceed to treat of the different zymotics separately.

(a.) CONTINUED FEVERS.-This is not the place to enter upon the discussion of the views still held by some as to the specific identity of various forms of febrile diseases, or even the identity of those diseases commonly known as continued fevers-namely, simple continued, typhus, enteric, and relapsing fevers. The view we adopt is that there are three specific diseases-typhus, enteric, and relapsing feversincluded in the title "Continued Fever." Now, why do we deny to "simple continued fever" a specific position? We believe that the fever called "simple continued" is in every case either a secondary fever attending some disease—not a specific fever, or a mild or badly marked form of one of the three specific fevers, more commonly (perhaps always) typhus

or enteric fever. That such is the case is pretty well shown by the following statement, compiled from the records of Cork-street Hospital, which shows that it nearly always prevails in conjunction with typhus and enteric fevers, but especially with typhus. Of 12 houses, furnishing more than 5 cases of fever each

13 houses furnished cases of three kinds of fever.

19 houses furnishing typhus, furnished also simple fever.!

Although "simple continued fever" is comparatively harmless, yet the officer of health must look upon its prevalence as an indication of insanitary conditions, and it should at once lead him to inquire into the surroundings of the patient, when he will probably find a ready prepared nidus for typhus or enteric fever.

1. Typhus.-The primary condition necessary to the production of typhus fever is overcrowding.

Although overcrowding favours the spread of all kinds of contagion, yet in no disease has it been so frequently and closely associated with the first appearance of disease as in typhus. Dr. J. Heysham (1781) traced an outbreak in Carlisle to a house inhabited by six families, and where no windows that could be built up were left open, consequently there was no ventilation whatever. Typhus began here without any trace of contagion, and then spread through the rest of the town. In 1859 typhus fever, which for some months had disappeared from Edinburgh, arose in a poor locality where the houses were overcrowded, and in no instance was there any suspicion of contagion.

1 T. W. Grimshaw. Prevalence and Distribution of Fever in Dublin. P. 26. 1872.

Important evidence in favour of the view that the typhus fever poison may be generated from overcrowding, may be derived from the various records of what have been termed "Black Assizes," where judges, juries, and others in court contracted fever from the exhalations from the prisoners, who, in the days prior to the time of Howard, frequently suffered fearfully from what was termed "gaol fever" in those days, but which was nothing more or less than typhus produced by the overcrowding of gaols. The latest, therefore, most reliable account of a Black Assizes is that of 1750 at the Old Bailey, where 100 prisoners were tried. These were either placed at the bar or confined in two small rooms opening into the court. Many present were affected with a noisome smell. Within a week or ten days many of those present were seized with typhus. More than forty persons died, including the Lord Mayor, two of the judges, an alderman, a sub-sheriff, and several of the jury. Neither the prisoners on trial nor any of those in gaol were affected by fever.

From this account it appears that the poison produced in those prisoners by overcrowding was exhaled by them, and affected those in their vicinity without any other apparent cause.

The following is a good example of the conditions under which typhus fever is produced :—

A court, 11 feet wide, with all matters as to drainage and water supply in good order, and recently constructed. Fever arose in house No. 10, which consisted of two floors connected by a narrow staircase.

Before the arrival of the grandmother each had 163 cubic feet, after her arrival 142 cubic feet. Windows had all been shut up for the winter, and there was no means of ventilation. The rooms had the well-known animal odour of overcrowded houses. 2

This is only one sample of the conditions under which typhus is produced, selected as an extreme instance, but others could be easily quoted. The records of the Dublin Sanitary Association afford instances of

1 Murchison. Continued Fevers of Great Britain. Second Edition. P. 104, seq.

2 Loc. cit. P. 100.

typhus outbreaks arising where overcrowding was not so extreme as in the above example, the space for each individual amounting to 250, or nearly 300 cubic feet, but in such cases the surrounding insanitary conditions increased the liability to the disease. Further proofs of the intimate connexion between overcrowding and typhus are derivable from the valuable Tables of Dr. Murchison, with regard to the density of population in the localities furnishing cases of typhus fever to the London Fever Hospital, and also from the fact that typhus is more prevalent in winter than in summer, overcrowding being more common in the former than in the latter season.

These latter proofs are, of course, applicable also to all contagious zymotics, typhus being one of the contagious zymotics. A large number of the cases are produced by contagion, especially when favoured by insanitary conditions. Thus, typhus arising among members of the higher classes of Society almost invariably has its origin in contagion. The distance to which the typhus poison can be transmitted through the air is very limited, so that there is absolutely no danger of its being communicated from the inmates of one dwelling to those of another, or carried by a third person, and there is even but slight danger to the attendants in typhus wards, provided that the ventilation is sufficient, although the medical attendants and nurses who are in absolute contact with the sick are constantly attacked by the contagion. The disease is also communicable through foul clothing or bedding, and persists for some time in rooms, or buildings, or ships which have been occupied by, or vehicles which have conveyed, typhus patients. The period of incubation is about twelve days, and it is said to extend even to twenty-one days, but such cases are extremely rare. Many high authorities are of opinion that patients convalescent from typhus are especially liable to communicate the disease, and the experience of the convalescent wards of some fever hospitals tends to confirm this opinion. This should be borne in mind when making provision for convalescents in fever hospitals.

2. Enteric Fever.-The evidence that enteric fever is the

direct product of food, drink, or air contaminated by the presence of decomposing sewage matter, or by the miasma exhaled thereby, is, if possible, stronger than the evidence of the production of typhus by overcrowding; because in the case of the latter many other of the causes favouring the spread of zymotic diseases co-exist, but, with regard to the former, nearly all other causes except the presence of the decomposing matter can be generally excluded.

the

poor

While typhus is a disease almost exclusively belonging to and badly fed, enteric fever makes its appearance in all ranks of society. Careful inquiry almost invariably discovers a pythogenic origin.

A few examples will illustrate this. An outbreak of enteric fever in a large educational establishment in Dublin arose under these circumstances:1

The class-rooms in which the various students attended lectures were

situated in one building. In this same building some of the male students resided. The remainder of the male students resided in a separate house in another street. The female students resided in a third building at a considerable distance from the building containing the lecture-rooms.

In the area of the building containing the lecture-rooms were situated latrines for the use of the male students only; there was also a pump in this area, but at some distance from the latrines, from which drinking water was occasionally obtained. This pump was partly supplied by well-water and partly by Vartry water, but there was no evidence that this pump supplied the usual drinking water for the male pupils. The situation of the latrines was so low (only slightly above high water mark) that their drainage was driven back at each rise of the tide, and when the tide rose very high the area itself was flooded with sewage matter of the most disgusting character. Thus all the gases from the decomposing sewage was mixed with the atmosphere breathed by the unfortunate pupils each time they visited the area. The result was that many (14 out of about 70) of those who frequently visited this area were attacked with fever, and of these 4 died. None of the female students and none of the others who frequented the lecture-rooms and who did not visit the latrines, were affected with fever.

As instances of localised outbreaks of fever depending upon sewage

1 Lectures on Public Health, Roy. Dubl. Soc. 1873. P. 94.