EPIDEMIC CEREBRO-SPINAL MENINGITIS, BY MOREA U MORRIS, M. D., Formerly CITY SANITARY INSPECTOR OF Health Department. Jyfew York; TOWER, GILDERBLBEYE 15 & 20 i Years. ** M tO X CO Between 15 & ‘20 Years. CO Between •20 & *25 Years. —1 CO if* Between ‘20 & ‘25 Years. fC s - to -d Between •20 & ‘25 Sears. to Between ‘25 & 30 Years. to • Between ‘25 & 30 Years. to OS S 5 Between ‘25 & 30 Years. - Between 30 & 40 Years. Cl i Between w 05 30 & 40 Years. Cl M Mi CO to Between 30 & 40 Years. Over 40 Yrs. Over - 05 40 I Yrs. CO If* r—* * C5 X Over 40 Yrs. Total. Q-, co Total. M O j ~d 05 X If* Cl o -d Total. During all these sanitary investigations, not one case occurred which presented any positive evidence of a personal contagious or infectious character; and indeed, the mass of recorded evidence by various writers in different parts of the world fails to prove that there is any specific con- tagion or infection from the person in this disease. Persons suffering with it during this epidemic, were removed to other and more healthy localities, 14 yet careful inquiries and investigation failed to show any case following such exposure. Although several isolated oases had been officially reported to the Bureau early in the month of January, the first well-defined group was presented in the family of Mr. Brown, residing at 443 Eleventh, avenue, a medical history of which was kindly furnished by Dr. John G. Sewall. The abstracts of other oases, as they occurred from time to time sub- sequently, with a condensed description of their local surroundings, as reported upon by the Health Inspectors at the time, are here given as illustrations. These oases and examinations afford a very striking corroboration that unsanitary and defective conditions of sewers and drain-pipes were the source from which this specific poison emanated. Whenever families were removed to other localities, no new cases oc- curred; and when these faulty conditions of drainage had been remedied, or filthy accumulations had been removed, and the atmosphere thus pu- rified, no new oases were developed upon the same premises. And, vice versa, when these unsanitary conditions were allowed to remain, other cases in the same family, or among other families dwelling upon the same premises, followed. GROUP OF CASES FROM DR. SB WALL’S RECORDS. I. “ Albert Brown, residing at 443 Eleventh avenue, aged six years and six months, was, on the forenoon of January 30th, 1872, kicked in the side by a boy, and fell, striking his head against an iron railing. At 1 o’clock P. M. he reached home, but made little complaint of his injury until towards 7 o’clock that evening. He died on the morning of the 31st, at 4 o’clock. No physician saw him whilst ill, and there is, therefore, no account of the symptoms. ‘‘ A post-mortem examination by the Deputy Coroner, Dr. Beach, showed a thin layer of extravasated blood covering the surface of the brain, and extending to its base, with bloody serum in the ventricles. Dr. B. looked on the case as one of concussion of the brain, with rupture of a small vessel. There was a large patch of ecchymosis at the site of the kick, but no signs of peritonitis or other abdominal mischief. Some dark purpuric spots, irregularly scattered over the trunk, were noticed. 11. u Maximilian Brown aged four years, in good health during the day, and playing up to 4 o’clock, was, at 11 o’clock P. M., February 4th, 1872, seized with vomiting and general spasms, without loss of con- sciousness. He seemed in a fright, and called constantly after his lost brother—(Case I). He was seen at midnight by a physician. He died 15 February sth, about 7A. M. The medical attendant states that the brain symptoms were prominent; he did not look for any eruption. Meningitis was reported as the direct cause of death. No autopsy. 111. “ Theresa Brown, aged thirteen years, was taken, February 6th, at 2 o'clock A. M., with pain in the head, moaning and crying out. She was seen by Dr. Sewall at 9A. M. She had been sitting up during the night at her brother’s “ wake,” and had been much affected by the sudden deaths of her two brothers. When first seen, intelligence was perfect, the pulse rapid, the skin of natural warmth and moisture. There had been some vomiting. She complained only of pain, not severe, over the whole head. Bromide of potash was ordered, with sinapisms to the feet and nape of the neck. “ February 7th. 10 o’clock A. M.—She was in much distress, com- plaining of her head, and her mind was wandering. The pupils were somewhat dilated. Intelligence good. There was much hypereesthesia of the entire surface, with tenderness of the large joints, which she said was rheumatism, having once suffered from it. Pulse 120 in the minute, and of good volume. The tongue was covered with a thin white fur, but was not dry. She had not slept during the night; had vomited, and the bowels had been moved. At 4P. M., she still complained of her head and limbs. The inhalation of chloroform had procured some sleep. A petechial eruption, not abundant, over the trunk and thighs. It varied in size from a pin’s head to a canary-seed, did not disappear on pressure, and was of a deep purple hue. A diagnosis of u Spotted Fever ” was made. Morphia, half a grain every second hour, beef-tea, and milk-punch were ordered. February Bth 9A. M.—Pulse 120, and feeble; extremities cool; tongue and purpuric spots as before. Still complained of head, and of great sensitiveness of the skin. Much de- lirium and crying out. but the intelligence was good, and attention easily secured. Body heat 98° Fahr. Treatment continued. At 4 P. M., she was more composed; the purpuric spots were paler; face a little flushed; skin natural ; pupils contracted readily to light; pulse 116, and with more volume ; mind clear; tongue unchanged. February 9th, 10 A. M.—Passed an indifferent night, having been restless and deliri- ous. Pulse 130 and feeble ; skin warm; tongue whitish. For the first time since her illness says that she has no pain in the head or elsewhere Petecbiee present; urine free; bowels open. Treatment continued. “ At 7 P. M. the pulse was 116 and fuller ; no pains ; had rather an uneasy day, though she slept at intervals. Takes milk and beef-tea moderately. 16 “ Feb. 10th.—Had been restless and delirious all night, and again complains of pain in the head. Pulse 108, and of good character. Eruption less, and of a paler hue; tongue more coated, but not dry. “ Feb. 11th, 2P. M.—Had slept soundly all night; pulse 86 to 88 j eruption nearly gone : no pain in head or back, though a little in the limbs. Skin, rather cool, particularly of the extremities; tongue cleaner. Sitting up. Takes milk and broth freely. “ Feb. 12th.—Slept well; very irritable ; pulse 96 ; a little pain in the head and back of the neck ; eruption scarcely visible; tongue clean- ing ; lips parched and dry; skin rather warm; urine free, clear, with no change on the application of heat; bowels costive. Drinks milk-punch freely. Subsequently recovered. IV. “ Berthold Brown, aged eleven years. Was first seen on the morning of February 7th, about 10 o’clock, lying on a couch, moribund; with a cadaveric expression, and deep icterode hue. Pulse very rapid and scarcely perceptible; skin dry and hot; mind not clear, and he could hardly be roused; pupils contracted; complained chiefly of his head. He had been to his brother’s funeral the previous afternoon, a distance of six or seven miles. He seemed well on his return home, and ate a hearty supper. Between 7 and Bon the evening of the 6th of February, he sickened, with pain in the head, vomiting, purging, and chill. There had been no convulsions. He died at 2P. M., Feb. 7th, eighteen hours after he was first attacked. “ Autopsy.—Feb. Bth, 11 o’clock A. M.—Rigor mortis strongly marked. An eruption similar to that in the girl (Case HI), but in greater quantity on the body. The serous and mucous coats of the stomach showed purpuric spots similar to those on the body. It was also scattered, though less abundantly, over the peritoneal coat of both small and large intestines. Lungs, heart, liver, and kidneys were healthy. The blood was very fluid. The whole of the surface of the brain was intensely congested, the veins and sinuses being gorged with very fluid blood, though not entirely devoid of coagula. On section of the brain little points of blood netted out everywhere. The ventricles were nearly dry. Consistence of brain natural. No exudation or puru- lent matter found. V. Feb. 10th.—“About midnight the baby, one year and three months old, was taken suddenly ill; she vomited, and had several loose stools. There were slight muscular spasms, but no decided convulsions ; she died at 9A. M. The body was covered with an abundant purple petechial eruption.” 17 Description of Premises.—The family lived on the ground-floor of a house which was one of a row of wooden buildings, whose cellars had been made by filling up and grading the avenue in front, and of the yards in the rear. A good stone-wall foundation had been built underneath. The apartments occupied were: (1) (see diagram on page 16) a medium sized front room, used as a tin shop and store; (2) a rear room, used for the general purposes of the whole family; (3) a small passage-way leading from the front to the rear rooms, in which some of the children usually slept in a small crib, and (4) a bed-room between the rear room and the shop. In this bed- room, which had no other means of ventilation than the door, the father, mother, and some of the children slept. The whole family was thus chiefly confined to the rear room and the small unventilated bed-rooms on one floor, and on a level with the street and yard. In one corner of the rear room where the children spent the greater part of the day, was a closet [E] about one foot in depth, built against the partition wall of lath and plaster, separating this house from the adjoining one, with a base board not close to the flooring, not tight. There was nothing be- tween it and the cellar, except the loose board floor. In this closet, which was chiefly used to hang up clothes, the children were in the habit of playing and spending much of their time. Immediately adjoin- ing it was an unused fire-place, tightly closed by boards. Almost directly underneath the closet, but on the other side of the stone foun- dation partition wall, was the sewer pipe from a privy vault, common to the two dwellings. This sewer pipe of stone-ware led from the privy vault to and through the i’ear wall of the cellar, entering it about two feet above the bottom and connected with its extension, which passed underground to the street sewer, by an elbow (K) of the same stone-ware pipe. The two ends of this elbow were found to enter into the pipes above and below the joints, and had originally been luted with cement or common mortar, which, becoming disintegrated, had fallen out, so that there was no obstruction to the free escape of the sewer gases at either end of the elbow joint. This portion (I) of the cellar had been boarded up to the flooring above, to be used as a wood-bin, and was a moderately tight compartment, about six feet square, having within it the elbow of the sewer pipe. Thus the escaping sewer gases were pretty effectually confined to that portion of the cellar, their chief means of escape being upward through the open partition wall and floor of the room above, through which they penetrated and diffused themselves, where the children usually played. 18 The mother stated that most offensive odors were constantly noticed, particularly in and about this closet. The oldest girl said to the In- spector, “Oh, sir, the smell is dreadful sometimes, making us sick, and almost vomiting. We had to open the doors and windows to get air. It smelt like rotten dead animals—it was awful !” The following diagrams will illustrate the course of the sewer pipe through these premises, and the open-jointed elbow connection, situated immediately underneath the room and closet [Ej where the children were in the habit of spending the most of their time. First Floor Plan of House 445 Eleventh Avenue. 1. Store in front. 2. Living room. | Bed-rooms. 5! Yard of 445. 6. Yard of 443. C. Closet. D. Fireplace. E. Closet, where children played. F. Stove. A. A. A. A. (dotted line) shows the course of sewer connection from privy vault. B. Bed. O. Bed. H. Lounge. I. Woodhouse, in cellar of No. 443. K. Elbow at joint between sewer pipes. P. P. Privy vault common to both houses. Side Elevation of Cellab and Yaed of 443 Eleventh Avenue. First Floor. Level of Yai Level of Yard. A. A. House sewer connection. B. B. Sewer pipe from privy vault. C. Elbow between the two pipes, with open joints P. Privy vault. VI. 131 Lewis street, 4 deaths; two girls, aged respectively eighteen and twenty, and two children; they all slept in a room 10 by 15 feet; this room was connected by a ventilating window with an adjoining 19 one (6 by 8 feet), in which there was an untrapped sink; there was no trap in the sewer pipe; the general waste pipe of the house passed into a concrete pipe in the cellar, which connection was exposed hy the removal of a large mass of decaying sawdust, when an opening was found in the concrete pipe having a superficies of about two square inches, from which so much foul air passed from the sewer as almost to blow out the flame of a candle. VII. 538 Sixth street, 2 deaths; a privy vault completely filled, and very offensive; a drain leading from it to the sewer, which was open in a part of its course, allowing the foul gases to escape freely into the cellar. Immediately above this the two children who had died of the disorder had slept. VIII. 39 East Broadway, 1 death* ; privy vault in yard, full; cellar filthy ; sinks throughout the house untrapped, and foul odors escaping therefrom. XL 230 East Broadway, 1 death; premises in bad condition; yard, very filthy ; sinks untrapped, and foul odors escaping. X. 23 Eldridge street, 1 case; tenement house in bad sanitary con- dition ; defective sewerage and drainage. XI. 24 James street, 1 death. The family lived in the basement of a large double tenement house, which basement was divided into a store in front, on the street; a kitchen in the rear, and two sleeping- rooms (or passage-way closets) between. All the rooms were below the level of the street and yard. The inner sleeping-room, or closet, had no other ventilation or light than by the doors into both the store and kitchen. The other closet was lighted by two small glazed windows, which opened into an inter-space between No. 24 and No. 26, at the level of the ground, i. e., five feet above the floor of the room, so that the air which came in when they were opened was very damp. The wall of this room, and of the whole side of the house wTas constantly wet, being directly against the earth. In this room, which the father described as always very foul at night, the child slept; he said that the child lay with its mouth open, and seemed to be affected by the bad air. About six feet in rear of the eastern side of the rear room, or kitchen, there was a large privy vault common to the front and rear buildings, and from it, directly under the floor of the kitchen bed-room (in which * It is not intended by these numbers to indicate that there was one death or one case only in that house. In many instances there were several; but the abstracts are taken from the reports of the Inspectors, made immediately after a case or death from epidemic Cerebro-Spinal Menin- gitis was reported to the Bureau, to show the condition of the dwelling at the time of the out- break of the disease in it. 20 the child slept), and store, passed the main sewer drain connection to the street. It was of brick, cemented on the outside; the moisture and gases of the sewer had penetrated and saturated the bricks and cement, and the exhalations which at times came from it ‘‘ fairly steamed.’' The sewer was also broken and defective. Immediately over all this lived the family. At the bottom of the area steps, leading from the street down to the store, was a large iron grating, opening into a sort of excavation under the basement floor ; through this came in full force the foul odors of the broken sewer; and hereabouts, directly in and around the doorway and steps, was the chief play-place of the infant. XII. 284 Seventh street, 1 death ; premises in bad condition ; no traps; privy vault very offensive. XIII. 204 Seventh street, 1 death ; a female, who moved into the house on the Ist of May in perfect health, and about one week after wards sickened with the disease. The sink*, untrapped and covered only with boards, projected into the bed-room, and the foul gases freely escaped into the room. XIV. 47 Avenue B, 1 death; premises in bad condition; no traps under sinks in the house; privy vaults foul and offensive. XY. 406 Broome street, 1 death ; rooms filthy ; sink in back room, untrapped, and emitting foul odors. XVI. 219 Division street, 1 death ; sinks untrapped; offensive odors constantly escaping therefrom. XVII. 208 Elizabeth street, 1 death ; rooms filthy ; a hydrant sink untrapped, with sewer gases escaping. XVIII. 153 Baxter street, 1 case ; house cleanly, and well venti- lated ; a sink in the room connecting with the street sewer, untrapped. XIX. 46 West Thirty-third street, 1 death ; a brown-stone house in one of the best parts of the city. In the cellar the main waste pipe, connected with the sewer, had openings at the section-joints and at the connections of the smaller waste pipes from above; these fissures and openings had been hid and covered with a sort of soft cement, quite per- meable, and useless for its purpose. Underneath the kitchen sink there had been such a leakage that the beams, together with the flooring over them, had rotted away, and emitted an odor like that from an old ice- box. This leakage had been only very recently repaired before the dis- ease appeared in the house; all the sinks remained untrapped ; the water-closet upstairs was without traps, and very offensive ; in the ex- * The word “ sink ” is intended to describe the kitchen slop-basin, where dishes are washed and the suds run off into the house drain by the pipe connection, or the usual wash-hand basins in other rooms. 21 tension room, on the parlor floor, there was a very peculiar and disagreea- ble odor, which was probably due to rotten or worn pipes in the wall or flooring. XX. 63 Columbia street, 1 case ; premises in bad sanitary condition all the sinks (8) untrapped, the privy vault full and filthy. XXI. 196 Second avenue, 1 death • condition of the house (tenement), good; but the cellar, contained large accumulations of rubbish and dirt, was very filthy and unventilated ; noxious gases escaped from this cellar, through a large hole in the floor, into the room immediately, under the bedstead on which the child who died of the disease slept. XXII. 23| Avenue B, 1 death ; privy vault very offensive; sinks untrapped, and sewer gases escaped into the room in which the patient slept. XXIII. 67 Cannon street, 1 death; no traps at bottom of waste pipe connecting with sewer in cellar. XXIV. 71 Cannon street, 1 death; same as above; no traps under kitchen sink in either house; the tenants complained of bad odors in this house at times. XXV. 219 Division street, 1 death ; no traps to sinks, and offensive odors escaping. XX VI. 640 East Thirteenth street, 1 death ; no traps to sink; privy vault full and offensive. XXVII. 11l Mott street, 1 death; no traps to sinks; privy vault in front of room in yard. XXVIII. 22 Avenue B, 1 death ; no traps to sinks; privy vault full and offensive. XXIX. 107 Clinton street, 1 death • sinks trapped, but not sufficiently. XXX. 406 Broome street, 1 death ; no traps to sinks in back room, and bad smell. XXXI. 10 York street, 2 deaths ; also, 4 cases of Typhoid, 2 of which were fatal; occupants Irish, German, Italian, and colored people, all extremely filthy ; house damp from cellar to roof, indescribably filthy and out of repair ; large privy vault, very full and offensive (common to 3 houses), near rear corner of house, and leakage from a hydrant was wetting and loosening the rear basement wall : cellar and cellar hallway distressingly filthy with rubbish and garbage ; privy smells were “ thick enough to cut with a knife f a hydrant basin, set loosely over the mouth of an untrapped (4 inch diameter) sewer pipe connection, contrib- uted powerfully to the impurity of air in the close damp yard; house subsequently vacated by order of the Board. 22 XXXII. 162 .Second street, 1 death. “An open space, about two feet wide, in the rear of premises, was filled with garbage, rubbish, etc., and noxious gases from this place, as well as from the waste pipes of the sinks in the adjoining premises (No. 160), escaped into the bed-room of the deceased.” XXXIII. 106 Avenue 0,1 case ; over a savings-bank. “ Premises in good condition, but the state of adjoining yard (Xo. 333 Seventh street) was such, in my opinion, as to lead to the disease ; the earth in the yard had been recently upturned in the removal of a privy vault; as the yard is inclosed on three sides by the walls of houses, and on the south by a high fence, the occupants must have breathed air contami- nated by emanations from this privy vault, especially as the windows of the rooms of the bank open directly upon the yard, and were kept open day and night to allow the odors to escape from paint, turpentine, &c., which are present in new buildings.” XXXIY. 206 West Sixteenth street, 1 death. “ Family dive in a front basement, which is dirty and very damp ; the sink in the hall often overflowing on account of obstruction in waste pipe ; yard filthy, not paved ; water runs from yard into rear area and rear entrance to hall.” XXXY. Northeast corner Twenty-third street and Eleventh avenue 1 death (sick ten weeks). “ A new sewer is being constructed in Eleventh avenue, below Twenty-third street, and together with the stench from the gas-works and neighboring large horse-stables, the air at times is very offensive; at times, also, the stench comes up from the sewer through the waste pipes.” XXXYI. 560 West Twenty-sixth street, 1 death. “ House, low basement dwelling; damp ground ; filthy house and street.” XXXVII. 324 West Seventeenth street, 1 death; case on ground- floor ; no basement; no sewer connection. XXXVIII. 119 Baxter street, 1. death, “Six in family; apart- ments filthy; hydrant sink in room untrapped, and emits an offensive odor.” XXXIX. 105 West Forty-ninth street, the Assistant Engineer ex- amined, and says: “ Found sewer under basement door open, and a water-closet in front basement in bad condition.” XL. 441 West Twenty-sixth street. “Found eighteen slop-sinks connected to 2-inch iron pipes with badly constructed lead traps and connections; some of them had no “ dip,” or hollow, to hold water, and neither cement or anything in the connections to prevent the escape of foul odor.” 23 XLI. Shanty on south side Sixty-seventh street, 300 feet west of Eighth avenue, i death. “ Shanty is directly on brink of the exposed sewer which runs diagonally through this block and the next, to the north ; the surface of the adjoining lot is perpetually covered with a deep layer of stagnant water and semi-solid sewage matter, and the effluvia is extremely detrimental to health.” XLII. 176 East Sixtieth street, I death; private dwelling; several holes in sewer, in cellar. XLIII. 196 Mott street; sewer in cellar broken; no traps to slop-sinks. XLIV. 21 Morris street; privy vault and yard very filthy; no traps to slop-sinks. XLV. 209 East Forty-eighth street, 1 death; child, aged 3 years; foul odors escaped into the house from an opening, occasioned by a 1| inch waste pipe, dropped in a 4-inch soil pipe, with no caulking or stop- ping of the space between the two. Side Elevation of No. 209 East Forty-Eighth Street. Basement Floor, Sewer Pipe. A. lead pipe. B. Joint open. O. 4-inch iron pipe. XLVI. 354 West Thirtieth street, 1 death; this house a brown- stone front; the fountains of noxious odors, in this case, were cesspools in the cellar, with large holes broken in the pipes connecting them with sewer. Ground Plan of No. 354 West Thirtieth Street. Ground plan of Cellar: A. Cesspool, with pipe open. B. Cesspool, with pipe ,open. C. St airs from CeUar to First Floor XLVII. 431 West Forty-third, 1 death ; child, aged 4 years. Side Elevation op Basement and Cellar of No. 431 West Forty-third Street. Side Elevation of Cellar of No. 431 West Forty-third street. W. C. Water-Closet. B. Open Joint. A, Trap to Water-Closet. C. Hole (1% inch dia.) in Pipe, open. “ In this case we found an open joint at the point of junction of the water-closet trap with the iron sewer pipe, and a large hole in side of said pipe, from both of which were a free and very perceptible escape of foul sewer gas.” XL VIII. Xo. East Fifty-first street, near Fourth avenue, 1 death; a young man aged 20 years. Nothing could be discovered wrong about the premises or in the house drainage. The patient, however, when questioned as to his habits and business, said he was employed as a car penter, and had been for two weeks previous to his attack engaged in repairing the large ice-boxes used in butchers7 shops for keeping their meats. He said he was obliged to go into these and remove the inside board lining which usually rotted out every year, and replace it with new. The stench emitted from these decayed boards and inside lining was so great, in almost every instance, as to compel him frequently to go out into the open air, and he sometimes vomited in consequence. At times some of these ice-boxes were so foul, that he could only work in them but a few moments at a time. He had not been well since he commenced this kind of work, having a constant distressing headache, and finally was taken with a chill, followed with the usual symptoms or Cerebro-Spinal Meningitis, of which he died. The autopsy disclosed the whole surface of the brain congested, veins and sinuses having considerable fluid blood, the ventricles having con- siderable effused serum in them, and the meningeal vessels intensely congested. The congestion extending as far down the spinal canal as could be seen from the opened cranium, with effusion in the canal. All 25 the other internal viscera of the body were found in a normal condition. Further illustrations would but add to the corroborative evidences here presented. In these examinations, and many others not given in the above list, when carefully made, (as they were in most instances, with the assist- ance of an experienced plumber attached to the Bureau, as Assistant Engineer), not only were sewer and drain pipes found disjointed and im- perfectly connected in the various houses, but in some instances the old lead soil pipes were found so corroded by the sewer gas, as to present a honey-combed appearance, through whose interstices it constantly es- caped, thereby befouling the atmosphere of the cellars and rooms above. It may not be deemed out of place here to notice the fact, that in a very large proportion of the dwellings in this city, whether private houses, tenements, or “ flats,” adequate and proper provisions are rarely ever made for the ventilation or escape of sewer gas, which is constantly being generated in the sewer and soil pipes. Such a provision may be easily and simply provided, by extending the main soil pipe with which all the waste pipes of the house connect, directly upwards and outwards beyond the roof of the house, from, the street sewer, without any inter- vening stench trap. By this simple and direct means, all the poisonous or offensive gases, generated in the street sewers, or soil pipes of the houses, would have an unobstructed outlet to the higher stratum of air. where they would become innocuous by rapid dilution. If, in addition, this soil pipe could be so arranged—as it might be in new buildings—so as to pass upwards, either into the chimney, or by a separate flue connected therewith, it would become heated by its proximity, and an additional impetus thereby afforded to the upward current, thus increasing its effect as a ventilating shaft both for the house drains and the public sewer connected with it. Such a construction has, in several instances, been recommended and applied, and is found to fulfill all that was an- ticipated in removing offensive odors from the dwellings, and purifying the atmosphere of the rooms. PRACTICAL DEDUCTIONS : That this disease is specific in its nature, possessed of great fatality, having an analogous etiology with Typhoidal diseases, hut depending upon the elimination of some special poison generated in the decomposi- tion of animal and vegetable matter, under certain meteorological condi- tions. 26 That it is not contagious or infectious from the person, or through the medium of fomites. That its mode of attack is by the operation of this special poison upon the blood, through inhalation or possibly cutaneous absorption. That its special lesions are congestion of the vessels of the brain and spinal axis, followed by the sequelae of acute and sub-acute inflam- mation. Its prophylaxes are the prevention of the escape of poisonous sewer gases into dwellings, by providing for their free outlet into the external atmosphere; thorough cleanliness and removal of all decomposing matter about the premises ; disinfection with carbolic acid in some form or some other equally powerful arrester of decomposition; free ventila- tion of all close or confined places, by the admission of fresh air in large volumes; and thorough washing or flushing out of all drains or sewer pipes connected directly or remotely with dwelling houses.