340 THE INDIAN MEDICAL GAZETTE. / [Sept. 1902.

REPORT ON CEREBROSPINAL MENINGITIS

IN THE BHAGALPUR CENTRAL JAIL, 1900-1901.

By

Captain E. A. E. Newman, m.d., i.m.s, Civil Surgeon, Bhayalpur. Fourth Outbreak (from to ).

Period Date of attack. Result. Date of result. Form of labour. Meteorological No. Sex. Caste. Age. in &J3 condition. jail. 5 f

3 6 8 10 11

Yrs, Y. M. D. 48 Male Hindu 32 0 5 17 7th Oct. 1900 Died 25th Oct. 1900 11 Mehter Strong on left 28th, 29th; windy 30th. 3 13 13th ? 49 Do. . Muhammadan 24 0 Do. 14th ,, ,, Public Works High wind 6th, Department 10th, llth; calm road work. 12th. 0 7 23rd 50 Do. , Hindu 24 13] Do. 26th ? ? 13 Aloe-pounding Calm weather. 51 Do. Do. 40 27th Recovered 7 Garden outside Ditto. 1 2 5! 52 Do. Do. 58 1st Dec. Died 7th Dec. 1900 7 Sweeping in Nov. 29th windy ; No. 4. 30tli calm. 0 6 18 1901 53 Do. Do. 30 18th Jan. Do. 28th Jan. 1901 14 Garden outside Windy two days previously. 54 Do. Muhammadan 26 14th Feb. Recovered 12 Public Works Calm after wind Department on llth, 12tli road work. Feb.

5 2 ? in on 55 Do. Do. 45 0 18th Died. 24th Feb.1901 11 Spinning Windy 14th, No. 1. 15th, 16th. 0 5 1 5th Mar. Do. 5 Do. in No. 5 2nd 56 Do. Hindu 45 "5th Mar. ,, Mar. windy; 3rd fine; 4th windy. 0 6 20 5 th ,, Do. 6th ? ? 6 in 57 Do. Do. 30 Sweeping No. 6. Ditto.

36 0 1 14 7th Do. 10th ? 1 58 Do. Do. May May Husking paddy May 4th?6th very windy. 0 1 14 26 th ? Do. 30th ? ? 10 Mehter 59 Do. Do. 40 May 24th, 25th windy. 0 1 7 27th ? Do. 30th ? ? 6 Godown 60 Do. Muhammadan 55 manfty. May 2dth, windy.

0 0 6th June Do. llth June ? 16 June 4th 61 Do. Hindu 28 22] Rice-cleaning... 3rd, sultry ; June 5th, high winds. 0 2 llth ? Do. llth ? 10 Ditto June 6th 62 Do. Do. 29 ? 10th, high winds. 0 0 221 15th ? Do. 19th ? 16 63 Do. Do. 50 Aloe-pounding 12th, 13th dust and storm ; 14th, wind and rain. 23th ,, Recovered Oil 64 Do. Do. 45 12 mill and 22nd, 23rd windy; water. 24th wind and rain. 1 22 Died ... 10th 65 Do. Do. 26 0 2?th ? July 1901 15 Power- loom 25th, 26th windy, weaver. *05 in. rain ; 27th fine. 1 66 Do. Do. 30 0 29 th ? Recovered 15 Rice cleaning 28th windy, no I rain. 1 Died 29th 67 Do. Do. 25 0 20th July July 1901 16 Wheat grinding Calm and sultry, break in rains.

Fifth Outbreak (from to ).

YR9. Y. M. D. 1 4th ... 68 Male... Hindu 35 0 6! 3rd Sep. 1901 Died Sep. 1901 Blacksmith Fine and hot, break in rain. 30 4 22 5th Do. 30th ? ? Garden outside 3rd and rain 69 Do. ... Do. 0 4th, and wind.

28 0 3 11 25th Do. 30th ? ? 23rd rain & 70 Do. ... Do. Wheat-grinding 22nd, wind; 24th fine. ... 0 0 6th Oct. Do. 7th Oct. ,, 71 Do. ... Muhammadan 56 Carpenter Calm, sultry. is! 20 th Recovered Public Works 72 Do. ... Hindu 42 Ditto. Department road work. 0 3 20th 25th Calm. Do. ... Muhammadan 18! Nov. Died Nov. 1901 Rice-cleaning 0 0 27 24th ,, Do. Public Works Do. ... Hindu Calm, sultry. Department, outside. Sept. 1902.] THE BHAGALPORE EPIDEMICS OF CEREBRO SPINAL FEVER. 341

Fifth Outbreak (from September 1901 to March 1902).?(Contdj.

Period Caste. Age. Date of attack. Result. Date of Result. Form of labour, Meteorological No. Sex. in jail. condition.

10 11

0 5 27 27th Nov. 1901 Died ... 28th Nov. 1901 gene 24tli 75 Male. Hindu Godown, calm; 25th ral. L. wind, 26th high wind, dust and storm. Public Do. Do. 28th ? Recovered Works Ditto. 76 Department, inside. 0 2 11 3rd Dec. Died 5th Dec. 1901 Mehter. (In hos Dec. 1st, 2nd 77 Do. Do. calm; pital 30 days L. wind on 3rd. before attack.) Calm weather. Do. Do. 7th ? Recovex-ed Rice-cleaning 78 0 1 Ditto Do. 8 8th ? , Died 9th Dec. 1901 Ditto 79 Do. Ditto 0 1 18 13th ? Do. 31st ,, ,, Calm. 80 Do. Do. Recovered Ditto Do. Do. Do. 18th ? 81 0 18th Do. 8 19 19th ? Died 23rd Dec. 1901 Cow-keeping... 16th, 17th, L. 82 Do. winds. Sonthal 0 1 15 1st Jan. 1902 Recovered 23rd Jan. 1902 Rice-cleaning 83 Do. Loom 14 Do. 3rd ,, H. Do. Hindu 0 6th ,, , May 84 0 1 13th Jan. Do. Do. 23 8 th Died ,, Sweeping 85 0 Oil mill and Do. 3 25 1st Feb. , Recovered 2nd Mar. ,, 80 Do. water.

lload work ... 0 0 21 28th ? Died 2nd ,, ,, K7 Do. Do. Under-trial ... 0 1 6 27th Mar. , Recovered 88 Do. Do. 0 15 ,, , Died 2nd 1902 89 Do. Do. 31st Apr. Sweeping

J. Buchanan cases in the latter out- The last report by Wk fifth outbreak. Twenty of the Indian Medical observation. and Captain C. R. Stevens break were under my personal cases to de- the 42 cases under re- Service included all up , Clinical features.?Of under the head of different 12 recovered?a scribing them port 30 died and only percentage the been over 71 deaths in the Since then disease has mortality of a little epidemics. in the some 3 cent, nripticallv endemic jail, almost every number attacked, or per higher 1900 a I death-rate calculated month since October showing case._ than the previous by Major all cases have included in this report occurring Buchanan, I.M.S. to March 1902. The follow- case died on the from October 1900 Duration of illness.?One the monthly incidence this (to which 1 shall ing table shows 57th day. Excluding

umber of attacks

Fourth outbreak. ? J'th outbreak.

1901 with 6 cases in occasion to allude), the duration o* June and December ?train have the heaviest inci- in the remaining 30 cases was as each month show monthly the illness to note with reference dence It is interesting follows:? the month in to the last April, epidemic tha^ in O hours of onset of illness. in 1900, shows no cases " within which it was worst cases died the of 1900- 4b ,o()i or 1902 I think epidemic 6 considered to end of 3 days inm mov naturally be July of 1001-1002 extends 4- ? inn the epidemic Voo 1 to the end of March ,002. 0 ? from'September of cases the whole 1 week The total number during in the fourth and 22 iu the 19 days period is 42., or 20 342 THE INDIAN MEDICAL GAZETTE. [Sept. 1902.

an average duration of a little over five days illness. In this case death was undoubtedly per case. From this it may be seen that nearly due to pyaemia, though typical post-mortem four-fifths of the total deaths occurred within appearances were found in the cerebral meninges. a week of the onset of symptoms. I may Other complications have been noted above, mention here that in Captain Stevens' experi- particularly diarrhoea, which is so constant that ence recovery took place if the patient lived it may be called a symptom. Herpes labiatis three weeks. This analysis bears out this opinion has also been noted. with the one exceptional case in which the is a not complica- patient died on the 57th Hyperpyrexia infrequent day. tion of severe cases, in the fulminant and especially Symptoms, complications, diagnosis.? type of the disease. It also occurs towards the The most constant are symptoms pyrexia, end, and is frequently the accompaniment, if frontal at the of the headache, pain nape neck, not the actual cause, of a fatal termination. and stiffness of the posterior cervical muscles, The curve varies and is conjunctival congestion, furred tongue, increased temperature greatly not characteristic. fluctuations are seen in reflexes, particularly knee-jerkings, symptoms Sharp some in others it maintain a varying from day to da}7-, diarrhoea usually, cases; may fairly constant line about 100? or 101? F. In all occasionally only looseness of the bowels, slight cases at the commencement I restlessness, sleeplessness, and delirium usually pyrexia is, believe, the rule, in one case it fell and of a low muttering type, occasionally active. though rapidly remained subnormal, while acute were Other symptoms that may be present are paresis symptoms of the facial muscles or limbs; herpes labialis present. and squint. General pains, particularly in the Diagnosis.?When the disease is epidemic joints, lumbago, and pain along the spine. Re- and the attention of the observer is on the alert, traction of the head may be marked, but is by diagnosis is not as a rule difficult. no means a constant to symptom. Inability The fulminant type of men- bend the head forwards and cerebral-spinal passive resistance, ingitis has to be distinguished from heat with in the back of the neck accompanied pain apoplexy or cerebral When the when the head is bent forward the haemorrhage. actively by conditions necessary to the production of heat is an almost constant and of observer, symptom apoplexy are present, the diagnosis may be very value on this account. In greater diagnostic ? ? difficult. Hyperpyrexia and coma are present some cases total unconsciousness is the rule, in both cases. Stiffness of the cervical muscles, on if it is not the first coming early, very and Kernig's symptom, if present, are the to attract attention. symptom symptoms on which reliance must be placed. of the There are three main types disease? The history and age of the patient may help in (1) The fulminant variety. the differential diagnosis from cerebral haemorr- (2) The acute. hage ; but in the absence of definite localizing (3) The subacute. symptoms on the one hand, and cervical stiffness and 011 the The nomenclature itself. Kernig's symptom other, the explains be almost In the fulminant the disease occurs with diagnosis may impossible. Pyrexia type to this is not remarkable suddenness. The is either points cerebro-spinal fever, though patient means A discovered unconscious with stertorous by any absolutely diagnostic. post- breathing mortem on one case in illustrates after he has been his my experience shortly pursuing ordinary this In this case bilateral cerebral avocations, or of illness and difficulty. complains rapidly was present, with falls into a comatose condition. haemorrhage actually early Jepto-meningitis and great injection of the In the acute there is some malaise variety cerebral vessels which had given way under with a rapid onset of the severe symptoms, the strain. while in the subacute variety the symptoms In the acute or variety pneumonia may either more slowly are never so compli- develop cate and overshadow the cerebral severe in character. The patient may some- symptoms. times retain consciousness throughout the illness When multiple arthritis is present, a diagnosis be or may be easily roused from low delirium. of acute rheumatism might erroneously made or pyaemia, though this is not so far from the Complications.?Lobar pneumonia is the mark. most important one, and was recognised clinically one that died More chronic cases in which diarrhoea is a in five cases. , In case double lobar was bear some resemblance to pneumonia found at post-mortem. It may prominent symptom is slow. be more prominent than the cerebral or ner- enteric. Convalescence vous symptoms, and the latter are then liable to Post-mortem appearances.?Captain C. R. be overlooked. Stevens, i.M.s., has given a very complete account Pain in the joints. The results of pyemic of the post-mortem appearances found in cerebro- arthritis were noticeable in three cases, parti- spinal fever. I have not described them here, cularly in the case that died after 57 days' as in}7 experience is limited to 12 post-mortems OF SPINAL 343 Sept. 1902.] DUST AS A FACTOR IN THE ETIOLOGY CEREBRO FEYER.

numbers from 1,650 to at times from vary nearly performed to March 1902 in The main industry is the second outbreak described. 1,800. blanket-making with looms inside a brick the steam-power large Etiology. -During period under report no about 700 A few examination of building employing prisoners. bacteriological the others make at and are fluid was, as far as I am cerebrospinal carpets liand-looms, aware, made The as smiths, and overseers. intracellulars is employed carpenters, diplococcus generally acceptedThis accounts for some two-thirds of the adult as the specific micro-organism of this disease male The third is em- and a population. remaining micro-organism answering this on the duties of the internal was found in certain cases in description' ployed general previous epidemics of the and their The conditions of economy jail, occupations . varying life in the central include at on rice-husking, wheat-grinding, sweeping, jail Bhagalpur depend two factors?firstly and the labour on which the road-making, aloe-pounding, cow-keeping, prisoners are employed outside work, while a few work in the and the barracks in garden secondly, which they sleep' at the oil presses, or at Apart from this, there is a grain godowns, drawing general similarity of water. The former occupations are chiefly vital conditions. The hours of work and rest carried on in closed buildings; the latter chiefly are the same. The food of all prisoners is in the air or open sheds. the same. A few open practically up-country Muham- The main distinction between these forms of madans meat and a few get weakly or con- labour is that in the former the atmosphere is valescent have a prisoners specially-cooked mrl free from dust, while the latter more diet. The comparatively easily-digested water-supply for are some of them very dusty occupations, parti- all is the same. road-making, and Before the cularly rice-husking, sweeping; considering various forms of labour and almost all these latter occupations carri- an being it will 0f are simplify understanding the subject ed on in the open air, the occupants far more to out that some 50 to point 70 females live to duststorms, which occur with at the end of the exposed great apart jail. Adjacent to the frequency throughout the cold weather and earlier female barracks are the juvenile and wards where part of the hot weather, with somewhat less a like number of under prisoners 20 are confined frequency until the rains break. Cerebro-spinal meningitis has never occurred Havino- thus the chief difference in the former and not explained amongst amongst the latter the under which the various kinds of the under conditions during period report. ^The disease labour are carried on, a comparison of the inci- has therefore been confined to the adult male dence of the disease amongst prisoners of the who employed population jail, occupy the main on different forms ot labour is instructive. This in the centre of the barracks jail and constitute is shown in the following tables : of the 85 to 90 per cent, total population The Fourth outbreak (October 1900 to July 1901.)

Nature of employment,

Rice-cleaning and husking 7th , 6th June and Public Works 1901. 1901, 11th June Road-making Department works 1901, 29th June 14th October 1900,14th Garden work, outside ... February 1901. 27th October 1900,18th . Sweeping 1 7th October 1900, 1st December 26th 1900, 5th Wheat-grinding I May 1901. 20th July 1901. Aloe-pounding 23rd | October 1900, 15th June 1901. Oil mill and water-drawing I 25tli June 1901. Total | (Dusty employments.) Manufactory godovvn JU5 1 ! 27th May 1901. Power-loom weaver 1 j 28th June 1901. Hand-loom ,, o ISth February 1901, 15th March Total 1901. (Non-dusty employments.) 344 THE INDIAN MEDICAL GAZETTE. [Sept. 1902.

Fifth outbreak {September 1901 to March 1902.)

Ilice-cleaning and liusking 20th , 7tli , 8th December 1901, 13th December 1901, 18th December 1S01, 1st . Road-making and public works 20th October 1901, 24th November 1901, 28th November 1901, 28th . Garden work, outside 5th September 1901. Sweeping 8th January 1902, 31st March 1902, Wheat-grinding 25tli September 1901. Cow-keeping ... 19th December 1901. General godown 27tli November 1901. Oil mill and water-drawin 1st February 1902. Total 17 (Dusty employments.)

Blacksmith ... 3rd September 1901. Carpenter 6th October 1901. Hand-loom weaver 6th January 1902. Total (Non-dusty employments.)

Mehter (SO days in hospital upon attack) 3rd December 1901. Under-trial prisoner in No. 4 ward 27th March 1902. Total (No employment.)

For the two outbreaks there were 33 attacks The following tables show the incidence of in prisoners employed on dusty forms of labour attacks on prisoners sleeping in different wards and 9 only in prisoners employed on non-dusty in the two outbreaks. Taking the two out- forms of labour, including in the latter category breaks together, ward 16 shows the highest one under-trial who had no work and one mehter number of cases, viz., 7- This is an old ward. who had been sick in hospital for 30 days with Next, ward No. 11, viz., 5 cases. Numbers 10 gluteal abscess before he was attacked. He and 7 also 4 each. These are new pucca wards. was in the general ward and not in contact The six old wards show collectively 15 cases; the with cerebro-spinal fever patients. 10 new pucca wards collectively 26 cases, or an of 2'5 cases ward. There does not I have included one blacksmith and one average per therefore seem to be the second category too, to any particular predisposi- carpenter amongst tion to the he Their work is, however, disease from sleeping in the old strictly impartial. wards. carried on a good deal in the open air, and is The five stories 5, 7, 9, show 13 certainly dustier than the power-loom weavers upper (3, 11) over 26 ward. in the steam factory. cases?-just per The 12 wards, old and new to- The comparative total of incidence in the two groundfloor show 28 cases, or 23 per ward. outbreaks is 78 5 per cent, in dusty employments gether, in short does not seem to and 21-5 on This Sleeping upstairs non-dusty employments. afford percentage would be raised to 85 if smiths and any protection. carpenters who work to some extent in the open Ward No. 16; which shows the largest air were included in the list of dusty employ- number, is the barrack where the short-term ments. Further, the total number of adult prisoners are accommodated, and these prisoners male convicts employed on dusty or outdoor are usually employed on the minor occupations forms of labour is roughly about 50 per cent, of in the internal economy of the jail, as it is not those working in the factory and elsewhere worth while training them to work in the fac- under cover on non-dusty employments. A tory. Though the ward may be at fault, the simple calculation shows that in these two out- nature of their employment must be taken into breaks there was one attack in every 17 men consideration too. An examination of the dates amongst the former to 1 attack in every 120 of the attacks shows the cases were scattered men amongst the latter; or, in other words, the about the various wards, and only in two in- disease was seven times more common in stances did cases occur in the same ward at men employed on dusty work than in men on such short intervals that a common source of non-dusty forms of labour. infection in the ward might be suspected. Sleeping barracks.?The conditions of life by These instances are ward No. 11 in the later day have been considered. It remains to con- outbreak?two cases, on 13th and 18th December, sider the difference in the condition of the various respectively, and ward No. 3 in the earlier out- prisoners at night. break?two cases, on 28th and 29th June, and The sleeping rooms are 16 in number, of which perhaps a third in ward No. 16?two cases, on in Nos. 1 and 2, 13 and 14, and 15 and 16 are old 6th and 15th June, respectively, the earlier buildings on the ground, while Nos. 3 to 12 are outbreak. A. fourth possible instance in ward more recent pucca buildings, arranged in two No. 16?two cases on 28th November and 8th stories, 3, o, 7, 9, and 11 being upper stories. December, respectively, in the latter outbreak. Sept. 1902.] THE INCUBATION PERIOD OF CEREBRO-SPINAL FEYER. 345

An 1001 to March 1902.) examination of the employment table showsFifth outbreak (September that the first cases were two both on the employed rice-cleaning; however, second two cases- 1 (5th . one at the 1 19tli December 1901. power-loom and the other on rice- and the cleaning, third two cases on rice- 1st February 1902, 27th March 1902. and 20th November 1901. cleaning aloe-pounding, respectively, while 28th 1901. in the fourth instance one February man was employed 6th October 1901. in Public Works work 5th September 1901, 1st January Department and "the 1902. other at In rice-cleaning. the case of only one 2Sth November 1901, 8th January power-loom worker, who was not 1902. particularly 25th September 27th Novem- to infection on 10 1901, exposed account of his work a ber 1901. mode of 3rd September 13th Decem- possible double infection does not 11 1901, apply ber 1901, 18th December 1901. and he was the first to be attacked. I may 12 here note that no case of infection of atten- 13 dants on 14 patients suffering from 7th December 1901. cerebro-spinal 15 fever has ever been noticed in 20th October 1901, 28th November hospital. 16 1901, 8th December 1901, 31st From these considerations it seems certain March 1902. 3rd December 1901. that the conditions obtaining in the sleeping Hospital barracks have little or to for one nothing saj' to the pn> month. pagation or spread of the disease. In barrack Total ... No. 1G, which shows most cases, the employment factor applies and robs it to a extent of great tables show the any Further, the other old bar- The following period passed significance. of 35 attacked. racks, similar in construction, do not show in jail in the case prisoners any recovered is not avail- particular unhealthiness. The record of seven who able :? Fourth outbreak in (October 19Q0 to July 1901). Number attacked. Pei;iod iail-

" U}-ear,4montl.s|re8pect;ve|( 1 ? ? J the 9th 1 During month, Date of 8th ? attacks. 2 ? Gtli ? 4 ? 5 th 1 ? ? 4th 4 ? 3rd ? 2 2nd ? 13 ? 1st ? 17tli May 1901. 5 18 I Ins is not the shortest being days. period as some ouite an accurate statement, prisoners as under-trial in passed a certain time prisoners the before conviction. jail woiks out at about ^our otli March 1901. Tli6 average period, months. , . 5th ? ? , that the new 27th May 1901. From this it appears comer is 13th to the disease, as this is a October 1600, 27th October more liable especially 1900, 1st a . central jail, and there are large proportion of long-term prisoners. factor com- Here again, the employment the question, as short-time men are 26th May plicates and outdoor forms 1901, 11th June 1901. iiquillv employed on dusty of this due 1 think 7th October 1900, 18th labour But giving weight, 1901. February remains m favour of that a balance of evidence of 14tli Greater recently-admitted February 1901, 25tli June 1901. the susceptibility are not acclimatized. 23rd October 1900. men?who is Incubation period. It difficult to make 28tli on this One case . any definite statement point. after 18 m ; four others 28th June 1901, 29tli was attacked days jail June 1901. a but in three weeks. This gives limit, nothing 6th June 1901, 15th June 20tli case of a mehter who July 1901- 1901, more. In the developed the disease on the sixth day after admission to hospital, there is some support to the supposition that the period of incubation may be about seven 346 THE INDIAN MEDICAL GAZETTE. [Sept. 1902. days, as exposure to infection while at work was Overcrowding.?This, from experience else- at least more probable than while he was in the where, is generally considered an important general hospital ward. The possibility of this factor in the prevalence of cerebro-spinal fever. latter condition is in the case the exemplified of The following table shows the average daily second mehter, who developed the disease after number throughout the year of adult male one month in hospital. On the whole, I am convict in the jail during the various outbreaks inclined to think that the period of incubation since 1897 : ? is usually a short one?from one to three days. connected with this are Intimately subject N umber now Daily average meteorological conditions, which I will Outbreaks. Date. of adult male consider. cases. population. Meteorological conditions.?In the table ap- pended it will be noted that, as a, general rule, the weather was windy and boisterous a few before each attack. The meteorological First January to April 1,501 for 1897 days 1897. are the conditions noted from observers' records Second 3 October 1897 to ' 1,504 ? ,. In 10 entirely of the jail. the last April 1S98. 1,455 ,, 189S independent Third 4 August 1899 to 1,605 ,, 1899 of the year 1901, rough weather was quarter July 19(1). 20 1,638 ,, 1900 a not the and few cases occurred Fourth October 1900 to 5 ? always rule, 1,638 ? 1901. 15 of calm. July '1,714 ? 1901 after Fifth 15 periods September 1901 1,714 ? ,, to March 1902. 7 1902 The general meteorological conditions in 1901 '1,030 ? were dry and windy weather up to the end of March. Occasional rain fell in April, and three or shown annually or four heavy showers in May accompanied with wind. In this month and in June the Average Year. Total cases. daily weather was hot. In June there were high population. winds, but very little rain till the 24th, when 1897 ... 12 1,504 the rains broke, though comparatively little 1898 ... 10 1,455 fell. The rains were deficient with 1899 4 1,605 generally 1900 ... 25 was a 1,63S frequent breaks. September dry month, 1901 ... 30 1,714 and the last rain fell on the 23rd. After this there was practically none except one slight There is an increase under both heads during shower in November till the end of the year. the last two years?hardly enough to draw The beginning of 1902 was also rainless, the any definite conclusion. Throughout 1901 the first shower falling about the 10th of April. The jail was overcrowded, especially during the last table of monthly incidence shows dropping cases six months; the total daily population during throughout the first-half of 1901, excepting October or November reaching the highest April, culminating in a maximum ot six cases figure, viz., 1,933. Early in 1902 the population in June when the outbreak practically ended, was largely reduced. except for one case in July in the wheat-grind- Summary.?To summarise these conclusions, ing shed. August, a month when the rains are sex, age, and caste seem to have no particular well established and the soil thoroughly satura- influence on the disease. The portion of the ted, was free. The disease appeared again in jail occupied by adult males was alone affected, September 1901, continued to the beginning of and the female, juvenile, and hajat wards, the hot weather, 1902, reaching its maximum which are quite cut off, were free. There is no in December 1901. June and December, the reason to suppose from experience elsewhere that hottest and coldest months, show equal numbers. females or juvenile males are less susceptible. One conclusion, it may safely be drawn that hot It is merely a question of topography. The sultry weather has per se no direct influence in conditions obtaining in the various sleeping the causation of the disease. Of six cases occur- barracks seem to have had no influence on the ring from 8th December 1901 to 1st January incidence or spread of the disease, excepting 1902, five were working in the rice-cleaning shed, perhaps ward No. 16, where other factors which points strongly to a common source ol apply. The food is practically the same for all infection in the shed. prisoners, and no predisposition could be traced The only other factors unconsidered are, age, through it. Til;? same sex, caste, and overcrowding. Ages vary from 21 water-supply is the for all, and the to 60. In sex all the patients are males ; caste same conclusion applies. Personal contagion shows a preponderance of Hindus. All these has never been traced in the special ward, facts are explained by the peculiar conditions where the cases are treated?the only place of jail life. The disease has appeared only where it could be recognised with certainty if amongst the adult male portion of the jail, and it occurred. Overcrowding seems to have some Hindu prisoners largely out-number Muham- influence. At all events attacks have been madans. more frequent when the jail was more thickly Sept. 1902.1 THE D,UST THEORY. 347

in a laboratory on which Captain populated. New prisoners, or those appertaining who have relies in of his contentions must been in under six Rogers? support jail months, are most fre-be different from those occurring in attacked ; and this widely quently though issue is com- In an editorial note on plicated the of every-day existence. by question labour, it is in the that want of acclimatization possibleMajor Buchanan's paper, published may exert some Volume No. 2, influence in to the Journal of Hygiene, I, April predisposition disease. also in the Commis- and boisterous weather 1901, and quoted Sanitary Dry appears to be a of 's Annual favouring factor in its sioner to the Government spread, that Germano in the distribution of presumably byReport for 1898, it appears dust, and, the most in lastly, was more successful preserving the probable?it may almost be said 1897 the only- the which he mixed definite condition which can vitality of organism, be traced in the or brickdust causation and of the with sand, earthware (?) (moist spread disease is the kind survived 80?90 of labour the are and dry), and found they days- prisoners on Germano's employed under these conditions. conclusion Those on torms of employed dusty work have, interest, viz., that the in these two outbreaks under is of particular diplo- been seven resistant report one of the most non-sporo- times as attacked as coccus is frequently those and that it may well cause on forms of employedaenic bacteria, very non-dust,y labour in in the air as dust. out off' from to the buildingsinfection when floating exposure and its is in- atmosphere Kamen cit.) believes viability atmospheric dust. the (loc. Rice-cleaning, dustiest a existence. It has occupation of accounted tor creased by saprophytic all, 10, or the dust that if dust <>5 cent, of the total nearlybeen to theory per objected are cases; a factor, the female and warden work for road-makingis so potent why together 9, or about 20 whose chief employ (gram-sifting) per cent, more ; for prisoners, sweeping 6, and various free from the disease ? other for or a is very dusty, occupations 8, total of SO is answered, as it is per cent, of all attacks. nearly This objection easily It is not dust s& The forms ot based on a misconception. per non-dusty show employment causes the disease, but plus infection. Given seven cases, or one that including prisoner attacked dust in some favour its while sick in for the infection, way about a month acts as a hospital pre- or How it whether one cn-owth spread. and under-trial prisoner on no viously work, cause irritation of the mucous 9 eases, or a total ot about 20 predisposing by per cent, of the of the passages, and so whole number attacked. After membrane respiratory reviewing all the individual more vulnerable to the these different conditions, it is rendering impossible to the bacterium, or because it is a suit- pome to any other conclusion invasion?of than that the for its growth isa question uresence of dust is an able nidus saprophytic important factor in the causation of of comparative unimportance. Captain Rogers cerebrospinal in this Cloths are worn over the meningitis sucmests the former. and nostrils in the rice-cleaning and can Claim no mouth "|a'l originality for tl.ese views. but it cannot be said to Thev were first formulated orain-sifting sheds, by W. J. the disease 1901. It is Buchanan and O. K. Major have reduced during Captain Stevens, in to how or when the disease was their reports on other impossible say epidemics, but it is a The first case in all these out- striking coincidence that an introduced. entirely indepen- had been in iail at least 3G days before dent examination of the cases breaks which have the disease. During November or occurred since issued their developing they reports corro- I made a post-mortem on the borates their findings so December^ 901 closely, and is a woman in who was additional of good body of an old Bhagalpur, proof etiological importance of of the result of foul 1 the of dust in the said to have died play. presence outbreaks of cerebro- of fever in this found the typical post-mortem appearances sninal jail. This is I lav stress on cerebrospinal meningitis. _ interesting particular this, as disease occurs in the Captain as that the Rogers; iu a 011 showing not? Captain Stevens' it had not been for the traverses his district. If entirely report conclusions. To his that foul was quote fortuitous circumstance play the would never have OXV" Admitting that we know suspected, post-mortem very little of this fact would not been made, and this interesting onanism outside the body, still such facts as we been discovered. I" 1894 there is a record are with all have acquainted point to dust town. Ordinari- strongly a similar case in Bhagalpur beincr the most unlikely of medium by which such cases are far too ill to seek cerebro-spinal fever could be ly speaking, communicated to in charitable dispensaries ; and even men and necessitate treatment great caution m now and it is accepting a case is admitted then, quite this medium as a one if probable it is and The evidence from actual conceivable that wrongly diagnosed and continued examina- can never be checked by post-mortem observation in this jail, on the contrary points There is no record of any admission in to dust not as the most tion. unlikely, but as the here. From the nature of median by winch the Sadar dispensary only probable is not but I think is The cerebro-spinal the disease it only possible, fever communicated. artificial conditions 348 THE INDIAN MEDICAL GAZETTE. [Sept. 190:

that it be a The were in medical probable may widely prevalent in followingO officers chargeO district, and yet never be recognised, deaths, during the period under report:? from it going to swell the deaths from fevers, Major W. J. Buchanan, m.b., d.p.h.,?August which bulk so largely in the mortality returns. 1900 to June 1901. The following theory will, I think, afford as Captain C. R. Stevens, m.d., f.r.c.s., ? adequate an explanation of the presence of the July to September 1901. disease in this jail as the state of our knowledge Captain E. A.R. Newman, m.d., i.m.s.,?October at present justifies. The specific micro-organism 1901 to date. was at some time introduced, and finding a suitable nidus in the dust or soil of the jail, has continued to grow and thrive, at times in- creasing in virulence in its saprophytic stage of existence under conditions that are not under- stood, until it manifests itself in an isolated case or an outbreak, which subsides again, especially when the soil is saturated and the dust laid. The process then again going on as before. As the disease is known in the district, it is possible that re-infection may at any time take place. This theory is in accordance with the bacteriological experience of Germano and Kamen above quoted, and with the experience of the practical conditions of life in the jail. Measures for prevention.?Finally, I suggest the following practical measures for its preven- tion :? (1) Provision of better sheds for rice and grain-cleaning, etc., with pucca, smooth walls, and rounded off angles to ensure the possibility of removal of all dust. (2) Provision of better sheds with thorough ventilation for carpenters, smiths, etc., and sub- stitution of pucca roofs for the present tiled ones in the old sleeping wards. (3) Prevention of overcrowding. (4?) Eviction of all cattle from the inside of the jail. (5) Thorough drying of all grain in the sun for prisoners' use before stocking in the godown or issuing for use. (6) Regular watering of the jail inside. A few water-carts should be sufficient for the purpose. Jail cattle and prisoner labour will supply the power. (7) Wearing of cloths over the mouth and nostrils in all dusty forms of labour. (S) Disinfection of the wards or workshops, as far as practicable, with strong solution of perchloride of mercuiy where patients attacked have been sleeping or working. Precautions 3, 5 and 8 are already in force; 6 and 7 are carried out to some extent, but the want of a cart prevents the full advantages of watering, and it is difficult to ensure cloths worn in all cases in the "anorq in being except ? ^ ? ? . 1 ? the grain-cleaning sheds, where it is insisted on. 1 and 2 necessitate some considerable outlay, but are, I think, very necessary. Number 4 would involve small expense, and is an urgently-required reform, especially now when the jail population has so largely in- creased.