climb about it. Then is the time when clothes and other infected articles are lent to neighbours for safe keeping till the patient returns, and when similar leakage of infection occurs. Secondary cases frequently originate at such a time.

CHAPTER IV

ACTUAL DETAILS OF ADMINISTRATION-continued.

ONE of the principal points to which your inquiries will be directed is the date when the rash proper first appeared. It is material to get this fixed as accurately as possible. It is easy then to calculate that infection must have taken place almost exactly a fortnight before, and, with the date of the appearance of the rash as a guide, it is often possible to get patients to recall how they spent the day when infection must have taken place. Valuable information may be thus elicited.

But often it is difficult to get out the facts; for they are apt to be wilfully concealed, Sometimes patients themselves are hidden; I knew this to have happened for certain in one case. A child had had a mild attack, and had got over it comfortably. Nothing was said about it. But smallpox is

obstinate in asserting itself; another case occurred, and a vigorous search was made for the cause; but for a long time, unsuccessfully. At first a smallpox hospital was credited with spreading infection, but as it turned out, mistakenly. By a piece of masterly investigation which occupied several days, it was ascertained that a child was unaccounted for, and was in fact concealed. Eventually the child was disclosed, and by the distribution of some recent scars, and by the actual presence of seeds on the soles of the feet, was diagnosed to have had a recent attack of smallpox.

Sometimes it happens that perfectly bonâ fide answers are given to inquiries, but that a previous case has been unsuspected by the friends themselves. So-and-so has had a "cold." Some one else, some friend perhaps, was away from school or from work for two days. Such people should always be examined. No harm is done, if it was only a "cold" that was the matter; but in many a case it has turned out that a few recent scars on face and neck and forearms, and the dried-up seeds still present and visible beneath the hard skins of the palms and soles, have shown that the "cold" was really mild smallpox.

An exhaustive list of all contacts is required; and here it is convenient to say that a "contact" is, as the name implies, an individual who has been in contact with an undoubted case of smallpox. A

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suspect" is a person who may have had nothing to do with smallpox, but from vague symptoms is suspected of having the disease, and the diagnosis is not yet settled; in an epidemic such suspects are often sent in large numbers to receiving stations and observation shelters. All the close contacts should be seen and cross-questioned, and as many as possible of those others who have been in less close contact. We shall see that the key to suppressing an outbreak is the successful handling of the contacts.

In making inquiries much depends on the circumstances of the individual case. In our example on page 19 the history was simple. The patient could be proved to have just come from abroad. On the day of infection, he was in Tangier, where smallpox is common. In all probability he had contracted it on the floor of a filthy house, where he was obliged to lodge. But sometimes it turns out that a smallpox patient has been home three weeks or more, or, instead of being an isolated

individual, has been one of a crew, or of some other party. Or perhaps it comes out that the patient has not been away at all for some time and the infection lies somewhere near home. A more thorough cross-examination and a closer examination of the contacts, is then necessary. It may then turn out that the patient whose notification you have just received, is the second, third, fourth, or even fifth generation of unrecognised smallpox in your district. In such an event you will probably have a serious outbreak to cope with.

Schools and laundries should be included in the inquiry. Special attention should be paid to the patient's occupation and workplace. Here is one case in point from the 1904 report of Dr. (now Sir George) Newman, when he was Medical Officer of Health of Finsbury. He writes: "On visiting one of these printing works in Goswell Road, we learned that S.N.P. had worked there about a fortnight before, but that all the employees were well and that there had been no illnesses. On pursuing the matter further, however, and pressing the point, six men out of some twenty employed were brought to me. After examination I found that the first was suffering from toothache and neuralgia, the second and