avail for a visitor to say, "Oh, I am not afraid of infection." If he contracts smallpox and proper precautions have not been taken, it is on the medical officer that the blame will fall, and it is for him to take appropriate measures.

CHAPTER IX

AN EXAMPLE OF A COMPLICATED OUTBREAK

AND HOW IT WAS HANDLED

WE pass now to consider the handling of an outbreak of a complicated nature. For the following account I am indebted to Dr. D. L. Thomas, the Medical Officer of Health of Stepney. See his Annual Report of the year 1911, p. 13. The problem with which he was confronted was that presented by the occurrence of three cases of smallpox in a ward of a Poor Law Infirmary. Inquiry showed very soon that the mischief was more extensive than had at first sight appeared, and that there was a most serious centre of infection. The events are quoted in some detail to show by what methods such an outbreak may be successfully handled. For the sake of convenience the story is here given, not

as it at first sight appeared, but as it was finally unravelled.

A. L., a girl of twelve, living at home, fell ill on January 28th, 1911, and sought advice at a Hospital Out-patient Department. She then had no rash. She went again to the Out-patient Department on February 4th and 5th, 1911, that is, eight days later. Chickenpox was diagnosed, and the patient was sent home. From home she was removed to the Poor Law Infirmary on the same day, being admitted to one of the women's wards containing sixty women and children. There she remained in the open ward till February 20th, that is, fifteen days later. By that time two of the infirmary patients developed the symptoms of an acute fever. They were examined and certified to have smallpox. Attention was thus called to the patient who had been believed to have chickenpox. She was now diagnosed to have smallpox. All three were removed to the Smallpox Hospital. That was on the night of February 20-21st.

At this point the Medical Officer of Health came on the scene, having had notified to him the certificates of these three patients. On the next day, viz. February 21st, two other patients

from the same ward were certified to be suffering from smallpox; also an Infirmary scrubber living outside in her own home; also S. L., aged eleven, a sister of A. L. the original case.

On the next day, that is February 22nd, L. L., another sister of A. L., aged fifteen, was certified, and R. L., aged eight, another sister; R. L., the last-named, was found to have the smallpox rash in a late stage. She had attended hospital as an out-patient and had been to school when the rash was out. The friends of the patient, A. L., had been visiting her daily during her fifteen days' stay in the Infirmary. On this same day, February 22nd, one more patient (fatal case) from the same Infirmary ward was certified; and also a nurse who had been on duty in the ward.

On February 23rd there were certified with smallpox ten more patients (one fatal case) and one nurse; and also L. L., a brother of the original patient, A. L.

On February 24th were certified two more patients (one fatal case) and one nurse (fatal case).

On February 25th were certified five patients from the Infirmary (one fatal case), and one Infirmary visitor who was a friend of a patient.

On February 26th was certified one patient who had been discharged from the Infirmary.

On February 27th and 28th two patients on each day were certified (two fatal cases).

Up to March 2nd there were thirty-seven cases with eight deaths. About seventy cases in all occurred in this outbreak.

This brief narrative shows what a serious hold this focus of infection had obtained. Incidentally also, it is a forcible illustration of the importance of the correct diagnosis of smallpox. Its special bearing in this place, however, is to illustrate the measures which need to be taken for the supervision of contacts. We will, therefore, consider what various groups of contacts there were and how they were dealt with.

It will have been noted that the period of time, during which infection was operating unsuspected, was from January 30th to February 20th.

The principal groups of contacts were :— 1. Other inmates of the patient's home. 2. Hospital out-patients, and staff (where the patient first attended).

3. Infirmary patients (where the patient was warded).