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BY    THE   SAME   AUTHOR 

HOW  TO  DIAGNOSE  SMALLPOX 

With  II  Illustrations.    Demy  8vo,  3s.  6d.  net. 


SMITH,  ELDER  &  CO.,  15,  Waterloo  Place,  London,  S.W. 


«  The  diagnosis  of  this  disease  is  one  of  the  most  important  and  re- 
sponsible duties  which  devolve  upon  the  medical  officer  of  health ;  upon 
the  accuracy  with  which  the  question  is  determined  whether  a  particular 
person  is  or  is  not  suffering  from  smallpox  may  depend  the  existence  of  a 
widespread  prevalence  of  the  disease,  involving  loss  of  life  and  a  great 
expense  to  the  community. 

"  It  is  therefore  with  much  pleasure  that  we  welcome  the  publication 
entitled  *How  to  Diagnose  Smallpox,'  from  the  pen  of  Dr.  W.  McG. 
Wanklyn,  whose  experience  of  this  disease  is  a  very  exceptional  one." 

— Public  Health. 

"This  is  a  book  which  well  fulfils  its  author's  aim.  Delay  in  the 
recognition  of  smallpox  is  an  important  factor  in  its  spread,  and  this  book 
will  be  of  great  assistance  in  its  earlier  recognition.  The  principle  diagnostic 
points  are  well  set  out,  the  whole  book  is  obviously  based  on  an  extremely 
wide  experience  of  smallpox  and  all  the  ills  that  have  been  mistaken  for  it, 
from  scabies  to  appendicitis.  ...  It  is  written  in  a  clear,  pleasant  style, 
and  robs  a  thorny  subject  of  practically  all  its  terrors.  Because  of  its  very 
practical  manner,  and  of  the  experience  which  underlies  every  page,  we 
cordially  recommend  this  book  to  all  who  feel  at  any  time  assistance  in 
making  the  serious  diagnosis  for  or  against  smallpox." 

—London  Hospital  Qazitte, 

"An  excellent  clinical  lecture.  In  fact  Chapters  IV,  V  and  VI  are 
written  in  the  question  and  answer  form,  so  reminiscent  of  Byrom 
Bram well's  duckpond.  ...  It  should  be  perused  by  every  practitioner." 

— Medical  Officer. 

"  Really  practical  books  written  practically  by  men  of  experience  who 
know  exactly  the  points  to  lay  stress  upon  are,  unfortunately,  rare.  This, 
however,  is  one  of  them.  Short,  extending  only  to  just  over  100  pages,  it 
is  practical  from  cover  to  cover,  and  each  one  of  the  ten  chapters  contains 
a  number  of  hints  which,  if  understood  and  taken,  will  assist  any  one  who 
comes  in  contact  with  a  case  of  smallpox  in  carrying  out  an  examination 
and  arriving  at  a  diagnosis.  This  book  is  one  to  be  recommended.  It  is 
small,  simply  and  pleasantly  written,  and  cheap." — Sanitary  Record, 


How  to  Diagnose  Smallpox — contd, 

"  The  writer  is  well  qualified  for  his  task,  as  his  experience  extends  over 
twenty  years  and  includes  the  London  epidemic  of  1901-2,  in  which  he  had 
to  revise  the  diagnosis  of  some  10,000  cases  ...  we  can  heartily  recom- 
mend the  book.  Dr.  Wanklyn  possess  the  gift  of  exposition,  and  writes 
with  the  authority  .  .  .  that  his  long  experience  justifies." 

— British  Journal  of  Children's  Diseases. 

"  Dr.  Wanklyn's  book  has  been  published  at  a  very  opportune  moment. 
The  author  has  had  a  very  large  experience  in  the  diagnosis  of  this  disease, 
and  is  well  able  to  lay  down  golden  rules  for  the  guidance  of  the  general 
medical  practitioner  and  the  post-graduate  student.  .  .  .  Dr.  Wanklyn,  by 
his  original  and  chatty  style,  brings  out  every  point  of  importance  with 
great  clearness  .  .  .  the  book,  from  its  eminently  practical  character, 
should  certainly  be  read  by  all  those  who  have  to  deal  with  smallpox  and 
allied  diseases." — Universal  Medical  Record. 

"  The  Author  sets  out  to  prove  the  contention  that  smallpox  is, 
perhaps,  of  all  diseases  that  in  which  a  certain  diagnosis  can  be  arrived 
at  in  almost  every  case,  and  is  sufi&oiently  lucid  and  emphatic  to  succefed 
in  giving  the  reader  greater  confidence  in  his  own  competency  to  deal 
with  possible  cases.  The  book,  which  is  the  outcome  of  twenty  years' 
experience  of  smallpox,  is  well  arranged  and  illustrated."— G'i^^/'s  Hospital 
Gazette. 

"  Readers  will  find  the  style  clear  and  easy,  and  the  subject  is  dealt 
with  in  a  practical  manner.  The  traps  and  difificulties  which  are  likely 
to  be  encountered  in  the  diagnosis  of  the  disease  are  pointed  out,  and 
directions  for  avoiding  them  are  set  forth.  .  .  .  The  original  manner  in 
which  the  subject  has  been  approached  has  been  much  appreciated  by  a 
reviewer  inured  to  the  more  conventional  method  of  yfriting."— Middlesex 
Hospital  Journal. 

"  An  important  practical  contribution  to  the  clinical  study  of  smallpox. 
.  .  .  After  carefully  reading  the  volume  we  can  say  without  hesitation  that 
the  author  has  been  singularly  successful  in  carrying  out  his  aim.  .  .  . 
Though  the  volume  is  primarily  intended  for  general  practitioners  and 
post-graduate  students,  it  ought  to  appeal  to  a  wide  circle  of  readers.  It 
is  very  well  written,  and  a  valuable  feature  is  the  inclusion  of  numerous 
illustrative  clinical  histories.  ...  We  have  pleasure  in  bringing  the 
volume  before  the  notice  of  our  readers,  and  we  advise  each  one  to  secure 
a  copy  and  carefully  study  its  pages."— T/je  Prescriber. 


THE   ADMINISTRATIVE 
CONTROL    OF   SMALLPOX 


BY  THE  SAME  AUTHOR 


HOW  TO    DIAGNOSE    SMALLPOX. 

With  1 1  Illustrations.    8vo,  p.  6d,  net. 

SMITH,   ELDER   &   CO. 

LONDON  PUBLIC  HEALTH 
ADMINISTRATION.  A  Summary 
showing  the  principal  authorities,  with 
their  origin,  services  and  powers.  With 
24  pages  of  writing  paper  for  Notes. 
Fcp.  8vo,  2J.  6d.  net. 

LONGMANS,    GREEN,   &   CO. 


THE    ADMINISTRATIVE 
CONTROL  OF  SMALLPOX 

HOW    TO    PREVENT    OR    STOP    JN    OUTBREAK 


BY 

W.  McC.  WANKLYN,  B.A.  Cantab. 

M.R.C.S.,  L.R.C.P.,  D.P.H. 

FELLOW   OF  THE    ROYAL    SOCIETY    OF    MEDICINE,    FELLOW    OF    THE    SOCIETY    OF    MEDICAL 

OFFICERS  OF  HEALTH,   AND   FORMERLY  REFEREE  IN  THE  DIAGNOSIS  OF  SMALLPOX 

AND   MEDICAL  SUPERINTENDENT   OF  THE  RIVER  AMBULANCE  SERVICE 

(smallpox)   OF  THE    METROPOLITAN  ASYLUMS  BOARD 


UNIV.  or' 


LONGMANS,   GREEN,   AND   CO 

39  PATERNOSTER   ROW,    LONDON 
NEW  YORK,   BOMBAY,   AND  CALCUTTA 

I913 

All  rights  reserved 


S(£ 


•"'J'InDLOQ  « 
I  inn*R*i* 


f 


Health 


PKEFAOE 

This  is  a  companion  volume  to  "  How  to 
Diagnose  Smallpox,"  and  has  the  same  object, 
namely,  to  contribute  to  the  prevention  of  that 
disease.  It  was  drafted  primarily  for  post- 
graduate students  reading  for  the  Diploma  of 
Public  Health  ;  but  it  will  be  found  useful  by  all 
who  have  to  deal  with  outbreaks  of  smallpox. 
My  cordial  thanks  are  given  to  those  who  have 
helped  me  in  its  preparation. 

Its  subject-matter  is  practical,  is  presented  in 
a  conversational  manner,  and  comprises  the  prin- 
cipal administrative  details  which  require  to  be 
borne  in  mind  and  put  into  practice  in  order  to 
cut  short  an  outbreak.  There  are  various  methods 
of  controlUng  smallpox  which  have  come  more 
into  use  during  the  last  thirty  years  or  so.  They 
include,  for  instance,  exact  diagnosis  of  the  disease, 


300704 


vi  PREFACE 

removal  of  cases  to  hospital,  regular  disinfection, 
and  close  observation  of  contacts  ;  and  the  import- 
ance of  these  methods  increases  in  proportion  as 
vaccination  falls  into  disuse. 

If,  as  I  think,  the  equipment  of  every  medical 
graduate  should  include  a  practical  knowledge  of 
the  diagnosis  of  individual  cases,  it  is  equally  im- 
portant for  every  one  who  intends  to  engage  in 
Public  Health  work  to  have  a  thorough  know- 
ledge of  how  to  handle  and  stop  an  outbreak. 
Those  who  aspire  to  be  Medical  Officers  of  Health 
should  reaUse  the  responsibility  which  an  out- 
break may  bring  upon  them.  Such  a  crisis  means 
hurry,  rush,  and  even  panic  ;  and  it  is  to  them  that 
every  one  will  appeal  to  secure  their  health  and 
business.      They  will  do  well  to  be  prepared. 

When  smallpox  is  not  prevalent,  nothing 
seems  so  remote ;  to  all  outward  appearance  a 
serious  outbreak  is  most  unlikely.  In  reality,  the 
very  reverse  may  be  the  case.  Communities  which 
are  collected  into  close  town  populations,  unpro- 
tected by  vaccination,  and  exposed  to  a  dropping 
fire  of  infection  from  all  parts  of  the  world,  are 
certain,  sooner  or  later,  to  suffer  from  a  serious 


PREFACE  vii 

invasion  and  spread  of  smallpox.  Medical  Officers 
of  Health  cannot  stave  it  off  indefinitely  ;  they  can 
only  avert  it  as  long  as  possible ;  and,  when  it 
comes,  do  their  best  to  cut  it  short  by  means  of 
effective  administration. 

London, 

Septemher,  1913. 


( 


CONTENTS 

CHAPTEE  PAGE 

I.     General  Eeview 1 

II.     Some    Points    in    the    Natural    History    op 

Smallpox 11 

III.  Details  op  Administration        .        .        .        .16 

IV.  Details  op  Administration  (continued)      .        .  25 
V.     The  Intelligence  Department         ...  32 

VI.     Other  Practical  Details 40 

VII.    The  Observation  op  Contacts  ....  47 

VIII.    Vaccination 60 

IX.    An    Example    op    a    Complicated     Outbreak, 

AND   HOW   it   was    HANDLED         .            .            .           .  70 

X.    Kecapitulation    .                79 

Index 85 


THE    ADMINISTRATIVE 
CONTROL    OF   SMALLPOX 

CHAPTER  I 

GENERAL   REVIEW 

Epidemics  of  infectious  disease  are  compared 
to  conflagrations.  The  comparison  is  just. 
Especially  striking  are  epidemics  among  island 
populations.  There  are,  for  instance,  the  well- 
known  outbreaks  of  measles  in  the  South  Seas. 
Prior  to  the  year  1875  the  Fiji  Islands  had 
been  free  from  that  disease.  But  the  population 
was  highly  susceptible.  In  December,  1874, 
the  native  chief  Thacombau  had  measles  while 
on  a  visit  to  Sydney.  On  the  voyage  home  in 
January,  1875,  one  of  his  sons  and  a  native  atten- 
dant fell  ill  of  the  same  disease.  They  landed. 
Another  of  the   chiefs    sons    sickened.     Visitors 

B 


2      '*' GENERAL   REVIEW  [ch.  i. 

thronged  the  houses  where  the  sick  people  lay. 
Infection  was  spread  broadcast.  There  was  a 
furious  outbreak.  Whole  villages  were  attacked, 
their  inhabitants  being  nearly  all  smitten  at  once. 
Food  could  hardly  be  obtained,  or,  if  obtained, 
could  not  be  cooked,  because  no  one  was  well 
enough  to  cook  it.  In  the  midst  of  plenty,  people 
died  of  exhaustion  and  starvation.  An  end  was  put 
to  the  epidemic  only  when  the  infectible  material 
was  exhausted,  that  is  when  nearly  every  person 
had  been  attacked.  By  the  end  of  May,  1875,  there 
had  died  about  one-fifth  of  the  population,  that 
was  about  20,000  persons. 

Recently  there  has  been  a  similar  tragedy. 
Rotume,  another  South  Sea  Island,  was  simi- 
larly swept  in  1911.  The  transactions  of  the 
Epidemiological  Section  of  the  Royal  Society 
of  Medicine  for  1913  inform  us  that  the 
Resident  Commissioner,  a  medical  practitioner, 
was  obliged  to  go  on  leave.  In  his  absence 
a  case  of  measles  was  landed.  Again  infection 
spread  with  great  rapidity  among  the  population, 
which  here  numbered  about  2000  persons.  Of 
this  number  about  350  persons  died. 

Epidemics  such  as  these  are  paralleled  in  our 


CH.  I.]  GENERAL  REVIEW  3 

own  islands  by  the  Black  Death  of  1349,  which  is 
believed  to  have  destroyed  one  person  in  every 
three.  In  each  of  these  cases  and  in  many  others, 
the  conditions  were,  that  into  an  island  population 
of  a  high  degree  of  susceptibility  there  was  im- 
ported a  highly  infectious  disease  ;  and  the  result 
was  like  that  of  a  spark  falling  in  long  dry  grass. 
A  furious  conflagration  raged,  till  all  that  was 
combustible  was  burnt  up. 

What  is  the  state  of  the  case,  in  regard  to 
smallpox,  in  our  own  islands  and  in  many  other 
communities  ?  It  is  important  to  get  a  just  view 
of  the  position;  for  upon  it  is  based  the  whole 
rationale  of  keeping  smallpox  out  as  long  as 
possible,  and  of  stopping  its  spread  when  it  has 
obtained  an  entry. 

The  position  is  something  like  this.  We  may 
imagine  a  huge  stack  of  fuel  composed  of  small 
bundles  of  brushwood  or  firewood.  Some  of  these 
bundles  are  as  dry  as  tinder  and  are  very  inflam- 
mable. Others  are  very  damp  and  in  no  danger 
from  fire ;  others  again  are  in  a  condition  between 
these  two  extremes.  We  may  further  suppose 
that  the  various  bundles  are  not  regularly  arranged 
as  regards  their  degree  of  dryness ;   in  one  part 


4  GENERAL  REVIEW  [ch.  i. 

dry  bundles  are  packed  together,  in  another  wet 
bundles  are  packed  together,  in  other  places  they 
are  about  evenly  intermixed.  There  is  a  third 
point  to  be  noted  about  this  imaginary  heap.  In 
some  places  the  bundles  are  packed  very  close ;  in 
other  parts  they  lie  wide  apart,  with  ample  clear 
space  between  them. 

We  must  further  imagine  that  on  to  this  stack 
of  fuel  there  are  continually  falling,  at  irregular 
intervals,  but  constantly  falling  and  certain  to  fall, 
lighted  brands  or  torches.  In  such  a  condition  of 
things  it  is  clear  that  fires  are  inevitable.  All  that 
is  doubtful  is  the  extent  to  which  they  will  occur. 
This  will  depend  on  a  number  of  factors ;  for 
instance,  on  the  number  and  fierceness  of  the 
burning  brands ;  whether  they  fall  in  places  where 
the  fuel  is  thick,  or  where  it  is  scanty ;  and  whether 
they  fall  on  wet  or  on  dry  material.  Much  also 
will  depend  on  whether  the  brands  are  noticed  at 
once  and  picked  out,  or  whether  they  are  over- 
looked till  a  patch  is  well  alight.  But  it  is  clear 
that,  sooner  or  later,  there  is  every  probability,  if 
not  the  certainty,  of  a  very  fierce  blaze. 

The  foregoing  comparison,  with  one  important 
reservation,  fairly  represents  the  state  of  things  in 


CH.  I.]  GENERAL  REVIEW  5 

our  own  and  other  countries  during  inter-epidemic 
periods.  At  such  times  we  are  free  from  the 
disease.  But  cases  of  smallpox  are  often  imported 
from  abroad  where  it  is  endemic ;  they  come 
to  this  country  from  Europe,  Egypt,  Africa, 
India,  and  many  other  parts,  even  from  China. 
They  arrive,  for  instance,  at  Hull,  Bristol, 
Liverpool,  London.  Port  Sanitary  Authorities 
are  constantly  stopping  them;  but  they  cannot 
keep  them  all  out ;  for  cases  may  come  in  at  ports 
where  there  is  no  regular  medical  inspection. 

There  is  also  a  class  of  case  which  is  alluded 
to  in  the  reservation  just  mentioned.  Infection 
may  be  imported  in  a  latent  form.  No  mere 
medical  inspection  can  keep  out  a  patient  who  is 
in  the  incubation  period  of  his  disease.  He  is 
then,  to  all  intents  and  purposes,  perfectly  well. 
He  settles  himself  comfortably  at  home,  and  then 
breaks  out  with  smallpox.  It  is  the  persons  who 
arrive  during  their  twelve  days  of  incubation  and 
settle  down  unobserved,  who  are  apt  to  do  the 
most  mischief.  Infection  may  also  be  imported 
in  clothes,  or  in  rags  and  other  raw  material  for 
manufacture.  In  these  ways  smallpox  can  always 
succeed  in  obtaining  an  entrance. 


6  GENERAL  REVIEW  [ch.  i. 

The  following  is  a  striking  example  of  how  on 
one  occasion  smallpox  was  introduced  into  this 
country.  It  was  related  on  July  13th,  1900,  to 
members  of  the  Epidemiological  Society  by  Mr. 
T.  W.  Russell,  M.P.,  then  ParUamentary  Secretary 
of  the  Local  Government  Board.  He  said:  ''1 
had  a  most  extraordinary  case  before  me  yesterday, 
in  which  I  am  sure  every  one  here  will  be  in- 
terested. A  deputation  came  to  see  me  from 
Lancashire,  representing  several  large  towns,  in 
connection  with  the  spread  of  smallpox  of  a  special 
character.  There  had  been  something  Uke  100 
cases  in  these  Lancashire  towns  within  the  last 
few  months;  and  the  story  as  detailed  to  me 
yesterday,  1  confess,  interested  me,  and  will 
probably  interest  the  members  of  this  Society.  It 
appears  that  a  man  left  Moscow,  in  Russia,  intend- 
ing to  travel  to  Staleybridge,  in  Lancashire.  He 
was  ill  when  he  left ;  he  arrived  at  Flushing ;  and 
when  the  vessel  was  boarded  by  the  medical 
officer,  the  captain  reported  that  there  was  no 
sickness.  The  man  came  on  to  Queenborough, 
landed  there,  and  it  was  noticed  that  he  had  to 
be  carried  through  the  baggage-room  on  a  chair ; 
but  he  accounted  for   that  by  declaring  that   he 


CH.  I.]  GENERAL  REVIEW  7 

was  suffering  from  rheumatism,  and  could  not 
walk.  He  was  put  into  the  train,  and  travelled 
to  Manchester,  and  from  Manchester  to  Staley- 
bridge,  where  he  died  the  day  after  his  arrival  from 
virulent  smallpox.  The  interesting  point  is,  that 
almost  every  one  who  travelled  with  him  in  the 
compartment  from  Queenborough  to  Manchester 
took  smallpox ;  the  ticket  collector  at  Manchester 
took  smallpox ;  those  who  travelled  with  him 
from  Manchester  to  Staleybridge  in  another  train 
took  smallpox ;  and  something  like  100  people, 
I  think,  had  smallpox  spread  by  means  of  this 
simple  case.  The  real  question  is:  could  that 
have  been  prevented  ?  Well,  that  is  exactly  the 
crux  of  the  situation." 

So  much  for  a  general  consideration  of  the 
manner  in  which  smallpox  may  be  introduced. 
Next  comes  the  question  of  the  general  policy  of 
meeting  it.  That  need  not  detain  us  long,  for  the 
decision  does  not  rest  with  us.  Pursuing  the  same 
line  of  thought  as  before,  it  may  be  said  that  there 
are  three  possible  policies  for  protecting  a  wooden 
village  from  fire.  The  first  is  to  secure  that  all 
the  houses  are  built  of  wood  which  is  non-inflam- 
mable.    The  second  is  to  allow  perfect  liberty  of 


8  GENERAL  REVIEW  [ch.  i. 

building  material,  and  to  maintain  a  fire-preven- 
tion organisation  warranted  to  limit  and  extinguish 
any  outbreak  that  may  occur.  The  third  is  a 
combination  and  modification  of  the  first  two. 
In  regard  to  smallpox,  Germany  furnishes  an 
example  of  the  first  policy;  our  own  country  of 
the  third.  Parliament  sanctioned  the  relaxation 
of  routine  vaccination  in  1898,  and  loosened  it  still 
more  in  1907.  At  the  present  time  very  large 
numbers  of  the  population  are  susceptible  to  small- 
pox, and  these  numbers  are  increasing.  As  the 
susceptible  material  increases,  so  does  the  risk,  and 
so  does  the  responsibility  of  those  who  are  engaged 
in  keeping  smallpox  out. 

Some  outbreaks  seem  to  have  required  a  com- 
bination of  circumstances  to  bring  them  about. 
For  instance,  the  1871  and  1902  epidemics  in  this 
country  were  preceded  by  an  unusual  prevalence 
of  smallpox  among  our  neighbours  in  France;  it 
is  obvious  that  must  increase  the  chances  of  its 
being  brought  to  us.  If  smallpox  in  that  country 
is  not  now  as  prevalent  as  it  was  in  the  years 
named,  we  have  to  remember  on  the  other  hand 
that  the  facilities  of  modern  travel  have  brought 
various    countries,    where    smallpox    is    endemic, 


CH.  I.]  GENERAL  REVIEW  9 

much  nearer  to  our  doors  than  was  formerly  the 
case.  It  is  a  novelty  in  sanitary  history  for  a 
patient,  whose  attack  of  smallpox  showed  itself  on 
his  arrival  in  London,  to  have  received  his  infec- 
tion in  Manchuria.  Yet  that  has  happened. 
Smallpox  has  many  more  resources  to  draw  upon 
than  formerly;  and  when  the  disease  breaks  out 
among  us  improved  internal  locomotion  offers 
greater  opportunities  for  its  spread. 

A  review  of  the  past  prevalence  of  smallpox 
in  this  country  shows  that  it  has  come  in  cycles. 
It  was  very  prevalent  in  1871,  in  1877,  in  1881,  in 
1884,  in  1893,  and  in  1902.  Nine  years  of  com- 
parative quiescence  elapsed  between  the  maxima 
of  1884  and  of  1893,  and  nine  years  between  the 
maxima  of  1893  and  of  1902.  A  further  nine 
years  on  brings  us  to  1911,  which  has  happily 
passed  without  an  epidemic.  It  is  now  eleven 
years  since  the  last  maximum  and,  in  the  autumn 
of  1913,  we  are  still  free  from  smallpox.  How 
long  this  freedoni  will  continue  cannot  be  said.  It 
is  impossible  to  prophesy.  Only  two  things  are 
certain.  Susceptible  material  is  increasing,  and 
infection  is  continuing  to  come  in.  Though  the 
infection  of  case  after  case  be  extinguished,  sooner 


10  GENERAL  REVIEW  [ch.  i. 

or  later  a  spark  will  come  in  contact  with  a 
collection  of  highly  combustible  material ;  in  that 
event  the  blaze  will  be  sudden,  and  it  will  be 
fierce. 

Whatever  the  future  has  in  store,  our  part  is 
plain,  namely,  to  be  forearmed.  It  is  to  assist  in 
that  object  that  these  pages  have  been  written. 


CH.  II.]        ADMINISTRATIVE  IMPORTANCE  11 


CHAPTER   II 

SOME   POINTS   IN   THE   NATURAL   HISTORY   OF 
SMALLPOX 

In  making  our  plans  against  smallpox,  we  shall  do 
well  to  begin  by  dwelling  on  one  or  two  points  in 
its  natural  history  which  bear  especially  on  its 
prevention.  First  as  to  the  incubation  period. 
This  is  singularly  constant.  Twelve  days  is  the 
rule.  Variations  occur ;  but  in  the  majority  of 
cases  signs  of  illness  show  themselves  with  re- 
markable conformity  to  the  expected  time ;  small- 
pox has  a  more  regular  incubation  period  than  any 
other  infectious  disease.  It  is  convenient  to  keep 
a  type  of  the  chronology  of  the  disease  in  mind 
for  reference. 


12  SOME  POINTS  OF  [ch.  ii. 

For  example : — 
Sunday,  January  1st.      Exposure  to  infection. 
Friday,  January  13th.     Onset  of  fever,  headache, 

other      pains,       malaise, 
vomiting. 
Sunday,  January  15th.   First  appearance  of  papular 

rash. 
Tuesday,  January  17th.  Rash  begins  to  be  vesicular. 
Thursday,  January  19th.  Rash  begins  to  be  pustular. 
Monday,  January  23rd.  Scabbing  stage  may  begin. 
Monday,  February  6th.  Scabbing  stage  may  end. 

These  dates  are  of  special  importance  in  admin- 
istration, and  the  earlier  ones  form  a  sequence 
which  may  be  counted  upon  with  some  confidence. 
If  a  susceptible  person  be  thoroughly  exposed  to 
infection  on  a  Sunday,  for  instance,  the  following 
Friday  week  will  not  pass  without  signs  of  the 
beginning  of  his  attack. 

Next,  as  to  the  infective  capacity  of  smallpox. 
We  all  know  how  highly  infectious  it  may  be. 
But  the  striking  power  of  different  cases  and  of 
different  groups  of  cases  varies  in  a  remarkable 
manner.  At  a  time  when  London  was  completely 
free  from  smallpox — it  was  in  the  year  1897  or 
1898—1  recall,  for  instance,  a  case  of  a  woman 


CH.  It.]       ADMINISTRATIVE   IMPORTANCE  13 

having  an  attack  of  smallpox  which  later  became 
almost  confluent ;  she  was  stated  to  have  sat  for 
a  long  time  in  an  out-patient  department  of  a 
hospital  awaiting  examination.  The  rash  was  then 
well  out,  and  the  patient  thoroughly  infectious ; 
there  must  have  been  many  people  in  contact  with 
her  before  her  illness  was  recognised.  As  a 
consequence,  a  small  outbreak  might  have  been 
apprehended,  and  it  would  seem  that  in  any  case 
secondary  cases  were  inevitable ;  but  no  secondary 
cases  occurred,  or  at  any  rate  came  to  knowledge, 
except  that  of  the  patient's  husband. 

On  the  other  hand,  there  are  recorded  cases 
whose  progress,  from  shop  to  shop  or  from  street  to 
street,  has  been  marked  and  traced  by  a  perfect 
trail  of  secondary  cases  to  which  they  have  given 
rise.  This  high  degree  of  infectivity  is  apt  to 
proceed  from  severe  or  haemorrhagic  cases.  Similar 
instances  of  this  kind  of  contrast  will  come  to  the 
minds  of  those  who  have  had  experience  of  smallpox. 

The  same  kind  of  phenomenon  seems  to 
hold  true  of  smallpox  in  the  bulk.  At  the  begin- 
ning of  an  outbreak,  cases  in  general  are  apt  to  be 
more  severe  and  to  have  a  higher  average  of  infec- 
tivity than  those  which  occur  during  the  decline  of 


14  SOME   POINTS   OF  [ch.  ii. 

an  epidemic ;  then  they  are  apt  to  be  both  benign 
and  only  shghtly  infectious.  It  seems  sometimes 
as  if  the  onset  and  rise  of  an  epidemic  were  de- 
pendent on  some  factor  other  than  the  mere  presence 
of  combustible  material  and  the  manner  in  which  it 
is  distributed ;  smallpox  seems  sometimes  to  become 
epidemic,  as  if  its  spread  were  almost  irresistible ; 
and  also  to  disappear  of  itself,  although  considerable 
numbers  of  susceptible  persons  still  remain.  The 
probability  is,  that,  at  the  beginning  of  some  out- 
breaks, the  virus  is  exalted  in  infectivity  and  is  of 
a  robust  type ;  and  that  later  it  grows  less  rankly 
and  luxuriantly,  so  to  speak ;  then  cases  are  apt 
to  be  benign  and  of  low  striking  power,  and  an 
outbreak  tends  to  die  out  of  itself. 

A  word  now  on  the  time  when  an  individual  case 
begins  to  be  infectious.  My  own  experience  is  that 
smallpox  is  not  infectious  before  a  rash  comes 
out.  But  this  should  be  added.  Haemorrhagic 
cases  are  often  the  most  highly  infectious  of  all, 
and  they  can  certainly  infect  before  the  true 
rash  appears.  But  I  do  not  recall  any  case  of 
smallpox  from  which  infection  spread  while  the 
skin  was  still  unblemished  in  any  way.  Neverthe- 
less in  practice,  it  is  often  difficult  to  fix  the  time 


cH.  IT.]      ADMINISTRATIVE   IMPORTANCE  15 

precisely  when  signs  of  the  disease  show  them- 
selves on  the  skin  ;  and,  if  there  is  doubt,  it  may- 
be wise  to  regard  cases  as  infectious,  for  adminis- 
trative purposes,  from  the  time  when  signs  of 
illness  first  appear. 

By  way  of  contrast  to  the  constancy  of  the 
incubation  period  which  has  been  mentioned,  is 
the  extraordinary  variability  in  the  clinical  mani- 
festations of  the  disease.  This  is  always  a  most 
important  matter  for  the  administrator  to  bear  in 
mind.  He  must  be  always  suspicious  of  stories 
of  "influenza  with  spots,"  mysterious  "blood 
poisonings,"  "  suppressed  measles,"  and  so  on, 
and  also,  of  course,  of  chickenpox  in  adults. 
The  elusive  habits  of  smallpox  cannot  be  exag- 
gerated. I  have  been  seeing  smallpox  since  the 
year  1892,  and  at  times  in  large  numbers ;  but  I 
still  find  it  surprising  when  I  see  in  what  varied 
and  extraordinary  disguises  smallpox  may  conceal 
itself.  Hardly  anything  is  more  remarkable  about 
the  disease  than  that.  Sequences  of  overlooked 
cases  such  as  those  quoted  in  Chapters  I  and  II 
of  "  How  to  Diagnose  Smallpox,"  or  those  given 
in  many  public  health  reports,  are  worth  careful 
study. 


16  ACTUAL  DETAILS  [ch.  iil 


CHAPTER  III 

ACTUAL   DETAILS    OF   ADMINISTRATION 

We  come  now  to  deal  with  an  actual  outbreak. 
A  certificate  of  a  case  of  smallpox  lies  in  front 
of  you  on  your  table.  The  question  is,  in  point 
of  fact  and  detail,  what  are  you  going  to  do  ?  If 
you  are  the  responsible  Medical  Officer  of  Health, 
that  is  the  question  that  you  must  answer.  If 
you  are  going  to  succeed,  you  have  to  be  ready 
with  the  answer,  to  act  instantly  and  to  overlook 
nothing. 

The  main  indications  are  three.  You  have  to 
ascertain  exactly  what  is  the  extent  of  the  existing 
mischief,  and  how  it  originated  ;  you  have  to  eradi- 
cate what  does  exist;  and  you  have  to  prevent 
fresh  cases,  or  render  them  harmless  as  they  occur. 
Those  are  the  three  main  principles ;  they  overlap 
and  depend  on  each  other  ;  they  cannot  be  separated 
in  practice ;  but  it  is    useful  to   consider  them 


CH.  III.]  OF  ADMINISTRATION  17 

separately   at   the   beginning,  and  also  afterwards 
when  you  are  reviewing  the  position. 

Coming  to  details,  the  first  is  that  such  a  matter 
must  take  priority  over  every  other  which  you 
may  have  in  hand.  It  requires  instant  attention. 
Promptitude  is  the  essence  of  success.  It  also 
requires  close  personal  attention.  It  is  of  little 
use  to  give  general  directions,  or  to  leave  their 
supervision  to  others.  You  require  to  have  full 
reports  and  knowledge  of  all  the  details,  and, 
according  to  the  circumstances  of  the  case,  per- 
sonally to  settle  or  be  aware  of  all  the  steps  that 
are  being  taken. 

In  the  absence  of  any  other  communication 
from  the  practitioner  who  has  certified  the  case, 
you  must  act  instantly  on  the  certificate,  and  set 
your  preventive  machinery  in  motion  at  once. 
The  patient  must  be  "  telephoned  away,"  that  is, 
arrangements  must  at  once  be  made  for  an 
ambulance  to  call  at  the  house  and  remove  the 
patient  to  hospital.  At  the  same  time  you  should 
send  an  inspector  to  the  patient's  house,  to 
represent  you  on  the  spot,  with  instructions  to 
prevent  any  person  or  article  entering  or  leaving 
the   infected   premises,  and   also   to   inquire   into 

c 


18  ACTUAL   DETAILS  [ch.  m. 

and  report  upon  the  origin  and  extent  of  the 
mischief. 

You  must  get  into  communication  with  the 
certifier  as  soon  as  possible,  and  learn  all  about  the 
case  from  him.  The  probability  is  that  he  has 
valuable  additional  information  about  which  you 
should  know.  One  important  point  that  must 
occupy  your  attention  early  is  the  verification 
of  the  diagnosis.  Until  you  can  satisfy  yourself 
that  the  case  is  not  smallpox,  your  preventive 
measures  ought  to  go  ahead  without  delay,  on 
the  strength  of  the  original  certificate.  But  it 
is  well  to  bear  in  mind  that  in  epidemic  times, 
when  the  proportion  of  correct  diagnoses  is  at 
its  maximum,  the  cases  certified  in  error  in 
London  have  been  found  to  be  10  or  12  per 
cent.,  and  in  non-epidemic  times  to  be  as  high 
as  80  per  cent.  So  that  it  is  advisable  to 
take  the  first  opportunity  of  verifying  the 
diagnosis. 

Let  us  assume  that  the  case  is  genuine 
smallpox,  and  that  the  result  of  your  inquiries 
is  to  disclose  some  such  tale  as  the  follow- 
ing. All  the  details  of  the  story  will  not 
be     obtainable     at    first,    but     for     our    present 


CH.  III.]  OF  ADMINISTRATION  19 

purpose  it  is  well  to  have  a  complete  account  to 
work  upon,  and  therefore  the  following  instance  is 
given.  For  the  details  I  am  indebted  to  Dr. 
Sidney  Davies,  the  Medical  Officer  of  Health  of 
Woolwich,  in  whose  annual  report  for  1912  an 
account  of  the  case  is  given.  It  is  an  instance  of  a 
district,  hitherto  free  from  smallpox,  being  invaded 
by  a  single  case,  and  is,  therefore,  a  simple  case  to 
consider.  Subsequently,  on  p.  71,  we  shall  con- 
sider an  outbreak  which  was  much  more  compU- 
cated.  The  facts  in  this  first  case  turned  out  to 
be  as  follow  : — 

A  man  was  shipwrecked  on  the  coast  of  Africa. 
He  spent  Christmas  Day  in  Tangier  and  slept  in 
quarters  which  were  very  dirty.  He  took  ship 
to  England,  and  arrived  at  his  home  to  all 
appearance  well.  That  was  on  a  Saturday. 
On  the  Monday  following  he  was  taken  with 
vomiting,  pains,  and  other  accompaniments  of 
the  onset  of  an  acute  fever.  He  attributed  his 
attack  to  a  return  of  a  fever  from  which  he 
had  previously  suffered  in  the  East.  He  took 
to  his  bed  on  the  Monday.  On  the  Tuesday 
an  erythematous  rash  came  out  on  his  arms. 
This     was     an     initial     rash     of    smallpox.      It 


20  ACTUAL  DETAILS  [ch.  iii. 

appears  to  have  passed  off  rapidly.  Medical  advice 
was  not  sought  at  this  stage.  The  papular 
rash  was  out  on  the  following  Thursday.  The  next 
day,  Friday,  the  patient  felt  better,  but  was  dis- 
turbed about  the  rash,  which  he  could  not  ignore. 
Accordingly  he  went  to  a  surgery,  and  took 
advice.  The  nature  of  the  disease  was  not 
recognised.  He  returned  home  that  same  Friday 
morning  and  went  to  bed.  He  did  not  get  up 
again,  and  died  on  the  Monday,  the  octave  of  the 
day  on  which  he  fell  ill,  from  confluent  smallpox. 
The  case  was  recognised  to  be  smallpox  on  the 
previous  day,  the  Sunday. 

It  is  worth  while  for  a  student  to  take  a 
case  like  this,  and,  for  the  sake  of  the  instruc- 
tion to  be  gained  from  the  exercise,  to  set 
down  in  writing  what  he  actually  would  do. 

Supposing  that  some  such  story  is  what  you 
have  received  over  the  telephone.  One  of  your 
first  steps,  if  you  have  not  already  attended  to 
it,  is  at  once  to  get  facilities  on  to  the  spot  for 
the  vaccination  of  contacts,  to  send  an  urgent 
message  to  the  Vaccination  Officer,  if  that  be 
necessary,  and  to  ask  that  the  Public  Vaccinator 
should  meet  you.     In  some  places  the  machinery 


CH.  iir.]  OF  ADMINISTRATION  21 

of  vaccination  may  be  outside  your  control,  and 
one  of  your  most  important  colleagues  may  be 
responsible  to  an  authority  entirely  different  from 
that  which  you  serve.  It  may  be  necessary  for 
you  to  communicate  with  the  lay  officer  of  the 
corresponding  Board  of  Guardians,  namely  the 
Vaccination  Officer,  who  in  turn  may  have  to 
communicate  with  the  medical  officer  concerned, 
namely  the  Public  Vaccinator,  and  this  may  give 
rise  to  delay.  It  is  well,  by  previous  arrange- 
ment and  consultation,  to  accelerate  this  process 
as  much  as  possible. 

The  time  when  vaccination  is  most  likely  to  be 
accepted,  and  the  time  when  it  is  most  likely  to 
be  beneficial  to  contacts  with  the  case,  is  the 
time  of  the  removal  of  the  patient.  Delay  in 
this  matter  is  apt  to  be  disastrous.  It  is 
true  that  vaccination,  if  efficiently  done  at  any 
time  within  the  first  three  days  of  exposure  to 
infection,  will  secure  the  vaccinated  from  attack. 
But  procrastination  is  easy,  and  is  apt  to  be  fatal. 
Contacts  may  change  their  minds,  evade  notice, 
and  escape  altogether.  In  consequence  it  may 
happen  that  a  little  focus  of  infection,  which, 
by  appropriate  measures,  could  easily  have  been 


22  ACTUAL  DETAILS  [ch.  iii. 

localised  and  rounded  in,  may  spread  without 
the  possibility  of  being  watched,  and  a  little 
outbreak  may  grow  into  a  serious  conflagration. 
To  be  able  at  once  to  render  immune  all 
the  contacts  with  any  given  case  is  often  to 
stop  the  whole  outbreak.  Therefore  get  vacci- 
nation facilities  on  to  the  ground  instantly,  if 
possible. 

The  matter  has  its  personal  aspect,  too,  from 
the  point  of  view  of  the  individual  contact.  So 
often  people  will  be  "done  to-morrow";  and  too 
late  they  find  delay  has  been  costly.  It  may  be,  of 
course,  that  contacts  may  not  take  the  disease  at 
all,  or  may  take  it  only  in  a  mild  form  ;  no  one  can 
prophesy.  But  no  one,  who  has  seen  valuable  lives 
trifled  with  and  thrown  away,  can  deal  with  a 
subject  of  this  kind  lightly.  The  delay  which  is 
pleaded  for  may  seem  to  be  a  small  thing  at  the 
time,  but  will  not  seem  so  when  a  life  has  been 
sacrificed  because  of  a  delay  of  a  few  hours. 
I  have  a  vivid  recollection  of  seeing  a  young 
fellow  with  smallpox,  who  had  been  vaccinated 
during  his  incubation  period.  The  vaccination  had 
taken  well,  but  it  had  been  done  too  late.  He  had 
haemorrhagic   smallpox.     A  few  hours'  delay  had 


CH.  III.]  OF  ADMINISTRATION  23 

cost  his  life.  Smallpox  had  got  the  necessary- 
start  ;  had  vaccination  been  performed  a  day  or  so 
earlier,  it  would  have  saved  him.  It  is  therefore 
a  valuable  practical  detail  to  have  a  standing 
arrangement  beforehand  with  the  vaccination  staff, 
so  that  when  you  call  on  them,  they  will  be  able 
to  respond  instantly. 

In  your  conversation  with  the  certifying 
practitioner,  whether  by  telephone  or  personally, 
you  will  have  obtained  as  full  details  as  possible 
about  the  history  of  the  cases.  These  will  be  most 
useful  in  assisting  you  to  trace  out  the  way  in 
which  infection  has  spread.  It  is  very  desirable 
personally  to  proceed  to  the  patient's  house  or 
other  centre  of  mischief  as  soon  as  possible.  If 
you  can  get  there  before  the  patient  is  removed, 
you  will  be  able  to  take  your  inspector's  report, 
and  to  ask  supplementary  questions.  It  is  specially 
necessary  to  have  adequate  staff  on  the  spot  when 
the  ambulance  arrives  at  the  house  and  while  the 
patient  is  being  moved.  Then  is  the  time  when 
leakage  of  infection  is  apt  to  take  place.  Children 
are  apt  to  collect  in  crowds,  and  so  are  the 
neighbours  generally.  They  will  press  close  to 
see    the    patient,   peer    into    the   ambulance   and 


M  ACTUAL  DETAILS  [ch.  iii. 

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. 


CH.  IV.]  OF  ADMINISTRATION  25 


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.  Some- 
times 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  comfort- 
ably.   Nothing  was  said  about  it.     But  smallpox  is 


26  ACTUAL  DETAILS  [ch.  iv 

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  small- 
pox 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  un- 
accounted for,  and  was  in  fact  concealed.  Eventu- 
ally 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  bona  fide 
answers  are  given  to  inquiries,  but  that  a  previous 
case  has  been  unsuspected  by  the  friends  them- 
selves. 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. 


CH.  IV.]  OF  ADMINISTRATION  27 

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 
"  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  dia- 
gnosis is  not  yet  settled ;  in  an  epidemic  such 
suspects  are  often  sent  in  large  numbers  to  re- 
ceiving 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  cir- 
cumstances 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 


28  ACTUAL  DETAILS  [ch.  iv. 

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  notifica- 
tion 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  suffer- 
ing from  toothache  and  neuralgia,  the  second  and 


CH.  IV.]  OF  ADMINISTRATION  29 

third  from  smallpox  in  an  acute  stage,  the  fourth 
was  recovering  from  smallpox,  the  fifth  was  aiFected 
with  a  minor  skin  disease  on  his  face,  and  the  sixth 
was  suffering  from  what  might  be  the  premonitory- 
symptoms  of  smallpox."  Here  was  a  serious  focus 
of  infection  which  might  easily  have  been  over- 
looked by  a  less  searching  inquiry. 

In  such  and  other  ways,  an  effort  should  be 
made  to  track  out  every  possible  ramification  of 
any  previous  and  of  any  existing  mischief. 
Appropriate  measures  can  then  be  taken  to 
check  its  spread,  and  to  keep  a  watchful  eye  on 
those  who  have  been  exposed  to  infection.  It  may 
be  that  you  will  find  reason  to  think  that  the  case 
immediately  under  notice  is  by  no  means  the  first 
of  a  series  of  cases;  if  this  be  so,  and  if  there 
be  any  evidence  pointing  to  the  infection  not  having 
been  closely  localised,  a  house-to-house  call  may 
very  usefully  be  made  in  the  suspected  neighbour- 
hood, or  throughout  the  tenements  on  the  stair- 
case or  block  of  buildings,  if  such  be  the  site  of 
the  outbreak.  In  this  way  there  may  be  found 
other  cases  with  the  rash  still  out  or  showing 
traces  of  having  had  it.  In  any  case  the  neigh- 
bours will    be  put   on   the  alert  and  should   be 


30  ACTUAL  DETAILS  [ch.  iv. 

asked  to  communicate  news  of  any  suspicious 
cases. 

It  is  a  most  useful  plan  to  have  a  card  register 
in  your  office  on  which  a  form  is  printed  showing 
the  name,  age,  sex,  address  of  the  patient,  nature 
of  home  premises,  of  work,  and  of  work  premises ; 
by  whom  certified,  with  date ;  the  date  when  the 
rash  appeared ;  condition  as  to  vaccination  and 
re- vaccination ;  also  blank  spaces  left  opposite 
such  headings  as  laundry,  school,  source  of 
infection,  recent  movements  of  patient;  names 
and  addresses  of  contacts ;  and  other  desirable 
points.  When  making  inquiries,  you  and  your 
assistants  can  take  blanks  of  this  card  with  you, 
and  use  them  as  memorisers,  so  that  as  many 
as  possible  of  the  necessary  questions  may  be 
answered  and  the  information  gathered.  It  is 
annoying  to  return  from  an  investigation  and 
find  that  some  important  item  has  been  over- 
looked. 

It  is  also  very  useful  to  keep  in  close  touch  with 
the  staff  of  the  hospital  where  the  patients  are 
being  treated.  Most  valuable  information  may 
be  obtained  by  the  medical  and  the  nursing  staff. 
The    hospital    should    be    in    direct    telephonic 


CH.  IV.]  OF  ADMINISTRATION  31 

communication  with  the  administrative  head  who 
is  controlUng  the  outbreak. 

It  goes  without  saying  that  the  inquiries  in 
each  case  must  vary  according  to  the  individual 
circumstances  and  be  guided  by  them.  The  main 
indication  is  clear,  namely  to  expose  and  thoroughly, 
to  understand  every  ramification  of  the  infection. 


THE   INTELLIGENCE  [ch. 


CHAPTER   V 

THE   INTELLIGENCE   DEPARTMENT 

We  assume  now  that  the  first  of  the  main  indica- 
tions mentioned  on  p.  16  has  been  fulfilled; 
namely,  that  the  extent  of  the  mischief  has  been 
ascertained. 

It  will  be  convenient  in  this  place  to 
devote  a  few  words  to  the  discussion  of  a  very 
important  matter,  namely  the  intelligence  de- 
partment. There  is  no  need  to  labour  its 
importance,  especially  if  it  has  happened  that 
some  cases  have  been  overlooked,  and  you 
are  called  on  to  repair  the  mischief  that  has 
resulted. 

Nothing  is  more  vital  to  successful  control 
than  full  and  early  information  of  the  mischief 
that  threatens  ;  or,  as  it  may  be  put  conversely, 
an  outbreak,  like  a  fire,  which  has  once  got 
a  good  hold  is  vastly  more  diflSicult  to  suppress. 


CH.  v.]  DEPARTMENT  33 

However  obvious  such  truisms  may  be,  they  are 
often  neglected  in  practice.  A  variety  of  causes 
may  contribute  to  the  responsible  officer  being 
left  in  ignorance  of  the  occurrence  of  a  case 
of  smallpox.  It  may  not  be  suspected ;  it  may 
not  be  recognised ;  it  may  be  forgotten  that  it 
is  a  matter  for  his  notice ;  it  may  be  wilfully 
concealed.  These  are  vital  matters  which,  for  the 
most  part,  must  be  met  in  advance  and  adjusted. 

A  careful  watch  must  be  kept  upon  the  state 
of  health  of  neighbouring  districts  and  countries. 
Endeavour  should  be  made  to  keep  in  touch  with 
neighbouring  authorities,  so  as  to  get  warning  of 
the  occurrence  of  any  cases.  Generally  speaking, 
no  source  of  information  should  be  neglected, 
whether  it  is  from  the  Press,  or  from  anonymous 
information,  or  gossip,  or  elsewhere.  It  is  not 
very  uncommon  to  hear  rumours  of  cases,  such 
as  "  haemorrhagic  chickenpox,"  ^'  influenza  with 
spots,"  "German  measles  and  blood-poisoning," 
or  "blood-poisoning  with  spots."  Such  rumours 
should  be  followed  up  and  verified. 

An  instructive  commentary  on  this  subject 
occurs  in  the  Annual  Report,  for  the  year  1880, 
p.  38,  of  the  late  Dr.  T.  Orme   Dudfield,  when 


84  THE   INTELLIGENCE  [ch.  v. 

Medical  Officer  of  Health  of  the  Parish  of  St. 
Mary  Abbot,  Kensington.  That  was,  of  course, 
before  the  notification  of  infectious  diseases  became 
compulsory  (1889). 

"A  difficulty  with  which  we  have  to  contend 
is  the  want  of  information  of  the  occurrence  of 
illness — information  that  would  be  of  the  greatest 
value,  particularly  at  the  commencement  of  an 
epidemic,  when  the  first  cases  are  often  mild,  and, 
therefore,  not  fatal." 

Dr.  Orme  Dudfield  enumerates  the  following 
as  his  sources  of  information : — 

1.  Notice  of  every  death  from  graver  infectious 
diseases  within  a  few  hours  after  registration.  This 
by  virtue  of  an  arrangement  with  the  sub-district 
registrars. 

2.  Relieving  Officers  were  directed  by  the 
Guardians  to  report  all  cases  of  infectious 
diseases. 

3.  The  Resident  Medical  Officer  of  the  In- 
firmary and  of  two  general  hospitals  gave  similar 
information. 

4.  General  medical  practitioners  similarly. 

5.  School  officers  similarly. 

6.  Clergymen  and  district  visitors. 


CH.  v.]  DEPARTMENT  85 

Facilities  for  obtaining  information  have  been 
much  improved  since  the  year  1880,  principally 
by  the  statutory  obligation  for  every  medical 
practitioner  or  head  of  a  family  to  report  cases 
of  infectious  disease.  Nevertheless,  the  above  list 
is  useful  as  suggesting  persons  w^ho  may  be  en- 
couraged to  be  on  the  look  out  and  mention 
any  suspicious  cases.  Especially  in  the  case  of 
schools,  the  medical  administration  of  which  has 
developed  so  much  in  recent  years,  medical 
officers,  nurses,  teachers,  attendance  officers,  and 
others  can  render  valuable  assistance.  So  also 
can  heads  of  large  institutions  and  of  business 
premises. 

If  smallpox  has  already  broken  out,  or  if  con- 
tacts of  cases  have  recently  come  into  the  district, 
an  intimation  may  very  usefully  be  made  to  pro- 
fessional colleagues  in  private  practice  in  the 
district.  "  Missed  "  cases,  which  often  play 
such  a  conspicuous  part  in  the  spread  of  small- 
pox, are  likely  to  occur  from  the  possibility 
of  smallpox  not  having  been  present  to  the 
mind  of  the  medical  attendant.  It  may  be  the 
saving  of  the  whole  situation  if  he  has  been 
recently  thinking  of  smallpox,  or  had  it  suggested 


36  THE   INTELLIGENCE  [ch.  v. 

to  him.  There  is  no  need  to  raise  a  scare  or 
alarm.  A  warning  can  be  conveyed  without 
doing  that. 

As  to  what  other  people  should  also  be  warned, 
the  circumstances  of  each  place  and  time  are  the 
best  guide.  What  you  want  to  secure  is  the 
intelligent  co-operation  of  every  one,  both  of 
those  within  your  administrative  influence,  and 
of  others  as  well.  In  a  quiet  time,  while  no 
smallpox  is  about,  inspectoral  and  other  staff  can 
do  valuable  service  by  being  constantly  on  the  look 
out  for  smallpox  in  the  area  of  their  work,  in  the 
press,  or  elsewhere.  Every  sanitary  inspector 
should  always  have  the  question  in  mind. 
Might  that  be  smallpox  ?  Not  so  much  in  refer- 
ence to  any  individual  that  he  may  see,  but 
rather  about  some  story  or  incident  of  which  he 
may  hear.  He  should  take  care  to  report  any 
suspicious  circumstances  to  his  chief.  Similarly, 
newspaper  accounts  of  smallpox  occurring  within 
fourteen  days'  journey  should  always  be  reported 
to  you ;  indeed,  it  is  useful  to  have  a  note  of 
smallpox  occurring  in  no  matter  what  part  of 
the  world.  It  is  well  to  keep  in  communication 
with   any  centre  that    may   be    better    informed 


CH.  v.]  DEPARTMENT  37 

than  you  are,  and  arrange,  if  possible,  to  have 
regular  reports  forwarded  at,  say,  weekly  intervals. 
In  whatever  way  obtained,  it  is  of  vital  import- 
ance to  have  immediate,  accurate,  and  full  informa- 
tion of  everything  concerning  smallpox  in  or 
affecting  your  district. 

Then  comes  the  matter  of  specially  dealing 
with  chickenpox.  Chickenpox  may  be  added  to 
the  list  of  diseases  which  are  compulsorily  notifiable. 
The  local  authority  may  look  to  you  for  guidance 
in  the  matter. 

It  is  dealt  with  in  the  following  passage  from 
the  Report,  for  the  year  1902,  p.  29,  of  Sir  Shirley 
Murphy,  the  late  Medical  Officer  of  Health  of  the 
Administrative  County  of  London  : — 

"Medical  Officers  of  Health  express  different 
opinions  as  to  the  value  of  notification  of  chicken- 
pox  in  bringing  to  their  knowledge  cases  of  small- 
pox which  would  otherwise  have  remained  unknown 
to  them.  Some  are  of  opinion  that  it  was  not  of 
practical  value ;  on  the  other  hand.  Dr.  Bate,  the 
Medical  Officer  of  Health  of  Bethnal  Green,  states 
that  sixteen  persons,  who  were  reported  to  have 
chickenpox,  were  found  on  examination  to  be  suffer- 
ing from  smallpox,  and  he  adds  that  *  undoubtedly 


38  THE    INTELLIGENCE  [ch.  v. 

these  persons  would  have  remained  at  home  dis- 
tributing infection  had  chickenpox  not  been  report- 
able.' In  Hackney,  twenty-two  cases  of  smallpox 
were  mistaken  for  chickenpox,  and  Dr.  Warry,  the 
Medical  Officer  of  Health,  states  that  notification 
of  chickenpox  was  a  measure  of  great  value.  A 
smaller  number  of  such  cases  is  also  reported  by 
some  other  Medical  Officers  of  Health  as  occurring 
in  their  districts.  Thus,  there  were  two  cases  in 
Paddington,  three  cases  in  Woolwich,  three  cases 
in  Finsbury,  as  well  as  two  cases  in  Wandsworth, 
which  would  not  otherwise  have  become  known. 
From  returns  furnished  by  medical  officers  of 
health,  relating  to  some  4000  cases,  it  is  recorded 
in  more  than  100  instances  that  infection  was  trace- 
able to  a  previous  case,  erroneously  regarded  as 
chickenpox.  The  use  of  the  notification  of  chicken- 
pox  cannot,  however,  be  fully  estimated  by  such 
occurrences,  for  not  the  least  of  its  value  must 
undoubtedly  have  been  the  direction  of  public 
attention  to  the  possibility  that  cases  of  smallpox 
might  be  mistaken  for  chickenpox,  and  to  the  need 
for  more  critical  examination  of  all  persons  suffer- 
ing from  eruptions  presenting  the  appearance  of 
chickenpox." 


CH.  v.]  DEPARTMENT  39 

Whether  this  particular  step  be  taken  or  not, 
and  whatever  be  its  merits,  there  is  great  advantage 
in  having  special  inquiry  made  about  every  case  of 
chickenpox  in  an  adult. 

The  sum  of  the  matter  is  this,  if  you  are 
to  succeed  in  averting  an  outbreak,  to  have  early 
and  full  information  is  imperative.  As  it  is  well 
put  in  a  passage  which  stands  at  the  head  of  the 
Public  Health  Reports  of  the  United  States  Public 
Health  Service :  "  No  health  department,  State 
or  local,  can  effectively  prevent  or  control  disease 
without  knowledge  of  when,  where,  and  under  -*' 
what  conditions  cases  are  occurring."  ' 


40  OTHER  PRACTICAL   DETAILS        [ch.  vi. 


CHAPTER  VI 

OTHER   PRACTICAL   DETAILS  OF   SMALLPOX   CONTROL 

We  will  now  turn  to  some  other  matters.  Having 
discovered  what  the  actual  extent  of  the  infection 
is,  it  is  your  business  instantly  to  clear  it  out  or 
to  destroy  it.  We  have  said  that  one  of  the  first 
points  to  be  attended  to,  as  soon  as  the  news  of  a 
case  comes  in,  "  is  to  telephone  the  case  away,"  that 
is,  to  have  an  ambulance  summoned  by  telephone 
in  order  to  remove  the  patient  to  hospital.  I  do 
not  propose  on  the  present  occasion  to  discuss  the 
details  of  hospitals  and  the  methods  of  isolation, 
except  to  say  this,  that,  in  preventing  the  spread 
of  infection  from  hospitals,  much  the  most  effective 
policy  is  to  get  and  keep  a  trustworthy  and  intel- 
ligent staff.  The  wise  plan  is  to  keep  such  staff 
together  during  inter-epidemic  periods,  for  they 
cannot  be  brought  into  existence  at  a  moment's 
notice.  It  is  much  more  effective  to  explain  your 
views    to    such    staff,    and,    while    laying    down 


CH.  VI.]  OF  SMALLPOX  CONTROL  41 

comprehensive  rules,  to  rely  upon  their  intelligence 
in  giving  effect  to  them  in  circumstances  that  must 
necessarily  vary,  than  to  attempt  to  prevent  the 
leakage  of  infection  merely  by  the  institution  of  a 
series  of  cast-iron  rules,  with  the  instruction  that 
they  must  be  rigidly  adhered  to.  Success  in  the 
prevention  of  leakage  of  infection  from  hospital 
depends  on  the  intelligent  and  loyal  interpretation 
of  well-understood  principles. 

Sometimes  difficulty  is  experienced  in  getting  ., 
a  patient  isolated  in  hospital,  owing  to  his  refusal  II 
to  leave  his  home.  There  should  be  no  difficulty 
in  dealing  with  this.  It  is  seldom  possible  for 
adequate  isolation  of  smallpox  to  be  secured  at 
home.  Application  for  an  order  for  removal  should 
be  made  to  a  magistrate  and  representation  made 
of  the  impossibility  of  home  isolation  and  the 
risk  to  the  public  thereby  involved.  Smallpox  is 
still  held  in  such  horror  by  pubHc  opinion,  and 
justly  so,  that  an  order  for  removal  is  usually 
obtainable. 

There  is  one  proviso  to  this  proceeding.  It  is 
that  every  possible  precaution  should  be  taken  to 
verify  the  diagnosis  before  application  is  made  for 
forcible  removal  of  the  patient.     I  recollect  a  case 


42  OTHER  PRACTICAL  DETAILS        [ch.  vi. 

which  several  circumstances  combined  to  com- 
phcate.  Removal  of  a  case  of  certified  smallpox 
from  the  home  was  refused,  a  magistrate's  order 
was  obtained,  and  carried  out.  So  far  so  good. 
But  the  diagnosis  was  subsequently  upset  in  favour 
of  chickenpox,  and  the  patient's  friends  were  liti- 
gious. Actions  for  damages  followed.  In  case 
you  should  ever  be  placed  in  a  similar  position  of 
difficulty,  the  main  point  to  remember  is  to  take 
every  possible  care  in  the  examination  and  verifi- 
cation of  the  case.  If  you  examine  the  case 
thoroughly  yourself,  or  obtain  the  best  other  advice 
that  is  available,  you  will  be  able  to  show  that 
every  possible  care  and  skill  had  been  brought  to 
bear,  and  to  repel  criticism  accordingly. 

Having  had  the  living  part  of  the  infection 
segregated  and  isolated  where  it  can  do  no  harm, 
your  attention  will  be  given  to  destroying  the 
infection  of  the  inanimate  objects.  Of  course,  if 
you  have  ample  vans  at  command,  and  ample 
steam  disinfectors,  your  task  is  greatly  simplified. 
Otherwise  there  is  nothing  like  a  good  bonfire,  and 
the  liberal  use  of  soap  and  water.  The  first  may 
be  expensive.  But  it  is  in  the  nature  of  a  smallpox 
epidemic  to  be  expensive. 


CH.  VI.]  OF  SMALLPOX   CONTROL  43 

As  to  the  second,  to  aim  at  absolute  cleanliness 
is  a  great  point  in  disinfection.  Again  in  this 
matter,  you  will  be  most  successful  if  you  can 
bring  an  intelligent  staff  to  bear.  You  may 
have  never  such  a  complete  set  of  rules  and 
regulations,  but  circumstances  must  continually 
arise  to  which  they  do  not  exactly  apply;  and 
also  unintelligent  persons  will  have  many  oppor- 
tunities of  carrying  them  out  in  the  letter  and  not 
in  the  spirit.  Speaking  from  a  fairly  wide  ex- 
perience of  the  niceties  of  disinfection,  I  can  say 
that  the  same  set  of  circumstances  seldom  recurs. 
Each  case  must  be  taken  on  its  merits.  General 
rules  can  be  laid  down,  but  their  interpretation 
must  depend  on  the  staff*;  more  important  points 
being  referred  to  and  settled  only  by  the  medical 
officer  in  charge.     So  much  for  disinfection. 

There  is  one  other  matter  of  much  importance 
to  the  administrator,  and  that  is  the  question  of 
reporting.  First  of  all,  there  are  the  reports 
which  you  will  require  from  your  assistants,  if 
you  are  in  charge.  You  will  have  to  impress 
upon  them  that  they  must  keep  you  informed, 
and  promptly  informed,  of  everything.  They  are 
to   see  and  hear  and  act  for  you ;  they  are  your 


44  OTHER  PRACTICAL  DETAILS        [en.  vt. 

agents,  for  the  reason  that  you  cannot  yourself 
be  everywhere  at  once ;  and,  until  they  are  sure 
that  you  are  fully  informed  of  their  proceedings, 
their  work  is  only  half  done.  It  is  for  you  to 
settle  how  their  reports  can  be  made  most  con- 
veniently to  yourself,  and  for  them  to  make 
a  point  of  carrying  out  your  wishes.  It  is  with 
them  that  the  responsibility  rests  for  getting 
reports  forward.  Any  delay  in  information  reach- 
ing you  reflects  on  the  person  or  persons  with 
whom  it  sticks.  Efficient  reporting  is  one  of  the 
main  tests  of  capable  staff*. 

Then  there  are  the  reports  which  you  have 
to  make  to  the  Authority  concerned,  and  also 
those  for  the  records.  Making  these  is  often  a 
great  difficulty  and  a  great  strain,  which  may 
not  be  understood  by  those  who  have  not 
been  through  an  outbreak.  I  have  a  vivid  recol- 
lection of  the  stress  of  a  speU  of  work,  when  a 
heavy  epidemic  broke  out  with  full  force.  It  was 
winter,  and  for  most  of  the  twenty-four  hours 
darkness  and  fog  prevailed.  From  the  first  thing 
every  morning  we  worked  throughout  the  day, 
never  sitting  down  except  to  a  broken  meal, 
and  having  no  relaxation  of  any  kind.     Sundays 


CH.  VI.]  OF  SMALLPOX   CONTROL  46 

and  other  holidays  made  little  difference.  The 
work  went  on  right  through  the  day,  till 
10  p.m.  or  midnight  or  later.  Every  day  was 
just  the  same ;  we  worked  while  we  were  awake, 
and  when  we  stopped  we  fell  asleep.  In  these 
circumstances  the  heaviest  burden  of  all  was  the 
reporting.  The  day's  work  done,  say  at  midnight, 
reports  had  to  be  cleared  up,  and  required  several 
hours'  more  work. 

Of  course  full  reports  will  be  required.  The 
clerical  work  and  clinical  records  are  a  matter 
of  organisation  which  cannot  be  followed  out 
here  in  detail.  But  it  may  be  said  that  the 
greatest  economy  and  the  easiest  plan  in  the  end, 
is  to  keep  them  up-to-date,  day  by  day.  The 
same  applies  to  reports  of  the  general  progress 
of  an  epidemic.  If  possible,  a  shorthand  note 
should  be  given,  every  day,  of  the  stage  to  which 
matters  have  advanced.  At  given  intervals,  every 
week  or  fortnight,  what  is  irrelevant  at  that 
particular  stage  can  be  omitted,  and  the  remainder 
of  the  report  is  ready  and  can  be  submitted. 
That  is  a  great  relief  to  overworked  officers,  and 
provides  accurate  information  for  record. 

One     further     matter     requires    mention,    in 


46  OTHER  PRACTICAL  DETAILS         [ch.  vi. 

connection  with  reporting.  Your  Authority  will  not 
only  want  information  as  to  the  origin  and  extent 
of  the  outbreak,  but  advice  and  recommendation 
as  to  how  it  is  to  be  met.  In  recommending 
remedial  measures,  vaccination  and  so  forth,  it 
is  imperative  first  of  all  to  point  out  what  is  the 
existing  mischief,  the  number  of  cases,  of  deaths, 
the  damage  to  business,  the  probable  spread,  and 
so  on.  That  must  be  very  clearly  demonstrated. 
The  position  then  makes  itself  clear.  That  is, 
that  smallpox  is  an  actual  fact,  that  there  is  so 
much  risk  of  it  spreading,  of  involving  more  lives, 
more  loss  of  business,  and  creating  a  greater  scare. 
The  point  is  that  an  outbreak  is  here,  and  how 
can  it  be  stopped  ?  The  answer  is  that  what  has 
to  be  done  is  to  check  it  and  stop  it  by  every 
available  and  possible  means.  Any  recommenda- 
tion is  then  not  a  question  of  professional  predilec- 
tion or  personal  preference. 


CH.  VII.]     THE   OBSERVATION   OF  CONTACTS       47 


CHAPTER  VII 

THE   OBSERVATION   OF   CONTACTS 

We  pass  now  to  the  third  of  the  general  indica- 
tions on  p.  16  ;  that  includes  the  observation  of 
contacts.  This  is  often  the  most  irksome  and 
difficult  part  of  controlling  a  smallpox  outbreak; 
and  it  is  one  of  the  most  important.  It  is  a 
duty  which  the  disuse  of  vaccination  increases 
enormously  in  importance  ;  and  we  will  consider 
it  in  detail. 

Let  us  consider  first  the  comparatively  simple 
example  which  has  been  given  on  p.  19.  In 
such  a  case  what  contacts  are  there  ?  The 
period  to  be  considered  is  that  between  the  time 
.when  the  patient's  skin  first  showed  any  sign  of 
rash  and  the  time  of  his  removal  from  his  house. 
Our  object  is  to  obtain  a  list  of  all  the  persons 
with  whom  he  came  in  contact  during  this  time. 
For     this     purpose,     his    movements    must     be 


48  THE   OBSERVATION  [ch.  vii. 

reconstructed  in  detail ;  patience  and  time  are 
required  to  effect  this.  It  is  surprising,  even 
when  a  patient's  movements  have  been  related 
in  the  most  honest  way  possible,  how  some 
forgotten  contact  may  make  an  appearance  later, 
and  perhaps  be  the  cause  of  much  mischief. 

However,  in  the  case  in  point,  the  contacts  fall 
into  three  categories.     There  are 

1.  The  other  people  residing  in  the  house. 

2.  Those  who  came  to  visit  the  patient. 
^  3.  Those  whom  he  met  outside  his  own  house. 
All  these  people  have  to  be  listed,  seen,  warned, 
offered  vaccination,  and  kept  under  medical 
observation,  with  the  view  of  being  instantly  dealt 
with  at  the  first  sign  of  illness;  if  necessary, 
isolated  for  observation,  or  removed  to  hospital. 
In  this  manner  fresh  centres  of  infection  are  ascer- 
tained and  eradicated,  before  they  have  had  time 
to  do  any  harm.  Special  observation  is  necessary 
during  the  time  when  the  rash  may  be  expected. 
This  day  can  usually  be  predicted  with  some  exact- 
ness, if  the  exposure  is  certain  and  single.  But 
very  often  that  cannot  be  known,  and  conse- 
quently careful  supervision  is  necessary  over  the 
whole  of  the  period  of  observation  ;  that   is,  for 


CH.  VII.]  OF  CONTACTS  49 

at  least  a  fortnight  subsequent  to  the  last  possible 
date  of  contact ;  it  may  be  advisable  to  extend 
this  period  to  16  or  17  days.  It  is  important 
for  the  patient  to  be  under  medical  observation. 
The  exact  degree  of  medical  observation  re- 
quired must  be  determined  by  the  circumstances 
of  each  case,  and  should  depend  upon  how  the 
object  in  view  may  most  effectually  be  achieved. 
As  a  rule,  however,  contacts  should  be  inspected 
daily  at  least. 

Objection  maybe  made  to  the  expense  of  extra 
medical  assistance.  Epidemics  must  necessarily 
be  expensive.  It  is  a  more  effective  policy  and 
cheaper  in  the  end  to  put  on  sufficient  medical 
assistance  to  keep  contacts  under  daily  medical 
observation.  Otherwise  cases  may  be  missed, 
and,  by  forming  fresh  foci  of  infection,  may  enable 
an  outbreak  to  keep  smouldering  on  for  weeks 
and  months.  In  any  case  a  contact  should  be  seen 
by  a  doctor  daily  during  the  days  when  the  onset 
of  his  illness  may  reasonably  be  expected.  Unless 
this  is  done,  a  slight  case  may  easily  be  missed. 
For  it  is  likely  enough  that  persons,  who  are 
left  to  report  their  own  health  or  that  of  a 
family,  may   disregard — whether  intentionally    or 


50  THE   OBSERVATION  [ch.  vii. 

not — both  the  initial  symptoms,  as   well   as  the 

rash  of  a  slight  attack. 

The  following  description  of  how  contacts  were 

observed  in  London  during  the  year  1902,  when 

about  8,000  cases  of  smallpox  occurred  in  London, 

is  extracted  from  the  report  for  that  year  of  the 

Medical  Officer  of  Health  of  the  Administrative 

County  of  London. 

"The   system   of   keeping  under    observation 

» 
persons  who  had  been  exposed  to  infection  was  * 

largely  adopted  during  the  epidemic.  This,  indeed, 
was  a  course  followed  in  every  district,  and  early 
in  1902  the  Council's  Public  Health  Department 
was  utilised  for  immediate  daily  distribution  to 
every  Medical  Officer  of  Health  in  London  of 
particulars  as  to  cases  of  smallpox  occurring,  and 
also  of  the  addresses  of  persons  who  had  been 
exposed  to  infection,  this  information  being  trans- 
mitted by  Medical  Officers  of  Health  for  this 
purpose.  In  this  way  Medical  Officers  of  Health 
obtained  information  of  the  addresses  of  persons 
residing  in  their  districts  who  had  been  exposed 
to  infection  in  other  districts,  and  such  '  contacts  ' 
were  able  to  be  visited,  offered  vaccination, 
and  removed  to   hospital    in  an    early   stage   of 


CH.  VII.]  OF  CONTACTS  61 

the  disease  if   they  subsequently  sickened   with 
smallpox. 

"  It  was  a  frequent  practice,  especially  in  the 
early  part  of  the  epidemic,  to  endeavour  to  limit 
the  extension  of  disease  by  informing  employers 
whenever  any  of  their  staff  were  found  to  have 
been  living  in  a  house  in  which  a  case  of  smallpox 
occurred.  The  result  was,  in  many  cases,  that  the 
employee  was  suspended  from  work,  and  where  no 
allowance  was  made  for  his  maintenance  or  that  of 
his  family  by  his  employers,  or  by  the  sanitary 
authority,  hardship  was  often  suffered.  Dr.  Warry 
gives  his  experience  in  Hackney  of  this  procedure. 
'The  result,  in  the  majority  of  cases,  was  that 
many  persons  were  reduced  to  the  brink  of  starva- 
tion, for  a  large  number,  although  in  great  want, 
would  not  apply  for  parish  relief;  and,  as  a  matter 
of  fact,  the  Guardians'  officials  did  not  like  persons 
coming  from  infected  houses  and  applying  for 
relief,  neither  did  they  like  visiting  the  unfortunate 
contacts  in  their  houses.'  Nor  does  the  result  of 
such  action  always  appear  to  have  been  of  sufficient 
value  to  compensate  for  the  disturbance  of  wage 
earning.  Dr.  Harris,  Medical  Officer  of  Health  of 
Islington,  found  that  *  these  employees  were  thrown 


52  THE   OBSERVATION  [ch.  vii. 

on  their  own  resources  to  fill  in  their  time,  and, 
although  they  might  stay  at  home  for  a  few  days, 
they  would  then  generally  go  into  the  streets,  loiter 
at  the  hall  doors,  or  find  their  way  to  the  nearest 
public-house.' 

"  Question,  therefore,  arose  in  a  number  of  dis- 
tricts whether  steps  should  be  taken  to  prevent  the 
extension  of  disease  by  inducing  the  inmates  of 
infected  houses  to  remain  within  doors,  a  course 
which  involved  the  abandonment  of  work  and  wage 
earning,  and  the  maintenance  of  the  household  at 
the  cost  of  the  rates.  In  February,  1902,  the  Local 
Government  Board  addressed  a  circular  letter  to 
London  sanitary  authorities  on  the  question  of  the 
quarantining  of  persons  living  in  dwellings  invaded 
by  smallpox.  The  letter  stated  that  the  Board 
'are  advised  that  under  ordinary  circumstances 
the  quarantining  at  their  homes  of  inmates  of  such 
dwellings  is  not  necessary  in  such  districts  in  which 
sanitary  matters  are  properly  administered  and 
vaccination  and  re- vaccination  are  properly  carried 
out.  If,  on  a  dwelling  becoming  invaded  by  small- 
pox the  actual  patients  are  at  once  removed  to 
hospital,  the  dweUing  and  all  articles  in  it  that  have 
been  exposed  to  infection,  including  the  clothes 


CH.  VII.]  OF  CONTACTS  53 

worn  by  the  other  inmates  are  properly  disinfected, 
and  the  other  inmates  of  the  house  are  immediately 
vaccinated  or  re-vaccinated  (as  the  case  may  be), 
there  is  no  material  advantage  to  be  gained  by 
keeping  these  other  inmates  at  home.  They  are 
not  likely  to  infect  other  people  unless  they  them- 
selves develop  smallpox  ;  and  all  that  is  required  is 
to  keep  such  persons  under  medical  observation  for 
a  fortnight,  and  particularly  to  examine  them  care- 
fully day  by  day  towards  the  end  of  the  second 
week  from  their  exposure  to  infection,  in  order  to 
ascertain  whether  any  of  them  are  developing  small- 
pox. If  none  of  them  do  so  by  the  beginning  of 
the  third  week  from  exposure,  the  re-vaccination 
(or  vaccination)  to  which  they  were  submitted  on 
the  occurrence  of  the  first  case  in  the  invaded  house 
should  secure  them  from  attack  by  the  disease. 
The  Board  considers  that  in  ordinary  circumstances 
the  course  of  action  indicated  above  is  the  correct 
one.  Occasions,  however,  may  arise  in  which  addi- 
tional precautions  may  be  necessary,  as,  for  example, 
when  laundries  are  in  question,  or  where  the  busi- 
ness or  habits  of  the  members  of  the  invaded  house 
are  such  as  to  make  it  difficult  for  medical  observa- 
tion of  them  to  be  maintained.     In  exceptional 


54  THE  OBSERVATION  [ch.  vii. 

cases  of  this  kind,  in  which  the  Council  are  advised 
by  their  medical  officer  of  health  that  in  the  special 
circumstances  it  is  essential  that  the  inmates  should 
remain  in  their  own  houses,  the  Board  would  be 
prepared  to  sanction  a  reasonable  expenditure  in 
securing  such  a  result.' 

"  The  impractibility  of  the  wholesale  quarantining 
of  all  persons  exposed  to  infection  when  smallpox 
is  widely  distributed,  is,  of  course,  obvious.  The 
actual  number  of  such  persons  during  the  recent 
epidemic  cannot  be  shown,  but  some  idea  of  the 
magnitude  of  this  number  can  be  formed  by  refer- 
ence to  the  annual  reports  of  a  few  of  the  medical 
officers  of  health. 

"  Thus,  in  Westminster,  where  there  were  301 
cases  of  smallpox,  there  were  2,677  persons  living 
in  houses  in  which  cases  of  smallpox  occurred  and 
there  were  3,108  additional  'contacts'  who  had 
otherwise  been  exposed  to  smallpox  by  visiting 
persons  suffering  from  the  disease,  or  working  with 
such  persons,  or  in  other  ways  ...  In  four  dis- 
tricts there  were  1,093  cases  of  smallpox  and  13,259 
contacts." 

These  figures  show  that  there  were  from  twelve 
to  thirteen   contacts  for  every  case  of  smallpox. 


CH.  viT.]  OF  CONTACTS  55 

It  is  a  rough  but  useful  rule  to  bear  in  mind, 
that  for  every  case  of  smallpox  there  may  be,  on  an 
average,  not  less  than  ten  contacts, 

A  special  department  of  the  supervision  of  con- 
tacts is  that  concerned  with  the  observation  of 
common  lodging-houses  ;  that  is  fully  dealt  with  in 
the  following  passage  on  page  35  of  the  Report 
quoted  above. 

"The  Council's  administration  aimed  at  the 
early  detection  of  cases  of  smallpox  in  common 
lodging-houses  with  a  view  to  their  removal.  For 
this  purpose  the  houses  were  kept  under  close  in- 
spection, especial  attention  being  given  to  houses 
in  which  a  case  of  smallpox  was  known  to  have 
occurred.  In  such  houses  systematic  inspection 
was  made  of  the  inmates,  the  houses  being  visited 
in  the  early  morning,  when  the  lodgers  were  most 
likely  to  be  within  doors,  by  officers  who,  for  this 
purpose,  were  relieved  of  other  inspectoral  duties. 
Effort  was  made  to  induce  lodgers,  who  had  been 
living  in  houses  in  which  smallpox  had  appeared, 
to  continue  to  reside  in  such  houses  so  as  to  pre- 
vent the  infection  of  other  houses  which  would 
result  if  they  were  to  remove  while  incubating  the 
disease. 


56  THE  OBSERVATION  [ch.  vii. 

"  With  a  view  to  insuring,  as  far  as  possible,  the 
continued  residence  of  such  lodgers  where  they 
could  be  kept  under  observation,  the  inducement 
of  a  free  bed  and,  when  necessary,  of  small  sums 
of  money  for  the  purchase  of  food  was  offered  to 
them,  and  this  was  done  with  much  success.  The 
money  thus  expended  by  the  Council  during  the 
whole  of  the  epidemic  amounted  to  £35.  The 
keepers  of  common  lodging-houses,  who  co- 
operated largely  with  the  Council  in  this  matter, 
were  able  to  learn  when  particular  lodgers,  who 
had  been  indicated  to  them  by  the  Council's 
officers,  were  likely  to  leave  their  houses,  and  thus, 
without  any  general  offer  of  bed  and  money  to 
the  lodgers  as  a  whole,  which  would  have  involved 
a  large  expenditure,  by  dealing  with  particular 
persons  the  officers  were  able  to  secure  the  object 
in  view  at  trifling  cost. 

"Lodgers  who  had  been  especially  associated 
with  any  person  attacked  by  smallpox  were  in 
their  sleeping  arrangements  kept  together  in 
a  particular  room.  Persons  showing  any  ail- 
ment which  raised  suspicion  of  smallpox  were, 
as  far  as  practicable,  kept  from  other  lodgers 
and  from    the    population   outside,   until  it  was 


cH.vii.]  OF  CONTACTS  57 

possible  to  determine  the  nature  of  their 
malady.  It  was,  of  course,  impracticable  when 
numerous  houses  were  invaded,  to  proceed  in 
the  same  way  as  in  the  beginning  of  the  out- 
break, when  the  Council  rented  the  common 
lodging-house,  8  and  9,  Parker  Street,  Drury 
Lane,  and  maintained  the  whole  of  the  inmates, 
keeping  them  in  quarantine ;  but  much  was  done 
by  the  early  detection  of  cases  of  smallpox  to 
prevent  the  continued  residence  of  infectious 
persons  in  these  houses.  Moreover,  the  Council 
obtained  the  sanction  of  numerous  Boards  of 
Guardians  for  the  Poor  Law  medical  officer  to 
examine,  without  previous  order  of  the  relieving 
officer,  the  inmates  of  common  lodging-houses 
whose  condition  created  suspicion  of  smallpox,  and 
in  certain  localities  where  the  common  lodging- 
house  population  was  much  involved  the  Council 
appointed  medical  men  to  examine  the  inmates 
at  a  time  in  the  morning  before  they  left  the  house 
so  as  to  ensure  the  early  detection  and  removal 
of  infectious  persons. 

"It  is  difficult  to  estimate  the  extent  to 
which  this  procedure  limited  the  spread  of 
smallpox  in  this  class  of  the  population,  although 


68  THE   OBSERVATION  [ch.  vii. 

there  cannot  be  doubt  that  it  was  of  consider- 
able value.  The  inmates  of  common  lodging- 
houses  do  not  appear  to  have  been  specially 
susceptible  to  smallpox;  indeed,  the  results  of 
inquiries  made  by  the  Council's  officers  showed 
that  a  considerable  proportion  had  been  re-vacci- 
nated or  had  previously  suffered  from  smallpox. 
Even,  however,  allowing  for  this,  the  attack  rate, 
which  was  only  about  three  per  cent,  of  the  popula- 
tion residing  in  these  houses,  must  be  regarded  as 
low,  when  the  frequency  of  invasions  of  common 
lodging-houses,  and  the  condition  of  aggregation 
in  which  the  inmates  live,  is  considered. 

"  When  a  common  lodging-house  was  involved 
to  the  extent  of  several  lodgers  being  attacked,  only 
the  vaccination  of  the  inmates  on  a  large  scale  can 
be  pointed  to  as  at  once  bringing  the  outbreak  to 
an  end ;  but  the  speedy  detection  and  removal  of 
infectious  cases  must  have  hmited  the  exposure 
of  other  inmates  to  infection,  and  reduced  the 
number  of  cases  which  otherwise  would  have 
occurred  among  persons  associating  with  the 
lodgers,  whether  within  or  outside  the  lodging- 
house.  As  a  rule,  comparatively  little  success 
attended  efforts  to  induce  the  inmates  of  common 


CH.  vii.]  OF  CONTACTS  59 

lodging-houses  to  submit  to  vaccination.  The 
Council  exhibited  a  notice  in  all  common  lodging- 
houses  advising  the  inmates  to  seek  this  means 
of  protection  against  smallpox,  and  the  Council's 
officers  exercised  such  influence  as  they  had  over 
the  lodgers,  but  the  only  inducement  which  was 
successful  on  a  large  scale  was  the  course  adopted 
in  a  few  instances  by  the  sanitary  authority,  viz. 
the  offer  of  a  small  sum  of  money  which  would 
enable  the  lodger  to  live  for  a  few  days  without 
work  if  the  effisct  of  the  vaccination  was  such  as 
to  prevent  him  from  following  his  employment." 


60  VACCINATION  [ch.  viir. 


CHAPTER  VIII 

VACCINATION 

There  are  various  points  regarding  vaccination 
which  require  to  be  mentioned. 

First,  as  to  the  efficacy  of  recent  and  successful 
vaccination,  a  matter  upon  which  I  have  known 
doubt  expressed  even  by  medical  practitioners  them- 
selves. Any  one  who  is  recently  and  successfully 
vaccinated  cannot,  by  any  loss  of  health,  by  any 
degree  of  exposure,  or  by  any  possibility  of  any 
kind  at  all,  contract  smallpox.  There  is  not  the 
slightest  risk.  If  it  were  possible  to  conceive  of  a 
recently  and  successfully  vaccinated  millionaire, 
who  wanted  to  have  experience  of  the  disease  in 
his  own  body,  all  his  millions  could  not  possibly 
gratify  his  wish. 

If  a  word  of  advice  may  be  suggested  to 
a  young  Medical  Officer  of  Health,  it  would  be 
this,  to   be  drawn  into   no  dispute  or  discussion 


CH.  VIII.]  AND   SMALLPOX  61 

on  the  "  vaccination  question."  An  inquirer 
is  entitled  to  his  opinion,  and  you  are  entitled 
to  yours.  Let  it  rest  at  that.  It  may  be 
different  when  your  opinion  and  your  reasons 
therefor  are  required  by  the  Authority  who  retains 
your  professional  services.  Then  of  course  your 
advice  should  be  fully  given  and  stated  with 
due  firmness.  Yours  is  the  advice;  the  respon- 
sibility of  the  ultimate  decision  rests  with  the 
Authority  who  employs  and  consults  you. 

In  the  matter  of  giving  reasons  to  those  whose 
right  or  wish  is  to  be  informed,  I  have  found  two 
items  from  my  own  experience  to  carry  weight ; 
they  may  be  worth  mentioning  here.  They  have 
the  advantage,  which  is  no  slight  one  in  discussing 
vaccination,  of  being  observations  in  the  actual  field. 
The  first  is  this. 

It  is  the  practice  at  the  London  Smallpox 
Hospitals,  when  a  patient  is  dangerously  ill,  to 
inform  the  near  relatives  that  their  visiting  would 
be  allowed  in  the  special  circumstances.  Such 
visitors  are  warned  of  the  risk  which  they  run 
of  contracting  the  disease,  are  instructed  to  take 
suitable  precautions,  and  are  offered  vaccina- 
tion for  their  own  protection.     Not  a  few  refuse 


62  VACCINATION  [ch.  vm. 

the  offer,  and  proceed  in  charge  of  a  nurse  to 
visit  their  sick  friends.  It  has  not  infrequently 
happened  that  such  visitors  have  returned  to  the 
hospital  about  a  fortnight  later,  themselves  suffer- 
ing from  smallpox.  But  the  nurses  who  have 
accompanied  them,  and  were  equally  exposed, 
have  escaped.  There  has  thus  been  carried  on,  as  it 
were,  a  series  of  experiments,  in  each  case  of  which 
two  persons  have  been  exposed  to  infection.  On 
some  occasions  both  nurse  and  visitor  have  escaped. 
On  other  occasions  the  visitor  has  sickened  and 
the  nurse  has  escaped.  It  has  never  happened  that 
the  visitor  has  escaped  and  the  nurse  has  sickened, 
or  that  both  have  sickened.  An  independent 
inquirer  would  be  struck  by  such  a  series  of 
phenomena  and  would  cast  about  for  an  explana- 
tion. He  would  find  that  the  only  factor  common 
to  all  the  occurrences  was  that  the  nurses  were 
recently  and  successfully  vaccinated,  and  that  the 
visitors  were  not  so  conditioned. 

The  second  item  is  this.  During  the  1 901-1 902 
epidemic,  when  about  10,000  patients  passed 
through  my  hands  at  the  London  Receiving 
Station,  I  saw  a  considerable  number  of  mothers 
who  themselves  had  smallpox,  and  had  infants  at 


CH.  VIII.]  AND  SMALLPOX  68 

the  breast  who  were  entirely  free  from  the  disease. 
The  mother,  when  apart  from  the  infant,  had  been 
exposed  to  infection  and  taken  it,  and  had  gone  on 
nursing  her  infant  until  the  rash  of  smallpox  came 
out.  Although  these  infants  were  then  exposed 
to  infection  with  extreme  thoroughness,  and  it 
would  seem  inevitable  for  them  to  take  smallpox, 
in  point  of  fact  a  number  of  them  never  took  it. 
Those  who  did  not  take  it,  differed  from  those  who 
did,  in  having  been  successfully  vaccinated  within 
three  days  of  exposure  to  infection. 

Questions  may  often  arise  about  the  necessity 
of  renewing  and  bringing  vaccination  up  to  date. 
The  fact  is  that  protection  conferred  by  vaccina- 
tion wears  out  after  a  lapse  of  time  which  is 
uncertain  and  varies  with  each  individual.  No 
one  can  say,  for  any  given  individual,  what  the 
length  of  that  lapse  of  time  may  be.  Re- 
vaccination  may  be  effective  for  a  period  of 
20  years.  Primary  vaccination  does  not  confer 
immunity  for  so  long  a  period  as  this. 

To  a  person  who  is  in  doubt,  or  who  is 
unwilling  to  be  re-vaccinated,  the  risk  may  be 
clearly  stated,  and  the  matter,  so  far  as  the  opera- 
tion is  concerned,  may  be  fairly  put  in  this  way.    If 


64  VACCINATION  [ch.  viii. 

vaccination  takes  well,  it  shows  how  much  it  was 
required  and  what  a  risk  was  run;  the  illness 
actually  experienced  is  nothing  to  the  attack  which 
would  have  been  experienced  had  the  infection  of 
smallpox  been  taken ;  on  the  other  hand,  if  immunity 
already  exists,  the  operation  means  a  scratch  and 
nothing  more. 

There  is  great  need  for  medical  terminology 
to  provide  a  word  which  should  signify  "  efficiently 
and  recently  protected  by  vaccination,"  and  should 
have  the  meaning,  as  regards  vaccination,  of  the 
word  "  salted  "  or  "  immunised."  The  necessity  of 
some  such  word  is  often  felt.  "  Vaccinated "  is 
necessarily  a  word  of  vague  meaning.  All  that  it 
means  is  that  the  operation  of  vaccination  has  been 
done  ;  it  may  be  one  year  or  fifty  years  ago. 

The  question  may  be  asked  :  Up  to  what 
day  in  the  incubation  period  may  vaccination  be 
performed  so  that  security  results  to  the  vaccinated 
person?  The  experience  gained  from  the  infants 
alluded  to  on  p.  62  is  instructive  on  this  point. 
What  was  noted  at  the  bedside  was  this.  If 
vaccination  was  successful  and  ran  a  normal 
course,  and  if  on  the  eleventh  day  of  successful 
vaccination    the    infant's     skin     was     otherwise 


CH.  viil]  and   smallpox  65 

unblemished,  that  is,  if  there  was  no  trace  of 
smallpox  rash,  and  the  infant  was  otherwise  in 
normal  health,  smallpox  never  afterwards  super- 
vened. That  meant  that  vaccination,  if  it  was  to 
protect  the  patient,  must  have  been  performed 
within  the  first  three  days  of  the  incubation 
period.  When  performed  on  the  fourth  day,  it 
did  not  avert  the  attack,  though  it  modified 
it.  It  is  therefore  very  desirable  to  get  contacts 
vaccinated  or  re-vaccinated  without  the  slightest 
delay. 

Since  the  above  passage  was  written,  my 
attention  was  drawn  to  the  following  passage 
from  the  pen  of  Mr.  Marson.  Mr.  Marson  was 
resident  Medical  Officer  of  Highgate  Smallpox 
Hospital  for  many  years.  He  wrote  in  Reynolds' 
"  System  of  Medicine "  :  "  Suppose  an  unvacci- 
nated  person  to  inhale  the  germ  of  variola  on 
a  Monday,  if  he  be  vaccinated  as  late  as  the 
following  Wednesday  the  vaccination  will  be  in 
time  to  prevent  smallpox  being  developed;  if 
it  be  put  off  until  Thursday,  the  smallpox  will 
appear,  but  will  be  modified ;  if  the  vaccination  be 
delayed  until  Friday,  it  will  be  of  no  use,  it  will 
not  have  time  to  reach  the  stage  of  areola,  the 

F 


66  VACCINATION  [ch.  viii. 

index  of  safety,  before  the  illness  of  smallpox 
begins ;  this  we  have  seen  over  and  over  again, 
and  know  it  to  be  the  exact  state  of  the  question. 
Re-vaccination  will  have  effect  two  days  later 
than  will  vaccination  that  is  performed  for  the 
first  time,  because  re-vaccination  cases  reach 
the  stage  of  areola  two  or  three  days  sooner 
than  in  those  persons  vaccinated  for  the  first 
time." 

I  was  interested  to  find  that  my  observa- 
tions corresponded  so  nearly  with  those  of  Dr. 
Marson.  I  am  not  in  a  position,  however,  to 
corroborate  his  note  about  re-vaccination  running 
a  two  days'  shorter  course  to  maturity  than  primary 
vaccination. 

The  possibility  of  vaccination  running  a  course 
longer  than  the  normal  should  also  be  borne 
in  mind.  I  have  seen  this  happen  when  vaccina- 
tion is  performed  upon  persons  who  are  suffering 
from  some  pre-existing  condition  of  ill-health, 
such  as  obtains  in  a  marasmic  infant,  for  instance, 
or  in  a  debilitated  old  man ;  vaccination  may  then 
take  a  period  considerably  longer  than  usual  to 
complete  its  course. 

An    important     matter,    in    connection    with 


CH.  VIII.]  AND   SMALLPOX  67 

vaccination,  is  the  protection  of  staff  engaged  in 
smallpox  duty.  At  the  beginning  of  epidemics 
smallpox  may  be  contracted  by  staff  who  may 
have  been  vaccinated,  but  whose  vaccination  has 
not  been  brought  up  to  date.  The  sound  rule  in 
this  connection  is  that  in  force  at  the  Smallpox 
Hospitals  of  the  Metropolitan  Asylums  Board. 
The  rule  is  to  re-vaccinate  every  applicant  for 
smallpox  duty,  unless  he  or  she  can  show  a 
pigmented  foveated  scar  indicating  recent  and 
successful  vaccination.  If  the  first  operation  is 
not  successful,  it  is  twice  repeated  with  a  strain 
of  lymph  known  to  be  potent. 

On  any  threatening  or  alarm  of  smallpox, 
one  of  the  things  that  a  medical  administrator 
has  to  see  to  is  that  the  state  of  vaccination 
of  his  staff  is  up  to  date.  This  must  be  closely 
attended  to.  Many  excuses  and  pleas  may  be 
put  forward  to  avoid  re-vaccination.  They  are 
not  to  be  regarded  if  accidents  are  to  be 
avoided.  Staff  should  not  be  allowed  to  proceed 
on  smallpox  duty  unless  their  condition  as  to 
vaccination  is  satisfactory  to  the  responsible  officer. 
Accidents  are  apt  to  occur  from  reliance  being 
placed    upon    second-hand    instead    of  first-hand 


68  VACCINATION  [ch.  viii. 

evidence  of  vaccination.  That  is  to  say,  staff 
assert  that  they  had  bad  arms  on  such  and  such 
a  date,  or  quote  some  one  else's  opinion  or  bring 
a  medical  certificate.  If  they  can  show  evidence 
of  recent  and  successful  vaccination,  Le,  by  means 
of  a  foveated  and  pigmented  scar — both  conditions 
must  be  present — they  may  be  passed ;  or  if  they 
bring  a  certificate  of  successful  vaccination,  at  a 
recent  date,  from  a  physician  whose  skill  as  a 
vaccinator  is  well  known,  they  may  be  passed. 
Otherwise  they  should  be  re-vaccinated.  To  allow 
persons  to  be  exposed  to  smallpox  about  whose 
protection  there  is  any  doubt  is  to  incur  grave 
responsibility. 

The  same  remarks  apply  to  visitors,  workmen, 
tradesmen,  contractors'  men  and  others  who  may 
be  occasionally  near  or  about  smallpox  cases. 
Each  case  must  be  taken  on  its  merits  and 
submitted  to  the  medical  officer  who  is  responsible 
for  their  safety.  It  is  for  him  to  decide  if  vaccina- 
tion is  necessary.  He  should  take  no  risks  in  the 
matter,  no  matter  what  pressure  is  brought  to 
bear.  If  accidents  occur,  the  responsibility  is  his 
and  his  alone,  a  matter  not  always  borne  in  mind 
by  persons  who  may  bring  pressure.     It  is  of  no 


CH.  VIII.]  AND  SMALLPOX  69 

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  v^ill  fall,  and  it  is 
for  him  to  take  appropriate  measures. 


70  A  COMPLICATED  [ch.  ix. 


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  compUcated  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  con- 
fronted 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 


CH.  IX.]  OUTBREAK  71 

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  De- 
partment 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  chicken- 
pox.  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 


72  A  COMPLICATED  [ch.  ix. 

from  the  same  ward  were  certified  to  be  suffer- 
ing 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  In- 
firmary visitor  who  was  a  friend  of  a  patient. 


CH.  IX.]  OUTBREAK  73 

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  super- 
vision 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). 


74  A  COMPLICATED  [ch.  rx. 

4.  Infirmary  visitors. 

5.  Infirmary  resident  staff. 

6.  Infirmary  non-resident  staff. 

7.  School-children  and  staff. 

8.  Friends,  workmates,  and  schoolmates  of  the 
later  cases. 

These  groups  of  people  the  Medical  Officer 
of  Health  arranged  to  keep  under  observation  in 
the  following  manner : — 

1.  The  patient's  family  was  removed  in  its 
entirety  to  a  Contact  Shelter ;  disinfection  was 
then  completely  carried  out  at  the  home,  and 
the  remaining  members  of  the  family  were  kept 
under  observation. 

2.  The  occasions  of  possible  infection  at  the 
hospital  were  ascertained,  re-vaccination  of  staff 
was  carried  out,  the  hospital  authority  fully 
apprised  and  due  warnings  given;  exposed  stafi 
were  kept  under  observation. 

3.  (a)  At  the  Infirmary  appropriate  measures 
were  taken,  including  examination,  re-vaccination, 
and  constant  observation  of  patients ;  disinfection 
was  attended  to,  and  the  Infirmary  was  placed  in 
quarantine. 

{b)  The  homes   of   the  sixty  patients  in  the 


CH.  IX.]  OUTBREAK  76 

affected   ward   were   visited    daily,   and    inquiries 
made  of  the  health  of  the  inmates. 

{c)  Sixty-five  patients  had  been  discharged  from 
the  Infirmary  while  the  original  unrecognised  small- 
pox case  was  there.  They  were  all  visited  daily 
and  examined.  One  case  of  smallpox  was  thus 
discovered. 

4.  (a)  There  had  been  visitors  to  the  infected 
ward  from  sixty-eight  houses  in  the  Borough 
during  the  time.  All  these  houses  were  visited 
daily  and  inquiries  made  of  the  health  of  the 
inmates.  One  case  of  smallpox  was  discovered 
among  them. 

(b)  There  had  been  also  visitors  from  forty-five 
houses  outside  the  Borough.  The  addresses  of 
these  houses  were  communicated  to  the  health 
authorities  having  appropriate  jurisdiction,  and  the 
persons  concerned  were  kept  under  observation. 

(c)  Visitors  to  the  Infirmary  from  the  work- 
house were  kept  under  observation. 

5.  The  Infirmary  indoor  staff  were  re- 
vaccinated. 

6.  There  were  sixty-five  non-resident  staff. 
Their  homes  were  visited  daily  and  inquiries  made 
of  the  health  of  the  inmates. 


76  A  COMPLICATED  [ch.  ix. 

7.  School-children.  First  it  was  necessary  to 
ascertain  what  schools  had  been  attended  by  the 
various  patients  ;  then  to  proceed  to  those  schools 
and  confer  with  the  head  teachers  and  learn  what 
classes  the  sick  children  had  attended  ;  to  learn  on 
what  days  they  had  last  attended  and  what  was 
then  their  condition. 

Any  contacts  residing  in  a  house  where  there 
had  been  a  case  of  smallpox  were  at  once  excluded 
from  school,  and  were  kept  under  medical  obser- 
vation at  home  like  other  contacts. 

The  schools  were  visited  daily  by  medical  staff, 
and  teachers  were  asked  to  bring  to  notice  all 
children  who  seemed  in  any  way  unwell,  or 
presented  any  suspicious  spots. 

A  note  of  school  absentees  was  daily  forwarded 
to  the  responsible  medical  officer  of  health,  together 
with  a  note  of  their  last  attendance.  Such  absentees 
were  daily  visited  at  home  until  smallpox  could  be 
excluded. 

The  result  of  these  various  proceedings  was 
that  the  Medical  Officer  of  Health  of  the  Borough 
was  able  to  cut  short  a  very  ugly-looking  outbreak, 
and  to  limit  it  to  dimensions  smaller  than  at  first  had 
seemed  possible.     Although  there  were  38  patients 


CH.  IX.]  OUTBREAK  77 

within  the  first  week,  the  whole  outbreak  totalled 
no  more  than  70. 

As  a  matter  of  detail  in  the  observation  of  con- 
tacts, it  is  useful  for  the  responsible  officer  to 
furnish  himself  and  his  assistants  with  simple 
manuscript  books  ruled  on  the  principle  of  a 
medical  practitioner's  visiting  book.  The  dates  of 
visits  and  conditions  of  contacts  can  then  be 
entered  at  the  time  and  on  the  spot  by  the  visitor 
reports  can  be  made  accurately  and  expeditiously  to 
the  supervising  officer;  who  is  thus  enabled  to  keep 
himself  well  posted  in  a  most  vital  portion  of  his 
work,  viz.  the  exact  condition  of  the  contacts. 

The  circumstances  of  each  outbreak  vary,  and 
so,  of  course,  must  the  details  of  the  remedial 
measures.  It  is  not  uncommon,  for  instance,  to 
find  that  infection  has  been  distributed  at  some 
social  function,  such  as  a  Christmas  party,  or  a 
funeral.  Another  example  was  that  at  the  begin- 
ning of  the  1901-1902  outbreak  in  London,  when 
smallpox  got  amongst  a  camp  of  hoppers  in  Sussex  ; 
of  those  who  were  ill  some  were  detected  on  their 
return  to  London.  From  the  description  which 
these  patients  gave  of  some  of  their  friends,  it  was 
certain  that  some  of  the  latter  also  had  smallpox. 


78  A   COMPLICATED   OUTBREAK        [ch.  ix. 

It  was  ascertained  by  what  train  they  were  travel- 
ling. The  train  was  met  in  London,  and  some  of 
the  passengers  were  picked  out  with  the  rash  of 
smallpox  on  them. 

The  subject  of  common  lodging-houses  has 
already  been  mentioned.  See  page  55.  They 
may  be  fruitful  breeding  grounds  of  smallpox, 
and  require  special  measures.  It  is  well  known 
how  likely  the  vagrant  population  is  to  spread 
smallpox,  and  how  difficult  it  is  to  keep  such 
contacts  under  observation.  For  instance.  Sir 
Shirley  Murphy  relates,  in  his  Report  of  the  year 
1901,  p.  28,  that  in  October  of  that  year  a  woman, 
who  frequented  common  lodging  -  houses  in 
Holborn  and  Westminster,  remained  at  large  for 
four  days,  having,  while  suffering  from  smallpox, 
escaped  from  an  Infirmary,  where  her  disease 
had  been  recognised.  As  a  direct  result,  a  very 
large  number  of  persons  were  infected  in  the 
two  districts ;  "  she  visited  nearly  every  public- 
house  in  the  district,  and  from  each  one  into 
which  she  had  been,  one  or  more  of  the  inmates 
or  customers  took  smallpox."  See  also  the  Report 
of  the  Medical  Officer  of  Health  of  the  City  of 
Westminster  for  the  year  1901. 


CH.  X.]  RECAPITULATION  79 


CHAPTER    X 

RECAPITULATION 

It  is  convenient  to  recapitulate,  by  way  of  con- 
clusion. There  are  certain  general  considerations 
to  be  borne  in  mind.  Instant  action  must  be 
taken ;  personal  attention  must  be  given ;  there 
must  be  a  well-thought-out  plan ;  success  depends 
on  the  closest  attention  to  details,  and  on  no 
detail  being  allowed  to  escape  notice. 

A  smallpox  epidemic,  in  the  nature  of  things, 
is  a  very  expensive  affair.  But  the  expense  of 
providing  and  working  an  effective  apparatus  for 
bringing  it  speedily  to  an  end  is  much  less  than 
that  of  allowing  it  to  drag  on.  It  is  necessary 
to  mention  this,  because  at  the  beginning,  which 
is  especially  the  time  when  an  outbreak  can  be 
got  under  control,  and  perhaps  the  only  time, 
there  may  be  a  tendency  to  work  with  the  smallest 


80  RECAPITULATION   OF  [ch.  x. 

possible  margin  of  men  and  money.  There  may- 
be a  small  saving  in  such  a  plan  at  the  moment. 
But  it  is  apt  to  be  a  most  costly  economy, 
and  to  be  followed  by  a  dragging  string  of  cases, 
or  even  by  a  big  outburst,  which,  from  the  direct 
loss  of  life,  the  dislocation  of  business,  and  the 
great  outlay  for  measures  which  ultimately  become 
necessary,  costs  much  more  than  ample  measures 
would  have  cost  at  the  beginning. 

True  economy  is  to  throw  the  whole  admini- 
strative weight  upon  the  mischief  at  the  earliest 
moment,  and,  where  there  is  any  doubt,  to  err  on 
the  side  of  excess.  It  may  be  that  the  out- 
break is  over-attacked,  so  to  speak ;  sometimes 
that  cannot  well  be  avoided.  Even  so,  it  is  far 
cheaper  in  the  end.  The  cheapest  policy  is  to 
throw  in  every  ounce  of  weight  instantly,  and 
to  crush  the  outbreak  at  the  beginning. 

By  way  of  summary,  it  is  useful  to  have 
a  handy  reference-list  of  steps  which  should  be 
taken  on  the  outbreak  of  smallpox  in  a  district. 
When  smallpox  suddenly  breaks  out,  there  is  little 
time  for  thinking  ;  plans  must  all  be  ready,  and 
put  into  instant  operation. 

The  main  indications  are  these  : — 


CH.  X.]  ADMINISTRATIVE  MEASURES  81 

1.  To  ascertain  the  extent  of  the  existing  mis- 
chief, and  its  origin. 

2.  To  eradicate  the  existing  mischief. 

3.  To  arrest  its  further  spread  by  watching  for 
fresh  cases,  and  rendering  them  harmless  as  they 
occur. 

Among  the  detailed  steps  which  have  to  be 
taken  are — 

1.  ^*  Telephone  the  case  away,"  ix.  summon  an 
ambulance,  and  arrange  for  the  patient's  imme- 
diate removal.  It  is  useful  to  give  instructions 
that  the  time  of  removal  of  patient,  or  any  delay 
in  removal,  be  at  once  reported  to  you. 

2.  Communicate  with  the  certifying  prac- 
titioner, and  obtain  all  particulars  possible. 

3.  Despatch  staff  to  the  spot  to  make  inquiries, 
to  superintend  the  patient's  removal,  and  to  carry 
out  disinfection. 

4.  Advise  the  vaccinating  officer  or  public 
vaccinator. 

5.  Personally  proceed  to  the  spot,  and  ascer- 
tain extent  of  existing  mischief. 

6.  Obtain  the  history  of  the  source  of  infection. 
Obtain  from  patient  or  friends  (1)  a  note  of  his 
movements  at  time    of   infection,   and  ascertain 

G 


82  RECAPITULATION   OF  [ch.  x. 

who  may  have  given  it  to  him  ;  and  (2)  a  note  of 
his  movements  after  his  illness  began  and  ascertain 
to  whom  he  may  have  given  it. 

7.  Obtain  list  of  contacts. 

8.  Push  further  inquiries  as  to  workplaces, 
schools,  laundries,  and  other  similar  collections  of 
persons. 

9.  Offer  re-vaccination  to  contacts,  and,  if 
necessary,  by  house-to-house  calls. 

10.  Make  house-to-house  inquiries,  if  necessary. 

11.  Bring  vaccination  of  smallpox  staff  up  to 
date. 

12.  Consider  notification  of  chickenpox. 

13.  Consider  sending  information  of  cases  to 
practitioners  in  district. 

14.  Arrange  for  medical  supervision  of  contacts. 

15.  Warn  heads  of  common  lodging-houses, 
casual  wards,  workhouses,  infirmaries,  hospitals. 

16.  Advise  public  health  colleagues  in  neigh- 
bouring or  other  districts  about  contacts  proceed- 
ing thither,  and  about  other  material  facts. 

17.  Make  reports  to  proper  authorities. 
Other  measures   may  be  necessary,   and  will 

be  dictated  by  the  special  circumstances  of  the 
case.        It    may    be     necessary    to    open    local 


CH.  X.]         ADMINISTRATIVE   MEASURES  83 

vaccination  stations  for  school  children  or  others, 
to  distribute  hand-bills  to  the  public,  or  take  other 
appropriate  measures. 

Success  depends  on  two  things.  The  first  is 
a  well-prepared  plan.  The  second  is  tireless 
attention  to  details  of  action. 


G  2 


INDEX 


Black  Death,  The,  3 

Card  register,  30 

Chickenpox,  diag-iiosis  of,  42,  71 

,  notification  of,  37 

Circular  of  the  Local  Government 

Board,  52 
Common  lodging-houses,  55,  78 
Complicated    outbreak,    example 

of,  70  et  seq. 
Concealment  of  smallpox,  25 
"  Contact,"  meaning  of  word,  27 
Contacts,  27,  47,  49,  51,  55,  73 

,  shelter  for,  74 

Cycles  of  smallpox,  9 

Dates  of  a  typical  case,  12 

of  the  rash  of  smallpox, 

12,25 
Davies,  Dr.  Sidney,  19 
Dudfield,  Dr.  T.  Orme,  33 

Early  morning  inspections,  55 

Epidemic  compared  with  a  con- 
flagration, 1,  3,  4,  7,  8,  10 

Epidemiological  Society,  2,  6 

Essentials  of  success,  83 

Evidence  of  recent  and  successful 
vaccination,  67,  68 

Examples  of  smallpox  outbreaks, 
6,  13,  19,  26,  28,  70,  71,  72,  78 

Fiji  Islands,  1 ,  2 
First  steps  for  stopping  an  out- 
break, 16  et  seq. 

General  review  of  subject,  1-10 


HiEMORRHAGic  smallpox,  13 
Highgate  Smallpox  Hospital,  65 
Hoppers,  smallpox  among,  77 
Hospital  administration,  40 

staff,  40 

House-to-house  inspection,  29 

Illustrations  of  smallpox    out- 
breaks, 6, 13,  19,  26,  28,  70,  71, 
72,78 
Importance  of  complete  informa- 
tion, 39 
Incorrect  diagnoses,  15,  18,  35, 

71 
Incubation  period  of  smallpox,  5, 

11 
Infants  escaping  smallpox,  63 
Infection,  striking  power  of,  13 
Infectiousness,  period  of,  14 
Intelligence  department,  32  et  seq. 
Introduction  of   smallpox  infec- 
tion, instance  of,  6 

Latest  date  for  vaccinating  per- 
sons exposed  to  smallpox,  65 

Laundries,  28 

Local  Government  Board  circular, 
52 

Lodging-houses,  common,  55,  78 

Main  indications  for  dealing  with 

smallpox,  16 
Maintenance  of  contacts,  61 
Marson,  Mr.,  65 
Measles,  1 
Medical   observation,  importance 

of,  49 


86 


INDEX 


Mischief  of  delaying  vaccination, 

21 
"  Missed^'  cases,  15, 18,  35,  71 
Modes  of  spread  of  infection,  5, 

6,23 
Murphy,  Sir  Shirley,  37 

NuaiBEK  of  contacts  per  case,  55 

Observation  of  contacts,  49 
Outbreaks  of  smallpox,  examples 

of,  6,  13,  19,  26,  28,  70,  71,  72, 

78 

Period  of  infectiousness  of 
smallpox,  14 

Period  of  observation  of  contacts, 
49 

Protection  conferred  by  vaccina- 
tion, 63 

Recapitulation,  79 
Removal  to  hospital,  41,  42 
Reports  from  staff,  43 

to  authorities,  44 

,  method  of  keeping  and 

making,  30,  45 
Re-vaccination,  66 
Review  of  subject,  general,  1-10 


Rotume,  2 

Russell,  Mr.  T.  W.,   6 

Schools,  28 

School  children,  observation  of,  76 

Smallpox  among  hoppers,  77 

in  an  infirmary,  70 

in        common       lodging- 
houses,  55,  78 

hospitals,  61,  67 

outbreaks,  examples  of,  6, 

13,  19,  26,  28,  70,  71,  72,  78 
Spread  of  infection,  5,  6,  23 
Staff,  vaccination  of,  67 
Staley bridge,  6 
Success,  essentials  of,  83 
Summary  of  administrative  steps, 

81 
^'  Suspect,^'  meaning  of,  27 

Tangier,  19 
Thomas,  Dr.  D.  L.,  70 

Vaccination,  8,  20,  46,  60  et  seq. 
Variability  of  type  of  smallpox,  15 
Visitors  to  smallpox  hospitals,  68 

Woolwich,  19 
Workplaces,  28 


THE   END 


PRINTBD  BY  WILLIAM  CLOWES  AND  SONS,  LIMITED,  LONDON  AND  BKOCLES. 


BY    THE    SAME    AUTHOR 

LONDON    PUBLIC    HEALTH 
ADMINISTRATION 

A  Summary  showing  the   principal   authorities,  with  their   origin, 

services  and  powers. 

With  24  pages  of  writing  paper  for  Notes, 

Fcp.  8vo,  2s.  6d.  net. 

"  This  handbook  will  be  of  great  use  to  others  besides  the  foreign 
visitors,  interested  in  public  health  administration,  for  whom  it  is 
intended.  It  presents  a  conspectus  of  London  public  health  adminis- 
tration in  very  handy  and  simple  form.  The  first  ten  pages  or  so  are 
occupied  with  a  list  of  the  authorities  and  a  summary  (but  adequate) 
account  of  their  origin.  This  is  followed  by  a  tabular  arrangement  of  the 
various  forms  of  service,  and  opposite  to  each  is  placed  a  short  account 
of  the  principal  legislation  and  the  authorities  concerned.  The  services 
are  grouped  into  (1)  Administration  principally  afEecting  the  normal 
individual,  from  birth  to  death ;  (2)  administration  principally  affecting 
the  dwelling ;  (3)  administration  of  the  food  supply ;  (4)  administration 
of  the  very  poor;  (5)  administration  of  the  sick.  This  useful  table  is 
followed  by  a  chronological  list  of  the  Acts  of  Parliament  concerned  and 
by  an  excellent  index." — Morning  Post. 

•'  Even  the  Londoner  himself,  whether  a  member  of  any  of  the  local 
bodies  or  not,  will  find  it  interesting  and  helpful.  Chapter  one,  pleasantly 
and  interestingly  written,  will  show  him  from  what  small  beginnings  the 
great  public  administration  has  grown,  and  chapter  two,  which  shows  the 
works  to  be  done,  by  whom  they  are  done,  and  the  powers  under  which 
they  are  carried  out,  will  convey  to  him  better  than  anything  else  the 
diversity  of  the  problem  of  keeping  him  in  health,  and  the  methods 
adopted  to  attain  that  object.  As  a  reference  and  guide  book  Dr. 
Wanklyn's  is  probably  unique,  and  should  admirably  fulfil  the  purpose 
for  which  it  is  intended.^' —Medical  Officer. 


London  Public  Health  Administration — cont. 

*' .  .  .  An  admirable  guide  to  the  intricate  working  of  Public  Health 
Administration  in  London,  and  in  addition  to  being  of  service  to  strangers 
who  wish  to  investigate  the  subject — the  object  for  which  the  book  is 
primarily  written — it  also  serves  to  bring  before  the  notice  of  all  who  may 
see  it  the  enormous  number  of  agencies  already  at  work  and  the  frequent 
Acts  of  Parliament  which  seem  necessary  for  their  evolution. 

"  It  is  !called  a  Summary,  and  such  it  is.  The  information  is  given 
in  tabulated  form,  and  in  the  most  concise  terms.  The  introductory 
chapter,  brief  though  it  is,  is  of  peculiar  interest,  and  all  will  be  interested 
to  read  it." — Middlesex  Hosjpital  Journal. 

"  This  is  a  useful  little  handbook.  The  authorities  are  such  a  chaos 
to  the  uninformed  that  the  average  person  never  attempts  to  make 
himself  acquainted  with  the  subject.  With  this  book  he  will  be  able  to 
get  on  the  track  of  any  question  he  desires.  For  instance,  if  he  wish  to 
know  what  authorities  deal  with  the  milk  supply  he  need  only  turn  to  the 
index,  and  under  •  milk '  he  will  find  a  list  of  the  Acts  of  Parliament 
containing  regulations  on  the  matter  and  a  brief  account  of  the  powers 
vested  in  the  various  local  authorities." — TJie  Clarion. 

"  ,  .  .  The  book  should  be  of  the  greatest  use  to  more  than  foreign 
visitors;  the  mass  of  information  it  contains  is  arranged  in  tabulated 
form  so  that  information  concerning  any  matter  is  found  easily  and 
quickly.  A  most  valuable  book  of  reference  for  all  whose  work  brings 
them  in  contact  with  Public  Health  Authorities  and  legislation." — 
Nursing  Notes. 

"  The  object  of  this  admirable  little  work  is  to  show  in  a  convenient 
form  the  principal  authorities  who  are  charged  with  preservation  of  the 
health  of  London,  with  their  origin,  their  services,  and  their  powers.  It 
is  invaluable  for  any  one  who  is  engaged  in  municipal  work  or  pro- 
visionaly  concerned  with  any  of  the  services  with  which  it  deals." — The 
Ohbe, 


LONGMANS,  GREEN  &  CO. 
LONDON,   NEW  YORK,   BOMBAY,  AND   CALCUTTA 


LJf> 


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