COMMONWEALTH OF AUSTRALIA

DEPARTMENT OF HEALTH

»

SERVICE PUBLICATION NUMBER 29

The History of Small-Pox

in Australia

1909-1923

J. H. L, CUMPSTON, M.D., D.P.H.,

Director-General of Health and Director of Quarantine, AND

F. McCALLUM, m.b., b.s., d.p.h., d.t.m„

Quarantine Officer,

Commonwealth Department of Health

ISSUED UNDER THE AUTHORITY OF THE MINISTER FOR HEALTH

1925

BY AUTHORITY »

H. J. GREEN. GOVERNMENT PRINTER, MELBOURNE,

°>fc bfif.&ioqq4

/» ¿ Ur MU


/ff öS

COMMONWEALTH OF AUSTRALIA

DEPARTMENT OF HEALTH

SERVICE PUBLICATION NUMBER 29

The History of Small-Pox in Australia

1909-1923

£y

J. H. L. CUMPSTON, m.d., d.p.h.,

Director-General of Health and Director of Quarantine, AND

F. McCALLUM, m.b., b.s., d.p.h., d.t.m.,

Quarantine Officer,

Commonwealth Department of Health

ISSUED UNDER THE AUTHORITY OF THE MINISTER FOR HEALTH 1925

BY AUTHORITY :

H. J. GREEN, GOVERNMENT PRINTER, MELBOURNE.

C.72Ï9.

*-



i!

¡i



PREFACE.

This volume follows on directly in sequence with a previous volume dealing with the History of Small-pox in Australia from 1788 to 1908. It provides much food for serious reflection and offers records of the occurrence of small-pox which are a material contribution to the literature on this subject.

The occasion of the occurrence of small-pox on shipboard and within a community which is normally free from small-pox and is largely without compulsory infantile vaccination, bring into relief the following aspects of the epidemiology of this disease :—

(1)    the short range of spread of the infection ;

(2)    the comparatively low degree of infectivity ;

(3)    the irregular incidence of attack amongst persons equally

exposed ;

(4)    the anomalies in the relationship between attack by small-pox

and varying degrees of vaccination immunity.

J. H. L. CUMPSTON, M.D., D.P.H.,

Director-General of Health.

June, 1925.

TABLE OF CONTENTS.

PAGE

1

20

30


79

85

87

87

95


Chapter I.—The Present Position of Australia in regard to the Risk from Small-pox ..    ..    ..    ..    ..    ..    ..

Introductory, 1 ; The development of a uniform quarantine system under Federal control, 2 ; Details of the quarantine administration and procedure adopted, 7.

Chapter II.—The World Course of Small-pox, 1909-1923, in relation to Australia ..    ..    ..    ..    ..    ..    ..    ..

Prevalence in oversea countries, 20 ; Seasonal variation, 27 ; extent of oversea communication with Australia, 30.

Chapter III.—Small-pox in New South Wales ..    ..    ..    ..

The 1913 outbreak, 30; Records of the epidemic, 31 ; Onset of the epidemic, 31 ; Origin of the infection, 33 ; Course of the epidemic, 34 ; Seasonal distribution, 42 ; Sex and age distribution, 44; Nationality, 47 ; Type of the disease, 48 ; Period of invasion, 49 ; Initial fever, 50; Duration of invasion period, 50 ; Quiescent period, 51 ; Prodromal rashes, 51 ; The eruption, 52 ; Classification of eruptions, 53 ; Type of eruption, 54 ; Distribution, 55 ; Small-pox without eruption, 57 ; Secondary fever, 57 ; Stage of convalescence, 58 ; Complications, 58 ; Influence of the disease on pregnancy, 59 ; Fatality, 60 ; Incubation period, 62 ; Infectivity, 63 ; Influence of vaccination, 66; Errors in diagnosis, 69; Laboratory findings, 70; Spread of the disease between different localities, 71 ; Variation in type of the disease during the course of the outbreak, 72 ; Comparison with oversea types of mild variola, 73 ; Administrative measures adopted for the control of the outbreak, 75 ; Quarantine measure, 75; Vaccination, 76; Isolation and treatment of cases, 76 ; Control of contacts, 77 ; Continuance of administrative measures of control, 79.

Chapter IV.—Small-pox in Victoria    ..    ..    ..    ..    ..

The 1921 outbreak, 79 ; The Melbourne cases, 80 ; The Geelong cases, 81; Measures of Control, 83; Review, 84.

Chapter V.—Small-pox in Queensland    ..    ..    ..    ..    ..

The 1913 outbreak, 85 ; Nature of the illness, 85 ; Coincident cases of suspicious eruptions, 86 ; History and source of infection, 86 ; Measures of control, 91.

Chapter VI.—Small-pox in South Australia ..    ..    ..    ..

One case amongst the shore community, 1915, 87.

Chapter VII.—Small-pox in Western Australia    ..    ..    ..

The Bunbury outbreak, 1914, 87 ; Origin of infection, 87 ; Particulars of cases, 89 ; Vaccination history of cases, 92 ; Control measures, 93 ; Features of the outbreak, 93.

Chapter VIII.—Immunity of Tasmania    ..    ..    ..    ..    ..

Chapter IX.—Vaccination in Australia    ..    ..    ..    ..

Statistics of vaccination in Australia, 1909-1923, 95 ; Recommendations of interstate conferences, 97 ; Vaccination in each State, 98 ; The extent to which the Australian community is now protected by vaccination, 106.

PAGE

Chapter X.—Vessels Arriving in Australian Waters which have been Infected with Small-pox during the Voyage, or which were Infected on Arrival    ..    ..    ..    ..    ..    ..    ..    107

(a) Vessels which have arrived in Australia with one or more cases of small-pox on board, 110 ; (b) Vessels which have arrived in Australia, having landed one or more cases at an oversea port, or having had cases on board which died and were buried at sea, 183 ; (c) Vessel not quarantined, but subsequently shown to have been concerned with the introduction of smallpox into Australia, 195 ; (d) Coastwise vessels on which cases have developed on board, 196 ; (e) Vessels which have been quarantined, having on board one or more cases suspected to be small-pox, 200.

Chapter XI.—The Epidemiology of Small-pox on Vessels Bound for

Australia ..    ..    ..    ..    ..    ..    ..    204

Chapter XII.—Occasions on which Small-pox has been Introduced into

Australia from Oversea by Known or Suspected Vessels ..    ..    217

New South Wales, 1913,217 ; Western Australia, 1914, 220 ; South Australia, 1915, 221 ; Victoria, 1921, 221 ; Review, 223.

Chapter XIII.—-The Epidemiology of Small-pox in Australia    ..    .. 225

Chapter XIV.—Small-pox in Australia, 1788-1908, Addenda    ..    .. 229

Chapter XV.—The Compilation of Records by Ships’ Surgeons of Smallpox Cases Occurring on Vessels at Sea ..    ..    ..    ..    237

The importance of developing records relating to maritime epidemiology,

237 ; Suggested schedule for records, 238.    ,

THE PRESENT POSITION OF AUSTRALIA IN REGARD TO THE RISK FROM SMALL-POX.

Introductory.

In a previous volume1 the history of small-pox in Australia has been traced, so far as records are available, from the earliest years of settlement up to the year 1909. In that year a Commonwealth quarantine service was established, a realization of the aims of those far-sighted sanitarians who had advocated the desirability of uniformity in quarantine control as long before as the Intercolonial Sanitary Conference of 1884.

With the inception in 1909 of uniform measures of maritime quarantine in all ports of the Commonwealth and the compilation of uniform records, there has accrued much valuable information of epidemiological importance. During the fifteen years, 1909 to 1923, 60 vessels have arrived in Australian ports having on board one or more cases of smallpox, and 22 vessels have arrived within the quarantine period of eighteen days after having landed one or more cases at oversea ports. On four occasions the quarantine barrier has been passed, and there have resulted two small localized outbreaks, in Western Australia and Victoria, and a widespread but singularly mild outbreak in New South Wales, which extended over five years. In 1914 one case occurred amongst the shore community in South Australia, following an outbreak on a recently arrived steamship.

In reviewing the history of small-pox in Australia during this period, it is the aim of this volume to analyse the records of vessels quarantined and of the outbreaks which have occurred. It has been pointed out in the previous volume (page 121) that there have been times when “ the measures of defence at the frontier (maritime quarantine) have been defective, yet there have been other times when no quarantine organization, however perfect, could have prevented the introduction of the disease. That such occasions as these latter will be many times repeated in the future, is in the nature of things inevitable, and a careful study of the behaviour of the disease under Australian conditions is, therefore, imperative, in order that the probable behaviour in the future may be forecasted and suitably provided against.7’ The matter is rendered the more urgent in that in those two remaining States where infantile vaccination was compulsory in 1909, Western Australia and Victoria, the loophole of a “conscience clause” has provided for the community a method of evading the protection of vaccination. The fact that quarantine is a “ sieve and not a dam ” has failed to be appreciated', although it was as long ago as 1852 that

Dr. H. Gr. Alleyne, then Port Health Officer at Sydney, enunciated the first principles of maritime quarantine in its relation to the public health of the community:—“ A perfect system of public hygiene should aim at the prevention and removal of all the accessory causes as well

as at the exclusion of all the existing causes of disease.....The

only mode of rendering our system of quarantine more efficient is to make our code of health more perfect, and not to allow the protection afforded by the use and common-sense precautions of quarantine to be weakened by laxity of all other sanitary rules.” (Minutes of Evidence of the Select Committee on the Quarantine Laws, Sydney, 1853.) In brief, the facts as they stand at present are these: The onus of preventing the introduction of small-pox into Australia rests entirely on the maritime quarantine measures in force; such quarantine measures impose on shipping restrictions which often result in inconvenience and economic loss to ship-owners, consignees, and the travelling public. On the other hand, the Australian community is fast becoming entirely unprotected by vaccination; whilst small-pox even in its so-called benign form is a troublesome and disfiguring disease, and the control measures necessary to combat an outbreak on shore, even when reduced to the minimum compatible with safety, impose on the community irksome and expensive restrictions. Such considerations emphasize the need for continuous study and review of the efficacy of the quarantine measures adopted, and of the recorded behaviour of small-pox as it has appeared in Australia in the past.

Any quarantine study obviously implies a world-wide survey of the behaviour of the disease in question, and more especially of the course of that disease in countries and ports in constant or close communication with, or lying along the trade routes leading to the country concerned. The position of Australia in the quarantine aspect is unique; firstly, in that, at the present time, none of the major quarantinable diseases (excluding leprosy, and possibly the typhus-like cases in South Australia) exist in the community; secondly, in that in its relation to endemic and epidemic foci, particularly of the Far East, Australia lies within easy striking distance of such a disease as small-pox, since a case in the incubation period can land prior to the onset of symptoms. This latter aspect becomes emphasized each year with the increased speed and extension of oversea transport, and the probable development within the near future of regular travel by air.

Development of a Uniform Quarantine System under Federal

Control.

The evolution of quarantine practice and administration, both in oversea countries and in Australia, have already been fully discussed in previous Service Publications.2 The International Sanitary Con

ventions which have met in various countries since 1851 have aimed at securing mutual safeguards against the export of, and protection against the invasion of disease, and uniformity of quarantine practice. These assemblies find a counterpart in Australia in the Intercolonial Sanitary Conferences which met in 1884 and 1896, with the fundamental difference, however, that in regard to European countries, cholera and plague were the diseases against which protective measures were aimed; in the American countries, yellow fever and small-pox were also considered; whilst in Australia the development of the system of quarantine was intended almost entirely to prevent the introduction of smallpox, of which there was, in 1881, and subsequent years, a serious outbreak prevailing in Sydney. As bearing on the subject under discussion, and as indicating the evolution of a- federal system of quarantine in Australia up to the time of its actual establishment in 1909, it might be well to quote verbatim the account which has been already published in Service Publication Ho. 2 now out of print.

Sanitary Conferences in Australia.

After Australia had been free from any extensive epidemic of smallpox for a period of thirteen years a serious outbreak occurred in Sydney in 1881. Following this there were scattered cases, and in 1884 the disease became extensively prevalent, affecting Hew South Wales, Victoria, and South Australia. Prior to this there had been several definite outbreaks in Australia-—Melbourne, 1857 and 1868; Sydney, 1877—and the danger of small-pox to the community was very definitely before the minds of those in authority. In addition to this, as each of the Australian States had its own law and practice, and these differed materially as between the States, considerable confusion and irritating obstruction to commerce, especially by sea, was found to result.

“ As a direct result of these two factors the Hew South Wales Government invited the Governments of the other States to send representatives to confer and report as to the best means of establishing a uniform and effective system of quarantine for Australia. The two words here used— “ uniform ” and “ effective ”—constitute the keynote of the objects of this and all subsequent Australian Sanitary Conferences. The striving after uniformity has had its direct outcome in the present Commonwealth system of quarantine—a system uniform for all Australia and under one central direction. The determination to secure efficiency led naturally to the discussion of those diseases wdiich wTere most seriously to be feared in Australia. The Australian Conferences, therefore, were moved by exactly the same impulses and toward exactly the same ends as all other Conferences; but just as the European Conferences discussed the disease which most threatened European countries—cholera, and later plague; and just as American Conferences devoted themselves almost entirely to the disease peculiarly dangerous to America—yellow

fever, and later, plague—so Australian Conferences inspired by identical apprehensions, have devoted themselves primarily to smallpox, and later, to plague.

Australia has never known cholera or yellow fever except on vessels arriving off the coast ; but it has known very serious epidemics of smallpox, and has learned how great a loss of human life and how serious a hindrance to traffic and commerce, and how great a burden of cost to the community, is produced by this disease.

First Conference, Sydney, 1881.The greater part of the deliberations of this Conference were directed towards the production of a uniform Federal system of quarantine, and many of the resolutions deal with the details of this system. At that time, and indeed until 1908, there was no system introduced under any Commonwealth Act, and accordingly the system proposed by their delegates was based upon the assumption that all the States would act in unison and co-operate in detail. Provision was made for the introduction into each of the State Parliaments of a uniform Quarantine Bill, so that although there was no combined action in any other political sphere, uniform administration in quarantine would be insured by the passage of these several Acts to be known in each State as the Federal Quarantine Act. It was agreed by the Conference that Part VI. of the Public Health Statute 1865 of Victoria, should be the basis of this Federal Quarantine Act, and, although the Act has in its evolution changed considerably, yet this original basis can still be traced in the form of the existing Commonwealth Quarantine Act. Provision was made for the establishment of Federal quarantine stations at Albany and at Thursday Island, the ports first reached by vessels making Australia from the westward and northward respectively, these stations to be under the joint control of all the States.

The procedure to be adopted on the arrival of vessels was also laid down.

In the case of clean ships, from whatever port they may have come, no obstructions to the landing of passengers was permitted. Certain measures of disinfection were allowed at the discretion of the Health Officer.

In the case of vessels infected with cholera it was prescribed that “ all hands except such as are actually necessary to cleanse the ship expeditiously and thoroughly, shall be landed at the quarantine ground at the terminal port, where they shall be detained for a period of not less than ten days.”

In the case of vessels infected with yellow fever it was prescribed that “ if no cases of yellow fever have occurred on board during the voyage, being more than ten days from the

date of leaving the infected port, the passengers may be admitted to pratique, but that if any cases have occurred on board, the passengers and crew shall be detained for ten clear days on shore at the quarantine ground, and their effects, as long as may be necessary to disinfect them to the satisfaction of the Health Officer.”

Plague was not referred to. Considerable attention was paid to small-pox, and the following rules were agreed upon Every passenger ship bound for Australia was to carry enough lymph to vaccinate all on board. If smallpox broke out the surgeon was to vaccinate all on board.

Persons able to satisfy the Health Officer that they have been successfully re-vaccinated at a date being not more than six months previous to their arrival in an infected ship may, at the discretion of the Health Officer, be released after such time as is necessary to cleanse and disinfect their clothing on shore.”

“ It may be seen from these provisions that except for the attention paid to small-pox the scope of the measures agreed upon as practicable did not differ from those agreed upon at the contemporary European Conferences. That the Australian Sanitarians were fully alive to the position taken up by their European colleagues is indicated by the following imtial resolution:—

“ That by quarantine this Conference understands such measures taken in regard to vessels coming to the various Australian ports as will effectually protect the Australian Colonies from the invasion of contagious or infectious disease consistent with the least possible interference with the liberty of individuals and with the least possible restriction to commerce.”

This Conference was not productive of any immediate result, nor were any of its resolutions put into practice by the Governments concerned. That it was, however, of great value in preparing the minds of those most concerned for the ultimate unification, and in establishing an understanding between the health officials of the various States, is clearly shown by subsequent events.

Second Australian Conference, 1896.—This Conference was held primarily, if not entirely, for the purpose of arriving at some uniformity of practice in regard to quarantine administration. Confusion and annoyance had been produced in the case of certain vessels infected with small-pox by reason of the varying procedure adopted in the different States. The discussions dealt with this question of uniformity of procedure in detail, but entirely with reference to small-pox, and the resolutions carried did not differ in any essentials from those

carried at the First Conference. In order that the reality of the fear of small-pox in Australia might be appreciated it is only necessary to mention that in the interval between the first and second conferences two disastrous epidemics of small-pox had occurred, namely, in Launceston (Tasmania), 1887; and Perth (Western Australia), 1893, and the necessity for placing this decision in the most important position amongst the subjects discussed at Australian Sanitary Conferences is indicated by the closing words of the President (Dr. D. A. Gresswell) at the conclusion of this Conference:—

“ The resolutions, if carried out, would secure a much greater degree of protection to the Colonies than they had previously enjoyed. Convinced though all might be that small-pox must one day become. endemic in Australia, the duty which had been confided to them of keeping it out as long as possible, and by such means as were fair and reasonable would at all times receive their most careful and anxious consideration.”

Third Conference, 1900.—This was known as the Intercolonial Plague Conference, and the only subject discussed^ was plague. The world-wide spread of plague, and the appearance of the disease in two of the Australian States, had rendered a conference imperative. The Venice Convention of 1897 was taken as the basis of discussion. Certain important alterations were made, and the resolutions finally agreed upon differed from the Venice Convention primarily in two directions.

The principle of surveillance was not adopted, but, as was the practice adopted by the French Government, taking advantage of the discretion allowed by the Venice Convention, observation was substituted for surveillance.

The precautions taken against rats and the measures for destruction of rats on board were much in advance of the provisions of the Venice Convention.

Fourth Conference, 1904.—The previous Conferences, which had had as their object the creation of uniformity in the measures adopted by the different States, had resulted in a much better understanding between the various health officials and also in considerable progress toward uniformity in the application of quarantine measures, but no common legislation and no binding agreement had been concluded between the States. With the Federation of the’Australian States into a Commonwealth in 1901, a new legislative condition had been • created, and amongst the matters upon which the Commonwealth Parliament was, by the Constitution, authorized to legislate for, was quarantine. Accordingly in 1904 the Prime Minister of

Australia summoned a Conference of the principal health officials in the various States. The principal object of this Conference was expressed in the Prime Minister’s letter as follows :—

The Conference will be asked to submit for consideration suggestions as to the provisions to be introduced into a Bill dealing with the question, and also as to the taking over of the administration of the quarantine laws from the several States.”

This Conference drew up a number of recommendations, most of which were subsequently embodied in the Quarantine Act 1908 —now in operation. The Quarantine Act for the Commonwealth of Australia was assented to on 30th March, 1908, and came into force on 1st July, 1909, and by this Act the aims of Australian Sanitarians, begun in 1884, were achieved. It was found necessary, however, before the transfer of administration from the State Governments to the Commonwealth Government was actually made, that the officials of the various Governments concerned should meet to discuss certain important details.

Fifth Conference, 1909.—The Fifth Conference, 1909, was accordingly held and the draft regulations were discussed, various; details of practical administration being laid down.

Throughout the Fourth and Fifth Conferences, and naturally also in the Commonwealth Quarantine Act and regulations, measures directed against small-pox take a prominent place, though the proximity of the Asiatic endemic centres of plague and cholera, and the danger threatening Australia from these sources, is also fully recognized.”

Details of Quarantine Administration and Procedure Adopted.

Since the measures necessary to prevent the introduction of smallpox loomed so largely in the discussions of the various Conferences, it naturally follows that a very complete system was finally adopted and incorporated in the Commonwealth Quarantine Act and Regulations and in the various departmental orders and instructions interpreting these legal enactments.

Administration.

The Quarantine Act and Regulations were placed under the administration of a Commonwealth Quarantine Service. Under the Director of Quarantine there were appointed Chief Quarantine Officers in local administrative control of each Division. The limits of these Divisions coincided with State boundaries, except that Queensland and the Northern Territory were incorporated as the North-eastern Division. Full-time medical quarantine officers were appointed to each major

port, whilst local medical practitioners were gazetted as part-time quarantine officers for other ports. A quarantine officer, Central Office, served as intelligence officer for the collection and circulation of all reports relating to disease prevalence. In 1921 the Quarantine Service became the Commonwealth Department of Health, the Permanent Head of the Department becoming Director-General of Health and Director of Quarantine. The detailed administration of the function of maritime quarantine is carried out by the Division of Marine Hygiene under, a divisional director at the Central Office, responsible to the Director-General. The development of the Commonwealth Serum Laboratories since 1918 and the installation of Health Laboratories at strategic points throughout the Commonwealth since 1922 has had a definite bearing in strengthening the quarantine system. In addition to the imedical staff of the Quarantine Service already mentioned, the personnel comprises clerical officers and launch, station, and fumigation staff, in all of whom a high standard of technical training is necessary to ensure executive efficiency. Encouragement is given to all officers to obtain higher certificates in training relative to their duties, such as accountancy, navigation, and engine-driving, in addition to the certificates granted by the Royal Sanitary Institute and similar bodies.

%

It must be stressed that the functions of the Commonwealth authority do not embrace internal health administration in any State. The quarantine measures carried out by the Commonwealth authority, in relation to such a disease as small-pox, apply to the prevention of introduction from oversea, the control of cases occurring on shipboard, together with all contacts and goods of such vessels, and during the epidemic occurrence of small-pox in Australia, the carrying out of such measures of control in regard to interstate traffic as may be necessary under the circumstances of the outbreak.

The control of an outbreak within a State is entirely a function of the State Health Department, the several State Health Acts making provision for notification, segregation, and control of contacts. Notification to the Commonwealth authority is provided for by section 87 (e) of the Quarantine Act, which gives power to make regulations “ for requiring notification to a quarantine officer of each case of a quaran-tinable disease which arises in Australia or within any specified part of Australia or within any quarantine area.” The relative regulation, 58, states : “ Every medical practitioner in Australia on becoming aware of or suspecting the existence of quarantinable disease affecting any of his patients in any part of Australia shall immediately report the case by telegram or by the speediest means available to the Chief Quarantine Officer of the State in which the case occurs.” ' The form of report provides for notification of name, age, sex, and address of patient, name and duration of disease, name of practitioner reporting.

In the event of an outbreak of small-pox occurring within Australia, co-operation and official interchange of information between the Commonwealth and State authorities is arranged for, small-pox under Australian conditions being accepted as a major quarantinable disease, not only from the view-point of States not infected, but in regard to the possibility of the spread of infection into the Pacific island groups.

Vaccination.

In regard to vaccination, the Conference of 1909, which met with the object of suggesting uniform regulations and future uniform administration, had again stressed the advantages of vaccination in the following terms :—“ In this connexion, the Conference feels it is its duty to point out, as has been done by previous Conferences, the present unsatisfactory condition of the greater part of the Commonwealth in regard to protection by vaccination from the risk of epidemic small-pox. Were every person vaccinated and re-vaccinated the quarantine restrictions on account of this disease could without danger be reduced to vanishing point. Under present conditions no such abatement could be considered.”

In regard to persons on board vessels quarantined for small-pox, this Conference recommended exemption for those “ successfully vaccinated to the satisfaction of the quarantine officer within six months and not less than fourteen days before arrival.” Recommendation was also made that all Pilots and Customs Officers specially liable to exposure should be required to be protected against small-pox by efficient vaccination to the satisfaction of the Chief Quarantine Officer.

The Quarantine Act and Regulations were therefore complete in ìegard to the lequirements and standard of vaccination, both as regards extent and age of the vaccinated area, whilst ample powers were given the quarantine officer in dealing with persons quarantined and in provision for release under surveillance of persons properly vaccinated. The ielevant section and regulations are shown hereunder;—

Section 75.—(1) A quarantine officer may in the case of small-pox lequire any person subject to quarantine or performing quarantine to be vaccinated, and any person so required to be vaccinated shall submit to be vaccinated accordingly.

Penalty: Five pounds.

'    .r

(2) A quarantine officer shall not require any person to bo vaccinated unless in his opinion vaccination is necessary for the protection of persons subject to quarantine or performing quarantine, or for the prevention of the spread of the disease of small-pox.

This section was amended by No. 47 of 1920 so as to include inoculation with any prophylactic or curative serum, so that the section now reads:—

Section 75.— (1) A quarantine officer may require any person subject to quarantine, or performing quarantine, to be vaccinated or inoculated with any prophylactic or curative vaccine, and any person so required to he vaccinated or inoculated shall submit to be vaccinated or inoculated accordingly.

Penalty: Five pounds.

(2) A quarantine officer shall not require any person to he vaccinated or inoculated unless in his opinion vaccination or inoculation is necessary for the protection of persons subject to quarantine or performing quarantine, or for the prevention of the spread of the disease of small-pox.

In regulations 12 and 13, vaccination referred to in section 75 of the Act is defined as follows:—

12.    Vaccinated means successfully vaccinated with active vaccine

over a total area of not less than one-half of a square inch, which

area shall, when healed, show distinct foveation.

*

13.    Properly vaccinated in regulation 14 means vaccinated not less than fourteen days nor more than seven years prior to examination.

Regulation 14, referred to in regulations 12 and 13, grants to the properly vaccinated person the privilege of release from quarantine under surveillance, in the following terms:—

,    14. (3) In the case of quarantine for small-pox any person who

has been properly vaccinated under the observation of, or to the satisfaction of the Chief Quarantine Officer, may, as soon as i practicable, be released under quarantine surveillance or released from quarantine.

Under section 87 of the Act, whereby the Governor-General may make Regulations, there was added by the amending Act, No. 42 of 1915, the following sub-section:—

(r) for prescribing the conditions under which any prophylactic or curative vaccine or serum may be prepared and offered for sale.

Under regulation 59 (Preparation of Vaccine) “ The Minister may—

(1)    undertake the preparation of vaccine; and

(2)    sell such vaccine at such prices as he determines from time

to time; or

(3)    at his discretion issue vaccine without charge.”

Quarantine Procedure.

The practical interpretation of the Act and Regulations and the technical details of procedure in regard to vessels and persons quarantined for small-pox are fully set out in Quarantine Service Publication No. 16, sections II. “ Quarantine Examination of Vessels ” and IV. “Management of Quarantine Stations in Active Quarantine.” The records to be kept in connexion with vessels quarantined for small-pox are set out in Quarantine Order No. 20, whilst Order No. 21 specifies the procedure in regard to release of persons under surveillance. Quarantine Order No. 7, in setting out the procedure in regard to inspection, gives the action to be taken in regard to adults or coloured persons suffering from varicella or a skin eruption of which the diagnosis is not certain. Form Q.258 provides for the compilation of the history of each case, recording both clinical and epidemiological data, and gives the quarantine officer a resume of the features to be remembered in differential diagnosis. Form Q.312 (Personal Detail Card) provides for an individual record, including vaccination history, of each person quarantined.

Since it is desired to assess the value of the quarantine measures which have been adopted against the introduction of small-pox, it might be well to summarize the procedure as it applies to vessels arriving in Australia from oversea. The .amending Act of 1920 also makes provision for air vessels, a procedure actually adopted on the occasions of the arrivals by aeroplane of Ross Smith in 1919 and Parer in 1920. It is understood that each detail in the procedure here outlined is in accordance with the principles laid down in the Quarantine Act and Regulations or in departmental instructions based on the legal enactments—

(1)    No oversea vessel arriving in Australia is allowed, except

from stress of weather or other reasonable cause, to enter any port other than a port declared to be a first port of entry.

(2)    The vessel is brought to at the prescribed “ quarantine line ”

displaying the specified quarantine signal (the flag Q by day and prescribed lights by night). Whilst this signal is so hoisted, no unauthorized person is allowed alongside or on board. If the pilot at a port boards outside the “ quarantine line,” action is taken to ensure that he is “ properly vaccinated,” and that his vaccination history is recorded in a register kept by the quarantine officer.

(3)    The quarantine officer for the port boards the vessel during

the prescribed hours between sunrise and sunset. He collects the specified Primary Health Report (Form

Q.360), witnessing the signature of the master and the surgeon (if carried) to the accuracy of the return submitted. He also extracts for record the details of the Bills of Health brought by the vessel from oversea ports of call.

The questions on the Health Report refer, inter alia, to the presence of any person suffering from fever attended with or followed by eruption, or from any eruption, or to any such case having existed on board during the voyage.

At the first port of entry, the quarantine officer collects a complete crew list and passenger list, showing the intended port of disembarkation and shore address of each passenger. This provides for locating passengers landed in Australia prior to the possible appearance of a ease on board.

(4)    If any sickness exists on board which he suspects may be

a quarantinable disease, the quarantine officer dons overalls and inspects the case.

(5)    If no sickness exists on board, the quarantine officer proceeds

with a complete muster and inspection of all1 on board.

(6)    If there is no sickness on board, and inquiry into the sanitary

history and circumstances of the vessel proves satisfactory, the quarantine officer grants pratique to the vessel on the prescribed form (Q.4), the extent of pratique being governed by the following provisions:—

“ When vessels arrive eighteen clear days from the last oversea port of call, pratique is granted for all Australian ports, and the vessel is not required to undergo further medical inspection. If under eighteen days out, then pratique is limited, on vessels carrying no surgeon, to the port where inspected. If a surgeon is carried, pratique is granted up to, but not including, the terlminal port. This granting of limited pratique for subsequent ports is conditioned, however, so that in the case of vessels from Asiatic or East Indian ports, proceeding by Torres Straits or via Western Australian ports, pratique is not granted beyond the last port of call before Brisbane and Fremantle respectively.”

Reference to a map showing the well-defined trade routes from oversea will indicate that this arrangement is practicable and convenient in Australia. Action at subsequent ports of call in Australia follows naturally on these provisions. It should be noted that from 1st July, 1921, onwards, under the provisions of the Commonwealth Navigation

Act, coastwise passengers were not permitted to join vessels not complying with the provisions of this Act, the practical result being that no passengers now join oversea vessels for the coastwise voyage, excepting under special permits granted at outlying ports, for example, at Darwin and Thursday Island.

(7) If a case of sickness exists on board which the quarantine officer diagnoses as, or suspects to be, small-pox, the action to be taken is clearly defined in departmental instructions. Four sets of circumstances may call for action—

a.    When small-pox actually exists on board a vessel.

b.    When small-pox has existed on board a vessel

during the voyage and the case, has died or been landed to an oversea port of call.

c.    When a vessel arrives carrying a coloured crew,

any member of which is found to be suffering from any skin eruption of which the diagnosis is uncertain, or from any febrile condition, the cause of which is not definitely clear.

d.    When a vessel arrives on which a case of varicella

is diagnosed and the patient is a coloured person or a white person more than fifteen years of age.

The instructions for the guidance of quarantine officers in each of these circumstances are here quoted practically verbatim from Part II. of Maritime Quarantine Administration (Dr. D. G. Robertson: Quarantine Examination of Vessels), Service Publication Ho. 16, and from the relevant Quarantine Orders.

A. When small-pox actually exists on a vessel.—The illustration of the procedure adopted on a vessel carrying a surgeon, arriving at Fremantle with small-pox on board, and bound for Sydney, via Adelaide and Melbourne, is described in the following :—

Fremantle.—The quarantine officer, before boarding the vessel, ascertains from the master or surgeon that the presence of a quarantinable disease is suspected. After putting on a suit of washable overalls and cap, and attended by an attendant similarly attired, and bringing all necessary papers, a spare suit of overalls and cap, disinfectant and vaccination outfit from the boarding chest kept on the launch, he boards the vessel and proceeds to the captain’s cabin, where he inspects the ship’s papers and witnesses the signature of the master and medical officer to the Primary Health Report.

He then proceeds to examine the suspected person, and confirms the diagnosis. After discarding the suit of overalls and cap he has been wearing, and carefully disinfecting his hands and boots, he

puts on the spare suit of overalls and cap and then serves a written order, in the form (Q.5) prescribed by the Quarantine Regulations, on the master of the ship. This form is worded as follows:—

I hereby order into quarantine the vessel    , of which

you are the master, together with all persons and goods on board.

The flag L is at once hoisted at the mainmast head. A rigorous medical examination of every one on board is then made, particular attention being paid to the skin surfaces of the forearm, face, forehead, wrists, and hands, the sites most favoured by small-pox lesions. Desquamation, stains, or “ seeds ” in palms or soles are also looked for, while secondary staphylococcic infection may draw attention to a recent eruption, particularly in Asiatics.

A Preliminary Report (Form Q.56) is then filled in, and, after disinfection, is handed to the boarding launch and sent ashore for transmission to the Chief Quarantine Officer for the Western Australian Division, either by telephone or telegraph. This report form gives the following information:—

1.    Name of vessel.

2.    Date and hour of arrival.    %

3.    Oversea port of departure. Last oversea port of call an'd

date of departure.

4.    Disease for which quarantined and number of cases on board.

5.    Class (if passengers), rating (if crew), of each case.

6.    Date of onset of illness in each case, and date of appearance

of rash (if any).

7.    Whether unsuspected, suspected, or recognized before arrival

in port.

8.    Particulars as to isolation (including date and location).

9.    Degree of isolation (satisfactory, apparently satisfactory,

unsatisfactory).

The facts as to the isolation of all attendants, and the precautions (change of clothing, personal disinfection, &c.) taken by the medical officer are taken into account.

10.    Precautionary measures other than isolation, if any, before

arrival.

11.    Probable source of infection.

12.    Suspicious cases—number and class, and rating.

13.    If disease small-pox—the supply of lymph carried, number

of vaccinations done in each class and among crew prior to arrival; it is indicated whether the vaccination has been thorough or slight.

14.    Total number of—(a) crew, and (b) passengers.

15.    Number of passengers in each class for each Australian

port.

16.    Action proposed to be taken in respect of—(a) infected or

suspected person or persons; (b) infected or suspected parts of the vessel.

On receipt of this information, the Chief Quarantine Officer immediately transmits it by telegram to the Director of Quarantine, in order that the Chief Quarantine Officer in the Divisions to which the vessel is proceeding may be warned.

A specimen telegraph report would read as follows:—

Argon. Arrived seven this morning. London Colombo thirtieth May. One case small-pox. Second class. Onset probably third June. Rash sixth. Recognized fourth. Isolated same day in separate cabin well removed with two attendants. Apparently satisfactory. Cabin occupied before isolation disinfected other occupants and effects after disinfection removed another cabin. Evidence infected before embarking Colombo. No suspicious cases. All second twenty first and two hundred ninety third vaccinated. Lymph supply exhausted further vaccinations now being carried out. Total crew three forty passengers eight twenty. Perth twenty thirty-five sixty-eight. Adelaide fifteen twenty-eight ninety. Melbourne twenty-eight thirty-five one ninety. Sydney fifty-five seventy four hundred nine. Propose land patient two attendants and all Perth passengers to-day and disinfect ship hospital and cabin previously occupied. Vessel leaves for Adelaide eight Thursday morning.

As soon as possible information is sent to the officer in charge of the Fremantle quarantine station advising him as to the nature and number of cases of disease and number of suspects and passengers about to be sent to the station, so that necessary arrangements for their reception may be put in hand. At the same time, the launch picks up a supply of vaccine lymph from conveniently located cold stores, where a fresh supply, periodically tested for potency, is maintained.

Arrangements are made for the immediate disembarkation of the patient, who, with his belongings, is either transported in the quarantine launch or is placed in a ship’s lifeboat and towed to the quarantine station. The ship’s boat is steered b}r a member of the crew who has been in attendance on the patient, or, failing this, by a member of the quarantine staff. Suspects are also treated in a similar way.

All infected articles of bedding, clothing, &c., are removed for disinfection, and the quarters occupied by the patient or suspects are prepared for disinfection.

The vaccination history of every one on board is taken and entered on the Personal Detail Card (Form Q.812). Those passengers who are not, m the opinion of the quarantine officer, properly protected, are vaccinated. Attendants on and close contacts with the case are always vaccinated first. The vaccination of passengers landing at the port

may be deferred until their arrival at the quarantine station. A sufficient supply of lymph is placed on board to ensure that all those whose reactions are unsatisfactory may be revaccinated by the ship’s surgeon.

The prescribed conditions in regard to vaccination have already been detailed on page 10. The interpretation of the results of vaccination forms one of the greatest difficulties in the duties of the quarantine officer, and in Quarantine Service Publication, FTo. 16 (page 97), a detailed discussion on the various results of vaccination is given for his guidance.

Passengers booked for Fremantle and their luggage are disembarked to a steam tender and taken to the quarantine station, where passengers eligible for release under surveillance are released after the prescribed personal and luggage disinfection has been effected, and the prescribed form (Q.306) of application for such release has been compiled (see page 18).

Cargo for the port is discharged into lighters, the crew working on the vessel, but no communication beyond the slings is permitted between the vessel and the lighters. Similar precautions are taken with regard to the coal and water lighters supplying the^ship.

Printed slips of instructions, describing the procedure at the next port of call, are placed on board, with the object of enabling the vessel to have everything in readiness for the visit of the quarantine officer at the next port. Arrangements are also made for the complete compilation of Personal Detail Cards (Form Q.312) for those passengers whose particulars have not been fully recorded.

The complete records to be compiled by the quarantine officer for transmission to the Chief Quarantine Officer of the Division are laid down as follows :—

(1)    A duplicate copy of the Primary Health Report.

(2)    A statement of the full clinical history of the case on Form

258, supplemented as required.

(3)    A statement of the location of the sleeping quarters of the

patient and of his duties.

(4)    A list of all persons working or living in contact with

patient before and after isolation.

(5)    A statement of vaccination condition of patient obtained as

accurately as possible.

(6)    A full, complete, and accurate compilation of all on board,

according to the details specified on the Personal Detail Card (Q.312). In the case of a vessel proceeding to subsequent ports, the list is compiled only for those disembarking at the port concerned, but arrangements should

be made to place on board sufficient cards for compilation by the purser’s staff of names and other personal details in readiness for the quarantine officer at each subsequent port.

(7)    An accurate statement of persons occupying the same living

quarters as the case.

(8)    A deck plan of the ship, showing location of the case in his

ordinary quarters.

(9)    A full passenger list, showing cabin numbers of passengers,

and a copy of the crew list.

(10) A detailed statement of measures of isolation carried out on board, with dates of each step, disinfection, with dates; and of vaccination done on board, with dates and relationship of subsequent cases to first case as regards degree of contact.

As soon as the patient, suspects, and passengers have been landed, the necessary measures of disinfection performed, all vaccinations completed, the mails and cargo discharged, and sufficient stores, coal, and water taken on board for the voyage, the master is given permission on the prescribed form to proceed in quarantine to the next port of call, viz., Adelaide. The surgeon of the vessel is requested to make daily examinations of all souls on board during the voyage, and to report by wireless any further developments. He is also asked to scrutinize the results of the vaccinations performed and to re-vaccinate where necessary.

The Chief Quarantine Officer notifies the next port of call of the time of the vessel’s departure from Fremantle.

Adelaide.—The vessel is boarded on arrival. If any fresh illness is reported, the sick are at once removed to the quarantine station, and measures of disinfection put in hand. The passengers landing at the port and their luggage should be ready for disembarkation after medical inspection, and are placed on a tender, and sent to the quarantine station. Cargo and mails are then discharged into lighters, and, after completion, the vessel proceeds to the next port in quarantine, advice being sent by telegram of the probable time of arrival.

Melbourne.—The quarantine station at Point ISTepean is situated about 40 miles from Port Melbourne, where the quarantine line has been fixed. Arrangements have, therefore, been made for vessels in quarantine to anchor off the quarantine station on their inward journey. The vessel is boarded by the quarantine officer in charge of the station, any sick removed, and, after medical inspection, the passengers for Melbourne and their luggage are taken to the station by launch. The vessel then proceeds to a bay anchorage off Port Melbourne, where vaccinated stevedores work the cargo. A daily inspection is made by

a quarantine officer during the vessel’s stay in port, and any cases of an infectious nature are removed to the quarantine station. As soon as the discharge of cargo is complete, the vessel is given permission to proceed on her voyage to Sydney, landing the stevedores for disinfection (prior to release under surveillance) whilst passing the quarantine station at Point Nepean.

Sydney.—-The vessel is brought to anchor off the quarantine station, North Head. As this is the usual terminal port, after medical inspection, the remaining passengers are at once landed, together with all members of the crew that can be spared with safety to the vessel. It is, of course, necessary to leave an anchor watch, and sufficient engine-room staff to keep up steam. Such parts of the vessel as require it are disinfected. All infected material is sent to the quarantine station for treatment. The members of the crew left on the vessel are later replaced by others who have undergone personal disinfection at the station. As soon as the vessel has been satisfactorily disinfected, provided sufficient members of the crew are eligible for release under surveillance, she is permitted to proceed to her berth at the Sydney wharves under surveillance. An inspection of the crew is held daily until the expiration of eighteen days from the last exposure to infection.

Considerable delay is saved to shipping by this permission to proceed on the voyage in quarantine. The average time taken by a mail steamer from Fremantle to Sydney is eleven days, including stoppages at the various ports. The majority of vessels carry vaccinated crews, and, therefore, may be released under surveillance several days before the expiration of eighteen days.

A similar procedure is followed in respect of infected vessels arriving by other steam-ship routes along the Australian coast. For example, a vessel reaching Darwin or Thursday Island with quarantinable disease on board will be under the control of the quarantine service at each successive port until she reaches her terminal port in Melbourne, after a voyage of some 3,300 miles in quarantine.

Persons Released under Quarantine Surveillance.—As indicated on page 10, Quarantine Regulation 14 grants to 'properly vaccinated persons the privilege of release under surveillance. The prescribed form (Q.306) is signed by the applicant for release, giving a definite place of residence and his pledge to report on specified dates, or on the appearance of any illness, to a specified medical practitioner, who is advised of the requirements of the case by the Chief Quarantine Office. No person so released is permitted to travel interstate without the express permission of the Director-General.

Date of Expiry of Quarantine.—The quarantine period ends on the expiration of eighteen days from the date of last exposure to infection.

At ports where no quarantine station is provided, all practical measures of isolation of persons suffering from small-pox are taken and vaccination performed of every person on board. The quarantine officer follows, so far as is applicable, the procedure already detailed, and orders the vessel in quarantine to the nearest port at which there is a quarantine station.

B.    When small-pox has existed on board a vessel during the voyage and the case has died or been landed at an oversea port of call.— Under these circumstances, the procedure adopted will vary according to the time that has elapsed since the case died and was buried at sea, or was landed at an oversea port. If less than eighteen days has elapsed, the vessel will be ordered into quarantine and handled in accordance with the procedure already detailed. If eighteen days has elapsed, the action taken will depend on the circumstances connected with the vessel, the quarantine officer bearing in mind the disinfection measures and vaccination of personnel required to ensure safety in granting pratique. In any case of doubt, the necessary measures will be adopted before the vessel is granted pratique.

C.    When a vessel arrives carrying a coloured crew, any member of which is found to be suffering from any shin eruption of which the diagnosis is uncertain, or from any febrile condition, the cause of which is not definitely clear.—Under these circumstances, the case is removed to the quarantine station, and the vessel granted pratique for that port only. Provision is always made in suspicious circumstances for a consultation with another quarantine officer or with the Chief Quarantine Officer, so that insofar as is possible, small-pox has already been excluded from the differential diagnosis before this set of circumstances would arise.

D.    When a vessel arrives on which a case of varicella is diagnosed and the patient is a coloured person or a white person more than fifteen years of age.—Under these circumstances, the patient is removed to the quarantine station, and the vessel is granted pratique limited to the port at which the case is removed. A full medical inspection is made at each port until the expiry of eighteen days from the removal of the case, and the responsibility of notifying any cases of illness arising in any subsequent Australian port is strongly impressed on the master. When the case is discovered at a port at which there is no quarantine station, the master is given written instructions as to the maintenance of effective isolation, and the quarantine officer at the next port is advised of the circumstances by telegraph. The case is removed at the first port at which there is a quarantine station, and full medical inspection carried out at each port of call until the.expiry of eighteen days after removal of the case.

This summary of the procedure, which aims to prevent the introduction of small-pox into Australia, indicates that a very complete

system has been evolved, carefully thought out in each technical detail, and amended from time to time in accordance with the practical experience gained by the quarantine staif in handling vessels in quarantine. It has been hoped that the analysis of records relating to the quarantine of vessels and to the outbreaks that have occurred during the period, may give an indication of the utility or the weaknesses of the present quarantine system and procedure, at the same time recording and reviewing the epidemiological records of the behaviour of small-pox in Australia. 1 he aim of such an epidemiological survey is wholly towards the perfecting of preventive and control measures under Australian conditions, at the same time bearing in mind the transport and economic necessities of modern life.

CHAPTER II.

THE WORLD COURSE AND DISTRIBUTION OF SMALL-POX, 1909-1923, IN RELATIONSHIP TO AUSTRALIA.

The striking feature of the world course of small-pox, during the period under review, has been the epidemic extension in many countries of an exceptionally benign form of the disease. Throughout the historical records that relate to small-pox, there has been noted by such observers as Rhazes, van Swieten, Sydenham, and Jenner, the occasional appearance of a form of small-pox so mild that fatal results were rarely heard of, and the eruption was only occasionally confluent. Since 1898, however, particular attention has been focussed on the continuance of a benign type of the disease in many countries and on its spread to, and extension and endemic establishment in, other countries. Naturally, in each outbreak of this type of disease there has been considerable diversity of opinion as regards diagnosis when the disease first appeared. The specific identity of the disease in each outbreak in its relationship to typical variola has been freely questioned, and the nomenclature adopted has resulted in a new and confused nosology—“ alastrim,” “ amaas,” “ varioloid,” “ variola-varicella,” “ para-variola,” and “ mild small-pox ” as distinct from “ variola vera,” “ classical ” or “ Asiatic small-pox.” With the continuance of the mild type or types of disease, and the accumulation of clinical, epidemiological and laboratory records, there have developed two schools of opinion which have been called by Professor Jorge the “unicists” and “dualists”— “ the umcists desire to see in alastrim merely an expression of variola; the dualists persist in believing it a species sui generis, autonomous and independent.” ■

Briefly reviewing the spread throughout the world of the benign type (or types) of disease, it appears that the present prevalence was first recognized in the West Indies, where, as long ago as 1863, an

epidemic of a benign type was described by I. W. Anderson as “ varioloid-varicella” {Trans. Epidem. Soc., London, Vol. II., p. 414). In 1897, at the time of the' Spanish-American war, a similar infection then prevalent in Cuba was imported into the south of the United States of America. From the south this type of small-pox gradually became disseminated throughout most of the States, and was introduced into Essex county, Canada, from the adjoining State of Michigan in 1899. The disease spread into most of the provinces of the Dominion, and has prevailed in various localities until the present time. The appearance of a mild type of small-pox in Great Britain since 1901-02 was probably due originally to importation from America. In 1902 cases described as “varioloid-varicella” were described in Trinidad, the infection probably having been imported from Venezuela, where it had existed since 1901. Since 1898 there has persisted in South Africa a mild type of small-pox, with periodic epidemic extension, called variously “ amaas,” “ Kaffir-pox ” or “ Kaffir small-pox.” In 1910 an outbreak was described in Brazil by the name “ alastrim,” a synonym now widely adopted. In 1913, a benign type of the disease appeared simultaneously in Hew South Wales and in Hew Zealand, probably imported by the same vessel by passengers from Utah, United States of America, who had joined the vessel at Vancouver.

It must not be forgotten that the “ classical ” type of small-pox has persisted during the same period, and has even appeared side by side with the mild type of infection. This is most apparent in the southern border States of the United States, where small-pox imported from Mexico has been responsible for outbreaks with a case-mortality rate up to 28 per cent., whilst generally the strain of infection prevalent in the United States has shown a case-mortality rate of under 1 per cent. Kor must it be forgotten that severe confluent cases do occur in the midst of a benign outbreak, whilst in certain parts of the United States there is at present some indication of an increasing virulence in the type of the disease.

Following the various International Sanitary Conventions which have met to formulate a uniformity in quarantine procedure, there has gradually developed an increased quarantine liaison of recent years between the more advanced countries of the world. Information of the course of the quarantinable diseases has been made available in Australia by the improved compilation of bills of health brought by vessels from oversea countries and recorded since 1915 in the Commonwealth Quarantine Service Fortnightly Bulletin (superseded in 1923 by the monthly journal Health) and also by the data recorded in the Bulletin Mensuel issued by the Office International d‘Hygiene Publique since its inception in 1907, in the United States Public Health Service

Amaas is derived either from the Kaffir word meaning “ milk in fermentation,” or from a corruption of the Dutch masels or masellen meaning “measles.”

Alastrim is a Brazilian word derived from the Portuguese alastrar meaning “ something which burns like tinder, scatters, spreads from place to place.”

weekly reports, and in the publications of the British Local Government Board (since 1919 the Ministry of Health), the latter two records being compilations from consular reports. Since 1922 the Health Section of the League of Hâtions has issued publications giving information of epidemiological importance compiled from various official sources. The periodical reports of Dr. B. Bruce Low, of the British Local Government Board, The Incidence of Small-pox throughout the World m Recent Years, although compiled too late to be of current use for quarantine purposes, are of exceptional value in an epidemiological survey of any period, as they describe accurately the distribution and behaviour of small-pox throughout the world. From these sources, the following summary of the course of srnall-pox during the period under review has been compiled, more particularly with reference to those countries in constant communication with and along the trade routes leading to Australia.

Country.

England

and

Wales.

Egypt.

India

(Registration

Districts).

Ceylon.

Philippine

Islands

(Provinces).

Japan.

U.S.A.

Registration Area.

California.

Census 1911,

Census 1911,

Census 1911,

Morbidity,

Approx.,

Census 1910,

36,189,685 ;

34,671,377 ;

Census 1'917,

Approx.,

4,120,813 ;

Approx.,

Approx.,

Approx.,

50-60,000,000.

2,377,519 ;

Population.

Census 1921, 37,885,242.

(1920),

38,500,000.

13,650,000.

300,000,000.

Census 1921, 4,497,686.

35,000,000.

10,000.000.

55,000,000.

Mortality, Approx. 75-97,OCO,0C0.

Census 1920, 3,426,861.

Data.

Cases.

Deaths.

Cases.

Deaths.

Cases.

Deaths.

Deaths.

Cases.

Deaths.

Cases.

Deaths.

Deaths.

Cases.

Deaths.

Cases.

Deaths.

Cases.

Deaths.

Year—

1909

(a)

21

4,634

758

4,046

1,023

101,150

(a)

82

(«)

(a)

4,337

106

26

20,679

79

180

6

1910

(a)

19

3,121

413

3,133

675

51,315

(a)

29

(a)

(a)

1,469

80

13

25,598

202

177

1

1911

289

23

17,047

4,828

3,117

648

58,558

(a)

89

(a)

{a)

1,182

202

34

21,767

130

185

10

1912

121

9

13,202

3,337

1,985

456

89,874

(a)

15

18,627

4,524

489

14

1

23,627

165

(«)

(«)

1913

113

10

1,414

150

2,934

706

98,155

(a)

1

45,189

8,397

568

108

39

37,109

125

800

15

1914

65

4

859

45

6,369

1,672

75,790

409

101

16,060

2,967

438

485

110

39,483

212

677

1

1915

93

13

626

6

5,222

1,262

83,282

451

156

5,317

1,039

273

17

3

28,798

174

336

3

1916

159

18

641

6

3,372

802

60,581

78

(a)

3,090

398

251

264

48

(a)

(a)

234

12

1917

7

3

(a)

(a)

(«)

(a)

(a)

105

(a)

2,177

263

390

5,121

1,158

(a)

(a)

329

13

1918

63

2

(a)

(«)

(a)

(a)

(a)

240

(a)

3,490

909

16,147

1,467

285

(a)

(a)

1,069

3

1919

311

28

34,365

(«)

7,928

(a)

136,077

35

(a)

4,383

955

49,071

4,055

1,115

56,332

(a)

2,002

5

1920

280

30

26,453

(a)

3,021

(a)

101,324

126

(a)

2,400

467

6,632

3,167

844

96,684

508

4,486

4

1921

336

5

4,644

(a)

93

(a)

40,446

18

(a)

1,445

274

728

889

212

102,787

641

5,581

19

1922

973

27

534

(a)

(a)

(a)

38,617

337

43

1,086

275

12

673

125

32,800

628

2,129

20

1923

2,504

7

253

(«)

519

(a)

16,056

175

(a)

4,922

506

(“)

1,915

381

29,968

(a)

2,025

1

(a) Not available.

Port.

London.

Liverpool (includes Cases on Ships and Imported).

Calcutta.

Bombay.

Rangoon.

Colombo

(Town

only).

Singapore.

Batavia

(Residency).

Semarang.

(Residency).

Sourabaya

(Residency).

Manila.

Hong-

Kong.

Shanghai.

(1911),

(1911),

(19H),

(1911),

(1911)

(1911),

(Town

only),

(1910),

(1911),

Population.

4,521,685 ;

748,157 ;

(1921),

979,445 ;

293,316 ;

185,704 ;

230,000 ;

(iown omy;,

(iown only),

234,000;

456,739-

(1915),

638,920.

(1921),

4,483,249.

(1921),

817,000.

907,851.

(1921),

1,175,914

(1921),

341,962.

(1921),

244,163.

(1921),

417,859.

(1921),

250,000.

(1921),

160,000.

(1921),

] 90,000.

(1918),'

285,306.

(1921),

625,166.

Data (Cases) (Deaths)

Cases.

Deaths.

Cases.

Deaths.

Deaths.

Deaths.

Deaths.

Cases.

Cases.

Deaths,

Cases.

Deaths.

Cases.

Deaths.

Cases.

Deaths.

Cases.

Cases.

Deaths.

Year—

1909 ..

21

2

9

3,784

473

158

114

41

7

(a)

(a)

(a)

(a)

(a)

(a)

25

38

19

1910 ..

19

10

48

1,008

421

80

415

135

{a)

(a)

(a)

(a)

(a)

(a)

31

317

1911 ..

72

9

19

41

443

700

65

254

84

(a)

(a)

(a)

(a)

(a)

(a)

275

166

1912 ..

4

1

4

1

77

979

188

(Few)

59

29

2,055

159

756

375

3,754

1,199

709

127

1913 ..

3

, .

13

1

120

212

107

(Few)

19

6

757

146

5,420

937

814

175

111

219

1914 ..

2

2

1,038

252

13

247

13

3

2.446

470

384

55

153

18

110

173

1915 ..

11

3

2,560

359

94

354

18

7

1,414

346

103

17

29

7

34

121

1916 ..

1

7

58

1,021

343

(®)

70

* 20

1,066

188

151

8

53

2

712

3

1917 ..

3

1

(a)

269

(a)

(a)

33

7

964

186

40

12

1

2

595

206

1918 ..

35

2

545

1,024

95

36

11

5

2,103

801

3

45

8

989

32

111

1919 ..

24

6

20

1

1,870

780

656

3

14

3

718

208

1

16

1

55

27

1

1920 ..

18

4

10

2

2,925

294

120

75

4

2

421

77

1

6

2

5

34

1921 ..

2

89

406

18

12

150

33

572

129

40

16

7

1

191

227

1922 ..

65

20

4

450

61

72

34

268

58

203

20

351

208

1

212

240

1923 ..

11

1

(a)

(a)

(a)

(a)

(a)

(a)

(a)

{a)

(a)

(a)

(a)

(a)

(a)

(a)

1,298

1,044

(a) Not available.

Distribution and Incidence of Small-pox in Oversea Countries.

The data relating to small-pox incidence in several countries and in ports in close trade relationship to Australia are shown in Tables I. and II. The geographical distribution and incidence may be briefly discussed from the view-point of Australian maritime quarantine.

Great Britain.—The history of small-pox in England and Wales during the period under review showed a steady decline to 1917, since which year there has been an increasing incidence year by year, the virulence of the infection remaining low. In Scotland and Ireland there was no epidemic or untoward occurrence of small-pox during this period.

The Continent of Europe.—On the Continent, small-pox has persisted with local epidemics from time to time. The risk of a serious epidemic spread throughout Europe following the war was feared when the prevalence that followed the Franco-Prussian War of 1870 was recalled. Although small-pox persisted and prevailed in many of the continental countries during and following the war, fortunately no considerable epidemic resulted. Foci have persisted in Switzerland, Spain, and Portugal and in the Hear East (especially amongst refugees during the war years), and to a lesser extent in Italy and Greece. The prevalence of small-pox in Europe is not associated with a direct menace to Australia excepting through those ports in communication by sea, although even then the duration of the voyage lessens the risk.

Africa.—In Egypt, small-pox has persisted, but with few cases in the seaports. In South Africa, the benign form known as Amaas has continued, with occasional epidemics. In equatorial Africa, small-pox remains endemic with epidemic extension from time to time.

Asia.—Small-pox may be said to be always present throughout the whole of Asia. In the seaports there is, however, “ a much lower incidence than one would expect, given the conditions in which the majority of the poorer classes live and the fact that infection is rarely absent.” (Dr. Horman White.) The data for the more important seaports in communication with Australia are given in Table II. In British India, a high small-pox incidence prevailed during the years 1909, 1918, 1919, 1920. In Ceylon, small-pox has not been seriously prevalent, and but few cases are reported from Colombo. Primary vaccination is compulsory, and is efficiently carried out with locally-prepared lymph. In Singapore, small-pox remains constantly present, but house-to-house vaccination during the epidemic of 1921-1922 resulted in a substantial proportion of vaccinations. In the Dutch East Indies, small-pox has markedly declined, following extensive vaccination of the community, although an increased incidence was reported m Mid and East Java in 1923. In the Philippine Islands, efficient vaccination had practically eliminated small-pox, but neglect in later years resulted in a widespread epidemic in 1918 and 1919. In Hong

Kong the close relationship with the mainland has maintained a

persistence of infection which resulted in epidemic prevalences in 1616 and in the latter part of 1923. On the China coast small-pox is always present, with periodic epidemic development. In Japan th6 present vaccination law of 1910 makes compulsory vaccination in infancy and re-vaccination in the ninth year, so that small-pox is well controlled, although there was some increase in cases between the years 1917 and 1920. Since the duration of the voyage from .almost any Asiatic port to Australia is less than eighteen days, obviously the Asiatic foci of infection present a constant menace to Australia, a fact that is borne out by quarantine experience.

America.—The presence of infection throughout the Americas has given opportunity for much detailed epidemiological investigation. With the increasing development of trans-Pacific trade, this prevalence is of considerable importance to Australasia from the quarantine viewpoint. In the United States of America there has been a widespread prevalence of a benign type of infection for the past 30 years, the very mildness of the infection undoubtedly contributing to its spread. Despite the general mildness of attack, individuals at times have developed a virulent form of the disease under conditions which are not clear. In addition, there have been occasional importations of virulent strains of infection, notably from Mexico, so that ‘in Southern California, for instance, the two types of infection may he observed side by side. The variations in fatality rates reported from different States and in different outbreaks do not appear to support the hypothesis that the prevailing benign form is attributable to an acquired partial immunity against the disease. Thus, whilst the general case-mortality for the whole of the United States has not exceeded 0.8 per - cent., there have been outbreaks with a far higher fatality. For example, at Pittsburg, Pennsylvania, in 1912, an outbreak comprising 121 cases occurred, and of these 33 died, giving a case-fatality rale of 27.8 per cent. At Los Angeles, California, in 1912, 119 cases were reported, of whom 17 (or 14.3 per cent.) died. In Oklahoma, an outbreak comprising 82 cases was reported in 1912, and of these 21 (or 25.6 per cent.) died. At El Paso, Texas, in 1914, 191 cases of small-pox were reported, due to infection from Mexico, and of these 49 (or 25 per cent.) died, while in 1915 there were 96 cases and 27 deaths, giving a case-fatality rate of 28 per cent. At Chattanooga, Tennessee, in 1914-15, there was a localized outbreak in which 56 persons were attacked, of whom 16 (or 28.6 per cent.) lost their lives. Between the years 1900 and 1920 the death-rate from small-pox in the registration area of the United States did not reach a rate as high as 7 per 100,000 of the population. The highest rate in any year in this period was 6.6 in 1902, in 1903 it was 4.2, in 1901 3.5, in 1904 2.1, and 1.9 in 1900. With the exception of these five years the rate for the registration area did not reach 1 per 100,000, although in

certain areas and amongst certain population groups a much higher rate was occasionally reached, as, for instance, amongst the unvaccinated coloured population of New Orleans, which in 1920 was 87.3 per 100,000 compared with 34.4 per 100,000 of the general population of the city. The prevalence of the disease in the western States is of importance from the Australian quarantine view-point. The data for California given in Table I. indicates a continued infection, which is shared by Washington and Oregon, although the major seaports, San Francisco, Portland, Seattle, and Tacoma have not suffered to the extent of the inland districts. In Canada a mild grade of small-pox has persisted widely in endemic foci with epidemic expansion from time to time. On the Pacific coast in the province of British Columbia the disease has persisted without assuming epidemic proportions, cases being reported in the seaports of Vancouver and Victoria. In Mexico small-pox was constantly present throughout the country, and although records are meagre there have been reported epidemics with a far higher fatality rate than that prevailing in the more northern parrs of North America. Endemic foci have persisted in the seaports of Tampico and Vera Cruz. In Central America, although definite records are not available, small-pox has persisted through the republics of Guatemala, Salvador, Honduras, Nicaragua, and Costa Rica. With the systematic vaccination of the inhabitants of the Panama Canal zone, small-pox has been practically eliminated in that area. In the West Indies the presence of the benign form of the disease which had been reported from Jamaica as long ago as 1865, persisted in endemic foci during the period under review until 1920, when the disease assumed epidemic proportions in Jamaica. Trinidad, Havti, San Domingo, and Antigua, followed in 1921-23 by outbreaks in Cuba, the French Antilles, Guadeloupe, and Martinique. In South America small-pox has persisted widely with occasional epidemic extensions during which vaccination is availed of, but generally neglected during the inter-epidemic periods. In Brazil the alastrim focus was discovered by Ribas and others in the interior in 1910, and there now appear to exist two separate strains of infection, the one virulent with a high mortality rate, and the other the alastrim type similar to the benign form present in North America.

Australasia. In Australia, as will be described in subsequent chapters, small-pox has appeared on three occasions during the period under review, a widespread but benign prevalence occurring in New South Wales from 1913 to 1917, and smaller but more virulent outbreaks in Western Australia and Victoria in 1914 and 1921 respectively. No introduction of infection occurred in the South Sea islands of the Pacific. In New Zealand an outbreak in 1913 coincided with that in New South Wales, the infection being probably introduced by the same vessel from the United States via Vancouver. The primary C.7279.—2

case was a Mormon missionary from Utah, who had joined the vessel at Vancouver, and landed at Auckland on 8th April, 1913. He fell ill on 15th April at Te Hova, and subsequently developed a rash. A week later he left the house at which he had stayed, and ten days after his departure illness with an eruption appeared amongst the family in that house, and quickly spread among the Maories, and to a lesser extent among the white population in the north island. The course of the epidemic was remarkably similar to that which prevailed in New South Wales, but amongst the Maori population the infection was apparently more severe. The infection persisted until April, 1914, by which time it was estimated that 114 Europeans had been attacked without a death, and 1,778 Maoris with 55 deaths.

Seasonal Variation of Small-pox in Oversea Countries.

Of particular importance from the quarantine view-point is the seasonal incidence of small-pox in oversea countries in communication with or along the trade routes leading to Australia. This will be discussed more fully at a later stage in its relation to quarantine experience in Australia (Chap. XI.). The tables given hereunder show the records of seasonal prevalence of small-pox in certain countries foi such periods as are available. It may here be briefly stated that these tables indicate for Europe generally, and also for the United States and Canada, that small-pox prevalence is greater in the winter months and least in the summer, the early months of the calendar year showing the highest incidence. In India, small-pox, as in Europe, is a disease of the winter and spring, the increased incidence commencing in December and continuing until April and May. The Australian quarantine experience in connexion with vessels arriving from Indian ports with cases of small-pox on board indicates that the period of maximum risk in this respect is in regard to vessels which have left India between the months of January and April. See page 207.) Throughout the Far East generally it may be stated that three-quarters of the annual total of small-pox deaths occur in the first six months of the year. Important variations may, however, occur, such as the Hong Kong epidemic in the latter part of 1923, when, for the four weeks ended 24th Xovember, there were reported 325 cases with 249 deaths; whereas, in the period 1912-1922, the only record of any unusual incidence in Xovember was during the epidemic of 1916-1917, when 68 cases were recorded for the month. The generalization does, however, hold good throughout the Ear East, with the exception of Java, where a maximum of small-pox mortality is reached towards the end of the third quarter of the year, that is about October.

Locality.

Period.

Data.

Jan.

Feb.

Marcii.

April.

May.

June.

July.

Aug.

Sept.

Oct.

Nov.

Dec.

Total.

England and Wales

[Only data available ; not a typical year.]

Italy . .

” Registration Area

Bengal Presidency

eg

-5

¿3 Bombay ..

A •<

'C

w

Calcutta . . Burma

1923

1907-16

1906-15

1918-22

19

19

11

Cases, 4 weekly

Percentage of Total

Deaths

Percentage of Total

Deaths

Percentage of Total

Deaths

Percentage of Total

Deaths

Percentage of Total

Deaths

Percentage of Total

Deaths

Percentage of Total

154

151

162

156

124

1

98

56

8

21

6

7

9

11

7

11

4

152

292

2,483

6-2

6" 1

6‘5

6-3

5-0

8-0

22-8

8-8

3-2

4-7

4-6

6-1

11-7

loo-o

5,636

4,51

2

4,455

3,

755

3,

682

2,940

C

2,920

2,792

2,733

1,512

4,836

5,977

49,750

11 ‘3

9-1

8-9

7-6

7‘4

5-9

5-9

5‘6

7-5

9-1

9-7

12-0

100-0

80,658

92,070

126,361

141,067

134,140

103,229

73,045

44,985

31,331

26,147

33,577

55,984

942,594

8-6

9-8

13‘4

15-0

14-2

10-9

7-7

4-8

3-3

2-8

3-6

5-9

100-0

7,158

9,717

14,620

15,914

16,384

12,617

7,464

3,747

2,401

1,559

1,878

4,338

97,797

7’3

9-9

14-9

16-4

16-8

12-9

7-6

3-8

-2‘5

1-6

1-9

4‘4

100-0

53

138

381

389

262

157

78

26

15

15

10

17

1,541

3‘4

9-0

24-7

25-2

17-0

10-2

5-1

1-7

1-0

1-0

0-6

1-1

100-0

874

1,141

1,154

951

725

347

152

87

47

36

87

278

5,879

14-8

19‘4

19-7

16-2

12-3

5-9

2-6

1-5

0-8

0-6

1-5

4-7

100-0

499

1,108

1,753

1,800

1,509

1,193

720

433

319

172

154

297

9,947

5-0

11 -1

17-6

18-1

15-1

12-0

7-3

4-3

3‘2

1-7

1-6

3-0

loo-o


British India.


I

f1

s

Ja\

' Rangoon ..

1918-22

Deaths

75

161

261

187

98

46

29

27

27

19

9

22

961

a ..

Percentage of Total

7-8

16-

7

9

7-2

19-5

10-2

4-8

3-0

2-8

2-8

2-0

0-9

2-3

100-0

1919

4 Weekly Deaths

92

62

81

52

55

64

4

6

£

11

11

6

1C

►7

£

13

38

955

Percentage of Total

9-6

6-5

8-5

5-4

5-8

h

■7

4-

7

8-5

12-2

11-2

8-

7

<?'2

100-0

Philippine Islands

1918-22

Quarterly

Cases

Percentage of Total

,_ _A_

>

49,91

5

37,824

27,974

20,917

136,630

36-5

27-7

20-5

15-3

100-0

1914-22

Quarterly

Deaths

24,934

20,787

16,444

11,625

73,790

Percentage of Total

33-8

_>

k

28-2

22-3

15-7

100-0

Y

■V"

"Y*

Hong Kong

1912-22

Cases ..

568

555

411

389

263

75

25

20

19

27

72

343

2,767

Percentage of Total

20-5

20-0

14-9

14-1

9-5

2-7

0-9

0-7

0-7

1-0

2-6

12-4

100-0

.la pan

1919

Deaths

139

257

258

142

13<9

77

25

10

4

8

21

35

1,115

Percentage of Total

12-5

23-0

23-2

12-7

12-5

6-9

2-2

0-9

0-4

0-7

1-9

3-1

100-0

U.S.A.

1910-13

Cases ..

14,834

13,078

13,819

12,061

10,026

7

,749

3,759

2,555

2,030

3,537

7,222

10,165

100,835

Percentage of Total

14-8

13-0

13-7

12-0

10-0

7-7

3-7

2-5

2-0

3-4

7-1

10-1

100-0

Ontario, Canada

1913-15

Cases ..

301

322

236

189

124

138

134

70

22

55

119

151

1,861

Percentage of Total

16-4

17ri

>

12-6

10-1

6'6

7-4

7-2

3-8

1-2

3-0

6-4

8-1

100-0

It is obvious that an increased volume of shipping from oversea, together with an increased average speed of vessels, will increase the risk of the introduction of disease. The following data, compiled by the Commonwealth Statistician, and published in the Y ear-Book, give the total oversea shipping that entered and cleared the Commonwealth during the period under review:—

Table 5.

Year.

Vessels.

Tons.

1909 .. .. .. .. .. ••

3,910

8,516,751

1910 .. .. .. .. .. ..

4,048

9,333,146

1911 .. .. .. .. .. ..

4,174

9,984,801

1912 .. .. .. .. .. ..

4,052

10,275,314

1913 .. .. .. .. •• ••

3,985

10,601,948

1914-15 .. .. .. .. .. ..

3,211

8,599,258

1915-16 .. .. .. .. .. ..

3,324

8,538,322

1916-17 .. .. .. .. ..

2,986

7,694,442

1917-18 .. .. .. .. .. ..

2,197

5,031,750

1918-19 .. .. .. .. .. ..

2,614

6,180,486

1919-20 .. .. .. .. .. ..

2,981

8,086,507

1920-21 .. .. .. .. .. ..

1,830*

4,758,916*

1921-22 .. .. .. .. .. ..

1,567*

4,560,381*

1922-23 .. .. .. .. .. ..

1,489*

4,737,854*

* Entered only.

On an average, some 75 per cent, of the total net tonnage entering Australia is of British nationality.

On two occasions during this period, aeroplanes entered the Commonwealth from oversea, both from England, overland across Europe and Asia, and arriving in Darwin from Timor; Sir Ross Smith and a crew of three arriving in December, 1919, and Parer and McIntosh in August, 1920.

Of the 23.500 odd vessels that arrived in Australia from oversea during the period 1909-1923, 60 had cases of small-pox on board on arrival in Australian waters, and 22 others had been infected during the current voyage, while four vessels were concerned in the actual introduction of infection into the community on shore. It will be remembered that in the previous volume (Chap. X.), dealing with the period 1788-1908, there were recorded the available histories of 182 vessels which had at some period of their voyage to Australia conveyed the infection of small-pox.

CHAPTER III.

SMALL-POX IX XEW SOUTH WALES.

In May, 1913, the owner and manager of a large factory for the manufacture of underclothing, situated in Chalmers-street, Sydney, and employing over 200 hands, chiefly girls, reported that a number of his

employees had, during the months of April and May, suffered from unusual rashes which appeared to be infectious. Outside cases of a similar nature continued to occur during June, and the findings of control vaccinations of recovered cases, and the clinical opinion of expert officers, indicated the disease to be h mild form of small-pox. The disease was officially proclaimed as such on 1st July, 1913, by the Board of Health for Hew South Wales, a press announcement being made to that effect. On the 4th July, acting under powers derived from the Commonwealth Quarantine Act, the Commonwealth Government declared Sydney, within an area of 15 miles from the General Post Office, to be a quarantine area.

Extension of the infection occurred in 1913 to 28 country towns and districts, 56 cases being recognized in these extra-metropolitan areas, together with 1,017 in the metropolis; a total of 1,073 cases for the State. In 1914 a total of 628 cases were reported, 445 from the metropolis, and 183 from outside areas. In 1915 there were 471 cases, 41 from the ¡metropolis and 430 from extra-metropolitan districts. In 1916, 108 cases occurred, of which only sixteen were in the metropolitan area, and 92 outside. In 1917, 119 persons were attacked, all in extrametropolitan districts. In 1918, with the exception of one case at Warren in January, no further cases were% reported. JDuring this period no extension of infection occurred in the other States, with the possible exception of five cases reported from Queensland in July and August, 1913.

Records of the Epidemic.

The particulars of the epidemic are available in the reports by Dr. W. G. Armstrong, Senior Medical Officer, which are -contained in the Annual Reports for the years 1913 to 1917 of the Director-General of Public Health for Hew South Wales, to which reports there are appendices recording the laboratory findings of Drs. J. Burton Cleland and E. W. Ferguson. The earlier records are also contained in papers contributed by these officers and published in the Proceedings of the Royal Society of Medicine (Section of Epidemiology and State Medicine), Yol. VIII. (1914-15), Part II. Other records are contained in the current numbers of the Australasian Medical Gazette (to June, 1914), and of the Medical Journal of Australia (from July, 1914, onwards). Records of the cases treated at the Quarantine Station, Horth Head, Sydney, up to January, 1914, are given in Quarantine Service Publication Ho. 4, “ Sinall-pox Epidemic in Hew South Wales, 1913,” by Dr. D. G. Robertson, Chief Quarantine Officer (General) for Victoria. The account of this epidemic is taken practically verbatim from these records. 1

Onset of the Epidemic.

On    receipt of the report of the occurrence of unusual

rashes, apparently infectious, amongst employees oi the underclothing factory at Chalmers-street, Sydney, during April and

May, 1913, a medical officer of the State Department of Public Health visited the factory on 30th May, and learnt that, between 20th April and the end of May, a number of young women employed in the factory had suffered from slight eruptions, for the most part on the face, but also extending to other parts of the body. In each case the appearance of the eruptions had been preceded by an attack of so-called “ influenza,” in which the most prominent symptoms had been headache, vertigo, shivering, and general pains. In some of the cases there had been backache, and in a few there had also been some vomiting, usually slight. The precedent illness, in all the cases, appeared to have been of a very mild type, and while some of the girls had stayed away from business for a few days, some had not considered it necessary to do so at all. Hot more than two of the girls affected had consulted a medical practitioner, and in those cases they stated they had been told that there was nothing much the matter. Further inquiries elicited that the first case had occurred on or about 25th April, at which date a girl, E. D., aged 22, had been attacked by “ influenza.” Three days later she developed a “ pimply ” rash on the face. She had been absent from work for a week, and had returned to duty feeling w^ell before the eruption appeared.

On examination of the employees of the Chalmers-street factory, it was found that nearly all the persons said to have been affected showed small stains, dried scales, and in a few instances very shallow, depressed cicatrices upon some portion of their bodies. In one or two instances these had been fairly numerous, but in several cases the total number observed upon any one person did not amount to twenty, while in some there were fewer still. One girl, for instance, had three such marks on her chest, and one on her arm. Another had twelve on the face, three on the' right arm, and one on the left arm. In some instances girls who had suffered from precisely similar symptons of “ influenza ” had completely recovered, and the symptoms had not been followed up by any eruption. On being questioned, the girls described the rash as having appeared as “ pimples,” and having come out in crops, which continued to erupt from day to day over a period of from three to four days to a week. Most of the girls appeared to have been rather more affected on the face than elsewhere, but this was not always the case, and in some instances the face had escaped altogether. Every girl affected by the eruption stated that after the attack of “ influenza,” and before the rash appeared, she felt quite well and continued so, and had returned to work either immediately or as soon as she was “ fit to be seen.”

On 31st May one of the girls (G. H.) employed at the Chalmers-street factory was admitted to the Coast Hospital, Little Bay, suffering from a copious rash on her face, body, and limbs. She had been seen by two medical practitioners, who diagnosed her illness as a severe form of chicken-pox. On 31st May she was seen by medical officers of the

Health Department in consultation with the hospital medical staff. Her temperature was then normal, and she did not appear to be ill. She also was unvaccinated. The eruption in her case was more plentiful than in any of the other cases which had been examined, but the absence of any serious symptoms of constitutional illness, when weighed with the symptoms observed in the other cases that had occurred at the factory, led to the formation of the opinion by the medical officers that they were dealing with a form of chicken-pox. According to the published records relating to this phase of the outbreak, diagnosis was made in regard to these cases after careful consideration of the clinical features. The vaccination test was not adopted until the 18th or 19th June. (See page 35.)

Origin of the Infection.

On inquiry from the original case, E. D., at the Chalmers-street factory, it was ascertained that she had been very friendly with a young man, B. E., who had been a steward on the s.s. ZeaA landia, which had arrived in Sydney on 12th April from Vancouver, British Columbia. She saw him at his mother’s house on the day of his arrival, and the following days, and he was then suffering from an eruption on his face. The young man, B. E., was seen and cross-questioned. He was aged 23, and was said to have been vaccinated in infancy, but showed no scars of the operation. The s.s. Zealandia left Vancouver on 19th March and arrived in Sydney on the 12th April. The ship touched at Victoria, British Columbia, Honolulu, Suva, and Auckland, and the steward, B. E., is said to have been ashore at each port. According to the records of the State Health Department, he is said to have stated that whilst ashore at Suva, on 4th April, he fell sick with severe headache, pains in the stomach, great weakness, but without vomiting, and he was confined to his bunk for two and a half days after leaving Suva, but he was not seen by the ship’s surgeon. The day after leaving Auckland, i.e., on 9th April, he stated that his face “ broke out ” in pimples, the eruption being scanty and confined to the face, forehead, and back of the neck, and that before this eruption appeared he felt quite well. He considered that the eruption was a crop of “ small boils,” and stated that it did not disappear until some days after his arrival in Sydney. On the other hand, this man, with all other members of the crew of the Zealandia, was carefully examined on inward medical inspection by the Quarantine Officer in Sydney, a senior officer with considerable experience in small-pox.

The further history of this man, B. E., showed that three weeks after landing in Sydney, he again joined the s.s. Zealandia, and acted as third-class steward for three weeks during a voyage to Perth and back, during which period there is no evidence that any passenger was infected by him. Subsequently, towards the end of June he was examined by several medical men with the object of detecting any signs of recent small-pox, there being no sign that he had so suffered. He was vaccinated

oil 3rd July, and the results of his vaccination were accepted by experienced quarantine officers as typical vaccine pustules, although the State Health Department records refer to these results as atypical “ mulberry ” marks with atypical large pock marks thirteen days later. The vaccination was performed in three insertions on the left upper arm on the 3rd July. On 16th July the three insertions were pustular, with a large areola around each. The upper arm was indurated and swollen, and the glands in the axilla were enlarged; at this period he was away from work for two days, owing to the results of the vaccination. On 2nd August the scabs were flat, that from the lowest insertion having fallen. On 6th August the scabs had disappeared, leaving three scars showing foveation. A successful reaction to vaccination did not result from the vaccination of any person who was attacked during the epidemic in Sydney, and as immunity to vaccination was a constant result of the disease, it is reasonable to accept this man’s vaccination as of importance in relation to his connexion with the introduction of the infection.

Inquiry into the circumstances of the voyage of the s.s. Z ealandia showed that a concurrent outbreak in Hew Zealand had originated from a passenger who landed from this vessel at Auckland on 8th April. Inquiries made in co-operation with the health authorities of Hew Zealand elicited the following alleged facts i—A party of Mormon missionaries left Utah, United States of America, and sailed from Vancouver on the Zealandia on 19th March. Two days later one of the party, F., fell ill, and a pustular rash developed. He was not very ill, but he saw the ship’s surgeon, and knowing that there had been small-pox in Utah, asked if he were suffering from that disease. The surgeon thought not, took no precautions, and the patient soon recovered. The party landed in Hew Zealand on 8th April, and proceeded to the Whangarei district, where, five days later, F.’s cabin mate took ill, developed a pustular rash, and during a mild illness, in which he saw no doctor, infected the household with whom he was staying, and originated an outbreak which persisted until 1914. This case, and the original case, F., were stated to have had the man B. E. as their cabin steward. It is interesting to note that small-pox was, in 1872, introduced simultaneously into Hew Zealand and Australia by the s.s. Nebraska, from San Francisco.

It was assumed by the health authorities of Hew South Wales that the steward, B. E., was the original source of infection in the local outbreak. The evidence that this man was the carrier of infection into Sydney is not wholly conclusive, but it appears not unlikely that the infection was carried simultaneously into Hew Zealand and Australia by the s.s. Zealandia, that the disease was carried by the Mormon missionaries, and that no other agent than the steward, B. E., was discovered as responsible for the introduction of infection into Australia.

It. was established that B. E. on landing from the Zealandia lived with his family. Every member of this family was unvaccinated, bat none developed the disease.

Course of the Epidemic.

Whilst the occurrence of the apparently infectious illness with eruption which had been reported in the Chalmers-street factory was being investigated by the medical officers of the State Health Department, on 31st May the occurrence of an unusual case of eruptive disease was reported in a girl in Granville. This girl, aet. 21, was employed at a clothing factory in Kent-street, Sydney, and had become ill on 23rd May with pain in the sides, slight chilliness and no headache. A pimple appeared on the nose on 27th May, and pimples continued to erupt on the chest, back, face, and scalp during the 28th, 29th, and 30th, fresh crops appearing every day. She had not felt very ill, but the itchiness of the rash had disturbed her sleep. She had never been vaccinated. On examination on the 31st May her temperature was normal, and she did not appear ill. She was marked on the face, trunk, and limbs with a discrete vesicular and pustular eruption which was most copious on the face and on the back, next on chest and abdomen, scanty on limbs, and fairly plentiful on scalp. The illness was diagnosed as chicken-pox. It was subsequently discovered that this girl was friendly with girls in the Chalmers-street factory, and had probably been in their company about three weeks prior to the development of her eruption. On vaccination she did not react to the vaccine, although two control vaccinations from the same tube of lymph were successful.

On 18th June the Sydney Hospital authorities notified the Health Department that a very unusual form of eruption had occurred in a patient in that institution. The hospital was visited by a medical officer of the Department, and a female patient, E. B., was seen. She was covered with a copious rash which, in its appearance and distribution, showed many resemblances to small-pox, although she showed little constitutional disturbance. She had never been vaccinated. This case was considered with such suspicion that the diagnosis of varicella made in the earlier cases was questioned. In order to obtain more conclusive evidence, six of the persons who had been affected by the illness at first believed to be chicken-pox were persuaded on 18th and 19th June to allow themselves to be vaccinated under control conditions, that is to say, the patient and one or two other persons who had not been affected by the illness were in each case vaccinated from the same tube of lymph. By the evening of 23rd June it had become apparent that in every instance the person who had suffered from the attack of supposed chicken-pox had failed to respond to the vaccinations, although all the controls showed signs of successful vaccination. Neither the “ controls ” nor the “ patients ” had ever previously been vaccinated. A further test in seven similar instances gave identical results, and the opinion of expert officers in regard to the clinical condition of the cases having been received, the Board of Health, on 1st July, decided that the disease present was in reality small-pox. Including those cases which were considered in the first place to be varicella, many of which only came within the purview of the Health Department after the complete establishment of convalescence, 111 cases had occurred up to 5th July. The epidemic showed no signs of abatement throughout July, August, and September, but at the end of the latter month a steady decline in the number of recorded cases set in and continued until the end of the year, by which time a total number of 1,073 cases had been reported. Nearly all parts of the metropolitan area contributed cases, whilst 28 localities outside of this area were affected, many of these country cases acquiring infection in Sydney, and being attacked later on reaching their homes in the country.

Throughout the year 1914, small-pox continued to occur, 628 cases being recorded, 445 of which were in the metropolitan area, 44 in the Hunter River district around Newcastle, and 139 in other country districts. The type of the disease continued unchanged from that observed in 1913, and was extremely mild. In the metropolis the 445 cases were widely distributed throughout the suburbs, the majority of the cases occurring in the winter months between May and October (see Table 6, page 37). In the Newcastle (Hunter River) district a case had occurred in a stowaway from Auckland, New Zealand, in July, 1913, but this case does not appear to have any connexion with the later epidemic of 1914, which commenced in two centres—Singleton in January and Newcastle in March. After a clear period a second outbreak occurred at Newcastle in September, and persisted until November. In all, 16 cases occurred at Singleton in January and February, and 28 cases at Newcastle in the two outbreaks. In other extra-metropolitan areas, 139 cases occurred, scattered through six country districts, the most extensive outbreak being one amongst workmen employed on the Yass-Coolalie railway deviation works, which also affected the ordinary residents of Yass. Forty-two persons were officially known to have been attacked in this outbreak.

In 1915, small-pox continued in the same mild form. Infection persisted in the metropolitan area in a desultory manner. Twenty-five cases were reported from 1st January to 25th March, when the last case was discharged from the Quarantine Station at Sydney. On 30th August there was a recrudescence, and 17 cases were reported up to 20th December, this second outbreak being attributed to re-introduction of the disease from the Newcastle district. In this year, the Hunter River district bore the brunt of the outbreak, reporting 411 cases in a total of 471 cases for the whole State. In Newcastle and immediate districts, including Tarro and Lake Macquarie, an outbreak occurred on 19th February and lasted until 23rd March, producing 7 cases. A second outbreak on 10th August resulted in 325 cases. In the Cessnock

Shire, particularly around Kurri Kurri, Cessnock, and Port Stephens, there were two outbreaks wuth 36 cases between 9th February and 13th May, and 39 cases between 25th May and 10th August. Of 5 cases which occurred at Gloucester, outside this district, one travelled down to ascertain whether he was suffering from small-pox, and was isolated at Newcastle.

In 1916, the same mild form of small-pox continued to appear, but steadily declined throughout the year, only 108 cases being reported throughout the State, and excepting imported cases in the metropolitan area, no cases occurred south of a line drawn from Coonamhle to Newcastle. The metropolitan area reported only 16 cases, all in the earlier months of the year, and all these cases being introduced from the north or traced directly to cases so introduced. In the Hunter River district, 33 cases occurred up till 18th May. In other country districts cases were confined to the north coastal area and the northwestern district of the State, the only considerable number of cases being at Narrabri (30) and Walgett (11), both in the north-western district.

In 1917, small-pox continued in the north-western district, the only exception being an outbreak of 14 cases in tfip Cessnock Shire in the Newcastle district, introduced from the north-west in July. Of the other 105 cases reported in 1917, the more important centres were Coonamble with 14 cases in April and May, Coonabarabran with 13 cases in June, and Warren with 66 cases from June to December, 61 of these Warren cases occurring between June and August. With the exception of one case at Warren early in January, 1918, no further cases of small-pox were reported from New South Wales.

The distribution of cases by weeks in each year during the prevalence of the infection and the localities in which cases occurred in each year are shown hereunder in the following tables, compiled from the Annual Reports of the Director-General of Health for New South Wales:—

Table 6.—Small-pox in New South Wales 1913-18. Seasonal Distribution of Cases. Notifications each week.

1913.

1914.

1915.

1916.

1917.

1918.

Week ended—■

Cases.

Week ended—

Cases.

Week ended—

Cases.

Week ended—

Cases.

Week ended—

Cases.

Week ended—

Cases.

Jan...

Jan. 10

5

Jan. 10

3

Jan. 8

6

Jan. 6

Jan. 5

1

17

17

15

10

13

24

9

24

5

22

4

20

31

31

29

5

27

Feb. 7

• 4

Feb. 7

1

Feb. 5

2

Feb. 3

1

14

8

14

24

12

5

10

21

4

21

9

19

2

17

2

28

1

28

5

26

2

24

10

Mar. 7

13

Mar. 7

7

Mar. 4

..

Mar. 3

, ,

14

2

14

6

11

..

10

• •

1913.

1914.

1915.

1916.

1917.

1918.

Week

ended—

Caees.

Week ended—

Cases.

Week ended—

Cases.

Week

ended—

Cases.

Week ended—-

Cases.

Week ended—•

Cases.

Jan...

Mar. 21

1

Mar. 21

3

Mar. 18

1

Mar. 17

28

9

28

2

25

24

Apr. 4

5

Apr. 4

Apr. 1

2

31

11

4

11

8

3

Apr. 7

18

11

18

2

15

3

14

25

3

25

1

22

1

21

May 2

5

May 2

Apr. 29

Apr. 28

9

11

9

May 6

May 5

1

16

30

16

13

2

12

5

23

17

23

20

19

30

19

30

2

27

7

26

June 6

12

June 6

June 3

June 2

13

10

13

1

10

1

9

12

Up to

20

32

20

2

17

16

2

July 5

Ill

21

9

27

9

24

3

23

July 4

17

July 4

6

July 1

4

30

18

12

94

11

24

11

3

8

3

July 7

19

93

18

10

18

3

15

3

14

26

49

25

9

25

3

22

1

21

Aug. 2

61

Aug. 1

19

Aug. 1

4

29

14

28

33

9

42

8

31

8

3

Aug. 5

9

Aug. 4

4

16

40

15

14

15

2

12

1

11

23

85

22

22

22

1

19

2

18

Î5

30

59

29

10

29

9

26

25

Sept. 6

67

Sept. 5

12

Sept. 5

12

Sept. 2

4

Sept. 1

2

13

59

12

14

12

13

9

1

8

20

46

19

19

19

5

16

15

27

30

26

20

26

22

23

6

22

Oct. 4

36

Oct. 3

10

Oct. 3

25

30

29

1

11

23

10

40

10

32

Oct. 7

Oct. 6

3

18

32

17

13

17

37

14

13

3

25

32

24

22

24

26

21

20

Nov. 1

17

31

36

31

35

28

27

8

18

Nov. 7

15

Nov. 7

22

Nov. 4

Nov. 3

2

15

18

14

10

14

39

11

10

22

7

21

9

21

19

18

17

29

13

28

12

28

8

25

24

1

Dec. 6

24

Dec. 5

5

Dec. 5

11

Dec. 2

Dec. 1

13

5

12

3

12

18

9

8

1

20

8

19

3

19

18

16

1

15

1

27

2

26

2

26

7

23

22

1

27-31

2

31

3

31

6

30

29

1

Total, 52

Total, 52

Total, 52

Total, 52

Total, 52

Total, 52

weeks

1,073

weeks

628

weeks

471

weeks

108

weeks

119

weeks

1

Table 7.—Small pox in New South Wales, 1913-1918.

Cases reported in each District during each year.

(lirom Annual Reports of the Director-General of Public Health of New South Wales).

Metropolitan.

District.

Population.

1913.

1914.

1915.

1916.

1917.

1918.

Total,

1913-18.

City of Sydney— Central City .. Blackfriars .. Camperdown .. Centennial Park .. Chippendale .. Darlinghurst .. Moore Park .. Pyrmont . . Surry Hills . . Ultimo .. . . Woolloomooloo . .

24

5

12

2

30

7

1

20

75

17

30

54

2

1

5

13

2

8

15 4 2

Not available

0j

s

£

Total, City of Sydney

116,150*

223

106

8

3

Nil

Nil

340

Municipalities—

Alexandria . .

10,123

58

7

65

Annadale ..

11,240

16

7

23

Ashfield . . . .

20,431

17

3

20

Auburn . . ..

5,559

9

1

1

2

13

Balmain .. . .

32,038

29

10

1

40

Bankstown ..

2,039

1

4

5

Bexley . . . .

6,517

9

1

.%

10

Botany .. ..

4,409

1

3

1

4

Burwood . .

9,380

3

3

6

Canterbury ..

11,335

17

5

22

Concord .. ..

4,076

1

1

2

Darlington ..

3,816

3

2

5

Drummoyne ..

8,678

5

5

Enfield .. ..

3,444

1

1

2

Epping . . ..

1

1

Erskineville . .

7,299

54

36

1

91

Fairfield . . . .

1

1

Glebe .. . .

21,943

62

14

76

Granville.. ..

7,231

28

2

1

31

Guildford . .

1

1

Hunter’s Hill ..

5,013

1

l

Hurstville ..

0,o33

19

4

23

Kogarah . . ..

6,953

8

8

Leichhardt ..

24,254

27

10

37

Lidcombe . .

1

10

11

Liverpool . .

3,938

2

4

2

8

Manly .. . .

10,465

2

1

3

Marrickville ..

30,653

21

16

1

38

Mascot . . . .

19

3

22

Mosman .. ..

13,243

7

7

Newtown . .

26,498

41

62

5

1

109

North Sydney ..

34,646

13

6

1

20

Paddington . .

24,317

51

6

57

Parramatta . .

12,465

15

2

2

2

21

Petersham . . Prospect and Sher-

21,712

9

5

2

16

wood .. ..

3,932

5

2

7

Randwick ..

19,463

18

15

2

35

Redfern . . . .

24,427

61

27

1

89

Rockdale ..

14,095

11

2

13

Ryde . . ..

5,281

1

1

Strath field ..

4,046

8

2

10

St. Peters . .

8,410

16

42

58

Metropolitan— continued.

District.

Population.

1913.

1914.

1915.

1916.

1917.

1918.

Total,

1913-18.

Municipalities—

2

88

Waterloo.. ..

10,072

81

5

Waverley ..

19,831

28

7

35

Willoughby . .

13,036

7

1

1

2

11

Woollahra ..

16,989

15

5

1

21

Shires—

Hornsby ..

8,901

2

1

3

Kuringai . .

9,458

2

2

Warringah ..

2,823

1

Nil

1

Port Jackson ..

8,051

1

Nil

1

Total, Metropolitan

Area (Combined

Sanitary Districts)

761,000*

1,017

445

41

16

Nil

Nil

1,519

Hunter River District.

District.

Population.

1913.

1914.

1915.

1910.

1917.

1918.

Total,

1913-18.

Municipalities—

Adamstown ..

2,660

2

18

20

Carrington ..

2,685

6

6

Greta .. ..

858

6

6

Hamilton . .

7,908

1

63

64

Lambton.. ..

2,796

3

14

17

Merewether ..

4,151

9

9

Morpeth .. ..

1,064

. .

1

1

Newcastle ..

11,610

1

15

47

13

76

New Lambton ..

1,827

2

31

3

36

Platts burg . .

2,661

1

. .

1

Raymond Terrace..

911

1

1

Singleton ..

2,996

12

2

14

Stockton ..

2,106

4

1

5

Wallsend.. ..

j- 3,346

2

35

4

41

West Wallsend ..

1

. .

, .

1

Waratah ..

4,419

, .

5

3

8

West Maitland ..

8,210

2

2

Wickham ..

8,434

1

60

4

65

Shires—

Cessnock ..

21,018

98

14

112

Lake Macquarie ..

14,610

. .

. .

11

3

. .

, .

14

Port Stephens ..

3,882

• .

. .

2

. .

2

Tarro .. ..

6,492

• •

• •

2

• •

• •

2

Total, Hunter River

District ..

135,000*

1

44

411

33

14

Nil

503

Table 7.—Small pox in New South Wales, 1913-1918-—continued.

Remainder of State.

District.

Population.

1913.

1914.

1915.

1916.

1917.

1918.

Total,

1913-18.

Adelong .. ..

4

4

Alburv ..

6,309

1

1

Armidale . .

4,738

3

3

Bega .. ..

1,969

, .

I

I

Blacktown (Rooty Hill)

3,847

2

2

4

Bogan Gate ..

1,774

1

1

Bowning .. ..

1

1

Breeza .. . .

1

1

Bourke .. ..

1,593

1

1

Burrowa . . . .

891

1

1

Brewarrina. . . .

798

7

7

Cawlev . . .

1

1

Campbelltown ..

1,825

3

3

Coolah .. ..

1,366

8

9

Coolalie .. ..

17

17

Coonamble . . . .

2,262

1

1

14

16

Coonabarabran . .

3,078

13

13

Coopernook . .

5

5

Cootamundra ..

2,967

6

6

Coraki .. . .

1,138

2

2

Cronulla .. . .

l

7

Erina (Wyong) ..

9,176

1

.. 1

Glen Innes .. . .

4,089

2

.. i 2

Gloucester .. ..

3,380

6

• • 1

Grafton .. ..

4,681

1

% . .

.. ! 1

Go ul burn .. ..

10,023

1

1

.. ; 2

Grenfell . . ..

1,145

1

.. i i

Harden .. ..

l

.. i i

Hastings (Wauchope)

5,746

1

I

Helensburgh ..

10

10

Howlong .. . .

1

1

Illabo .. . .

2,973

1

1

Katoomba .. ..

4,923

1

1

Kempsey . . . .

2,862

l

1

2

Kyogle . . ..

3,839

1

1

Lilyvale . . ..

1

1

Lithgow . . ..

8,196

3

3

Maclean .. ..

5

5

Manning (Cundletown)

J. 11,137

3

2

5

,, (Forster) ..

1

1

Moree .. • •

j- 2 931

1 5

1

16

,, (Pallamallava)

2

2

Mount Kosiuska ..

1

1

Mundoon .. • •

3

3

Mungindi .. ..

1

1

Muswell brook • •

1,861

2

2

Narrabri .. • •

2,514

1

30

31

„ West . ■

806

2

2

Nevertire .. • •

3

*{

Nyngan .. • •

1,200

2

2

Grange .. ••

4,220

2

2

Parlies .. • •

2,935

1

1

Patrick’s Plains (Wit-

tingham) • ■

6,894

1

1

Peak Hill .. • •

1,362

1

1

Penrith . . • •

3,682

2

2

4

Quirindi .. • •

2,240

20

20

Scone •• ••

1,156

4

4

is the

Remainder of State—continued.

1918.

Total,

District.

Population.

1913.

1914.

1915.

1916.

1917.

1913-18.

Scarborough .. Stroud (Buladelah) . . Tamarang (Werris

5,117

10

1

10

1

1

Creek) . . ..

3,998

1

Tamworth . . . .

7,145

•)

2

Tumut . . . .

1,517

2

2

Taree .. ..

1,205

1

2

3

Temora . . . .

2,784

4

4

Ulmarra . . ..

1,832

2

2

Walgett . . . .

1

11

1

13

,, (Collarenebri)

[ 3,200

2

2

,, (Burren.Junc-

1

tion) . .

J

1

Warren .. ..

1,142

66

1

67

Yass . . . .

2,136

20

20

Yass River ..

5

5

Total, remainder of

State . . ..

912,000

55

139

19

59

105

1

378

Population shewn is for the Census 3rd April, 1911, except where shewn (*), which is the estimated mean population 1913.

Table 8.—Summary—Small-pox Cases reported in New South Wales 1913-1918, by Districts, in each Year.

District.

Population.*

1913.

1914.

1915.

1916.

1917.

1918.

Total.

-Metropolitan . .

761,000

1,017

445

41

16

1,519

Hunter River ..

135,000

1

44

411

33

14

503

Remainder of State ..

912,000

55

139

19

59

105

1

378

Total, State ..

1,808,000

1,073

628

471

108

119

1

2,400

Estimated mean population, 1913.

Seasonal Distribution.

Table 6 (page 37), shows the notifications of cases during each week of the epidemic years in [New South Wales. The following Tables give such further particulars as are available in regard to the seasonal distribution of cases in certain localities:—

Table 9.—Admissions to the Quarantine Station, North Head, Sydney, from 1st July, 1913, to 25th March, 1915.

Year.

Month.

Ad

Males.

missions (Case Females.

S).

Total.

1913 .. ..

July . . . .

182

151

333

August .. ..

135

113

248

September . . ..

130

81

211

October .. ..

02

50

112

November .. ..

32

31

03

December .. ..

17

13

30

1914 .. ..

January .. ..

10

0

10

February .. ..

9

0

15

March .. ..

8

8

10

April .. ..

11

3

14

May .. . .

49

27

70

June .. . .

30

24

00

July .. ..

* 40

15

01

August .. ..

37

* 14

51

September . . . .

34

27

01

October .. ..

77

28

105

November .. ..

20

19

45

December .. . .

8

0

14

1915 .. ..

January .. ..

0

3

9

February .. ..

10

3

13

March .. ..

4

4

Table 10.—Notifications of Cases of Small-pox received by the Medical Officer of Health for the Hunter River Combined Sanitary Districts in each Month, 1914-1917.

Month.

1914.

1915.

1916.

1917.

Total,

1914-1917.

January .. ..

7

2

11

20

February .. ..

9

28

10

47

March .. .. ..

11

8

3

22

April .. .. . •

3

3

4

10

May .. .. ..

2

2

4

June .. .. ..

4

17

21

July .. .. ..

2

10

5

23

August .. . . ..

19

3

22

September .. ..

2

55

57

October .. ..

8

124

5

137

November .. ..

88

1

89

December .. • •

38

3

41

Total . . ..

48

400

31

14

493

-Table 11.—Summary—Cases of Small-pox in the whole of New South Wales in Four-weekly Periods, 1913-1918.

Four-weekly Period.

1913.

1911.

1915.

191«.

1917.

19.18.

I. . .

14

8

25

1

11. . .

17

39

11

13

111. ..

25

18

1

IV. ..

23

3

9

V. ..

1

r

63

2

6

VI. ..

y

298^

73

5

8

14

VII. ..

j

1

60

21

13

18

VIII. ..

192

73

12

25

37

IX. ..

270

58

35

7

17

X. ..

135

89

84

6

4

XI. ..

99

86

120

5

XII. ..

62

36

77

1

XIII. ..

17

11

49

1

4

Total . .

1,073

628

471

108

119

1

Although cases occurred throughout the year, the characteristic distribution shows a maximum, of cases in the winter months, and in each year a decline in incidence with the onset of warm summer weather.

This is in accord with the seasonal distribution of small-pox as it occurs in other countries (vide p. 27 sqq.)

Sex and Age Distribution.

The following table shows for the whole of the New South Wales epidemic the distribution of cases arranged according to age and sex during each year, and for the total period of the epidemic.

Table 12.—-Small-pox in New South Wales, 1913-1917. Cases reported under Sexes and Age Groups (Annual Reports of Director-General of Public Health, New South Wales).

Sex.

0-1.

1-5.

5-10.

10-20.

20-30.

30-40.

40-50.

50-60.

Over

60.

Unspeci

fied.

Total.

1913 ..

Male

7

16

46

129

237

86

33

16

6

576

Female

21

30

43

132

175

51

28

12

5

497

Total

28

46

89

261

412

137

61

28

11

1,073

1914 ..

Male

9

24

17

73

145

90

32

21

15

426

Female

5

26

23

38

65

21

12

5

7

202

Total

14

50

40

111

210

111

44

26

22

628

1915 ..

Male

8

18

23

49

110

38

21

11

2

3

283

Female

13

20

10

32

66

31

5

5

5

i 1

188

Total

21

38

33

81

176

69

26

16

7

4

471

1916 ..

Male

2

4

4

16

26

10

3

2

67

Female

2

7

3

10

12

2

I

2

1

••

40

Total

4

11

7

26

38

12

4

4

1

107

Sex.

0-1.

1-5.

5-10.

10-20.

20-30.

30-40.

40-50.

50-60.

Over

68.

Unspeci

fied.

Total.

1917 ..

Male

4

8

19

20

8

6

2

3

70

Female

3

7

8

15

6

6

3

1

••

49

Total

7

15

27

35

14

12

5

4

*•

119

Total, 1913-

Male

26

66

98

286

538

232

95

52

26

3

1,422

1917

Female

41

86

86

220

333

111

52

27

19

1

976

Total

67

152

184

506

871

343

147

79

45

4

2,398*

Percentage of Total, by Sexes, in each Age Group.

Total, 1913-

Male

1.8

4.6

6.9

20.1

37.8

16.3

6.7

3.8

1.8

2

100.0

1917

Female

4.2

8.8

8.8

22.6

34.1

11.4

5.3

2.8

1.9

.1

100.0

Total

2.8

6.3

7.7

21.1

36.3

14.3

6.1

3.3

1.9

.2

100.0

*One case in 1916, one case in 1918, not recorded.

Further details which also show the vaccinai condition for each sex and age group are given by Dr. Robertson in connexion with the cases, treated at the Quarantine Station, North Head, Sydney, during the period from 1st July, 1913, to 31st January, 1914. These are shown hereunder :—

Table 13.—Age and Sex Distribution Shewing Vaccinal Condition of 1,037 Cases Treated at the Quarantine Station, Sydney, DURING THE PERIOD 1ST JULY, 1913, TO 31ST JANUARY, 1914.

A ne Group.

Male.

Female.

Both Sexes.

Un-vaccinated.

Vac

cinated.

Total.

Un-vaccinated.

Vac

cinated.

Total.

Un-vac

cinated.

Vac

cinated.

Total.

0-5 ..

29

29

46

46

75

75

5-10 ..

42

42

42

42

84

84

10-15 ..

43

43

42

42

85

85

15-20 ..

73

73

76

76

149

149

20-30 .•

246

2

248

156

156

402

2

404

30—40 ..

73

7

80

48

5

53

121

12

133

40-50 ..

21

13

34

22

8

30

43

21

64

60 and over

18

7

25

7

11

18

25

18

43

Total ..

545

29

574

439

24

463

984

53

1,037

Subsequent records of the cases treated at the Quarantine Station are available for the periods 1st February to 31st August, T914, and 1st September, 1914, to 25th March, 1915, when the last case was admitted

to the Quarantine Station and the epidemic in the metropolitan area ended. These records are given hereunder :—

Table 14.—Cases Treated at the Quarantine Station during the Period 1st February to 31st August, 1914.

Age Group.

Male.

Female.

Both Sexes,

Un-vaccinated.

Vac

cinated.

Total.

Un-vac

cinated.

Vac

cinated.

Total.

Un-vaccinated.

Vac

cinated.

Total.

0-5 ..

13

13

21

21

34

34

5-10 ..

12

12

10

10

22

22

10-15 ..

10

, .

10

12

12

22

22

15-20 ..

24

24

8

8

32

32

20-30 ..

66

3

69

36

36

102

3

105

30-40 ..

39

13

52

19

2

21

58

15

73

40-50 ..

8

2

10

10

2

12

18

4

22

50 and over

7

15

22

7

3

10

14

18

32

Total ..

179

33

212

123

7

130

302

40

342

Table 15.—Cases Treated at the Quarantine Station, Sydney, during the Period 1st September, 1914, to 25th March, 1915.

Age Group.

Male.

Female.

Both Sexes.

Un-vaccinated.

Vac

cinated.

Total.

Un-vaccinated.

Vac

cinated.

Total.

Un-vaccinated.

Vaccinated .

Total.

0-5 ..

14

14

19

19

33

33

5-10 ..

6

6

6

6

12

12

10-15 ..

6

6

4

4

10

10

15-20 ..

23

23

9

9

32

32

20-30 ..

57

57

29

29

86

86

30-40 ..

30

2

32

14

1

15

44

3

47

40-50 ..

10

1

11

2

2

12

1

13

50 and over

4

5

9

3

4

7

7

9

16

Total ..

150

8

158

86

5

91

236

13

249

For the whole of the period of the epidemic in the metropolian area the age incidence of the total cases treated at the Quarantine Station, Sydney, is shown hereunder :—

Table 16.—Total Cases Treated at the Quarantine Station, Sydney during the Period 1st July, 1913, to 25th March, 1915.

Age Group.

Male.

Female. ^

Both Sexes.

Un-vac

cinated.

Vac

cinated.

Total.

Un-vaccinated.

Vac

cinated.

Total.

Un-vac

cinated.

Vac

cinated.

Total.

0-5 ..

56

56

86

86

142

142

5-10 ..

60

60

58

58

118

118

10-15 ..

59

. ,

59

58

58

117

, .

117

15-20 ..

120

. .

120

93

93

213

. .

213

20-30 ..

369

5

374

221

221

590

5

595

30-40 ..

142

22

164

81

8

89

223

30

253

40-50 ..

39

16

55

34

10

44

73

26

99

60 and over

29

27

56

17

18

35

46

45

91

Total ..

874

70

944

648

36

684

1,522

106

1,628

Table 17.—Table showing Percentage of Cases in each Age Group of Total Cases Treated at Quarantine Station, Sydney, during the Period 1st July, 1913, to 25th March, 1915.

Age Group.

Male.

Female.

Botli

Sexes.

Gases.

Percentage of Total.

Cases.

Percentage of Total.

Cases.

Percentage of Total.

0-5 .. . .

56

5.9

8G

12.6

142

8.7

5-10 .. ..

60

6.4

58

8.5

118

7.2

10-15 .. ..

59

6.2

58

8.5

117

7.2

15-20 .. ..

120

12.7

93

13.6

213

13.1

20-30 .. ..

374

39.7

221

32.3

595

36.6

30-40 .. ..

164

17.4

89

13.0

253

15.5

40-50 .. ..

55

5.8

44

6.4

99

6.1

50 and over . .

56

5.9

35

5.1

91

5.6

Total ..

944

100.0

684

100.0

1,628

100.0

These tables indicate that the heavier incidence fell on males, with the exception of the age group under five years, which showed throughout the epidemic a higher incidence amongst females. In the earlier stages of the epidemic in the metropolitan area the infection amongst the female employees at the Chalmers-street factory somewhat raised the female incidence figures for that period. For the whole period of the outbreak in Hew South Wales, in a total of 2,398 cases, 1,422 cases (or 59.3 per cent.) occurred amongst males compared with 976 cases (or 40.7 per cent.) amongst females. Of the 1,628 cases treated at the Quarantine Station, Sydney, 874 (or 58 per cent.) were males, and 648 (or 42 per cent.) were females. The distribution of the State population by sexes is indicated by the estimated population figures on 31st December, 1913, when there were 962,053 males (52.5 per cent, of the total poulation), and 869,663 females (47.5 per cent.) in a total population of 1,831,716. In the metropolitan area, females are somewhat in excess of males, the Census figures of 1921 being 433,559 males (48.2 per cent.), and 465,540 females (51.7 per cent.), in a total of 899,099 persons. The incidence of small-pox amongst males was therefore significantly higher than that prevailing amongst females. This is characteristic of small-pox as it occurs in other countries. One point raised in this connexion, although not applicable to the earlier period of the epidemic, is that in the course of a mild epidemic such as this, in which cases are known to have occurred in which no medical practitioner was called in, a larger proportion of male cases would report to a doctor in order to obtain a certificate for cessation of work and payment of sick pay.

The age incidence of attack shows that the disease affected chiefly young adults and adolescents; for the whole State during the epidemic 36 per cent, of the notified cases were within the age group between 20 and 30 years, and 21 per cent, in the age group between 10 and 20 years. The records of the cases treated at the Quarantine Station, Sydney, show

a similar incidence, with 36 per cent, of the cases between the ages of 20 and 30 years, and 20 per cent, between the ages of 10 and 20 years. There was no variation in the age incidence of those attacked through the course of the epidemic, nor between the age incidence of cases occurring in the metropolitan and the extra-metropolitan areas.

Nationality.

Of the 1,037 confirmed cases admitted to the quarantine Station, North Head, Sydney, from 1st July, 1913, to 31st January, 1914, 1,037 were whites, 6 Eurasians, 5 Negroid, 3 Chinese, 1 Indian, 1 Maori, and 1 aboriginal. Of the 544 cases admitted from 1st February, 1914, to 25th March, 1915, one was a lialf-caste Chinese and one an aboriginal, while several of the families admitted as cases and contacts appeared to have had aboriginal ancestry. In this connexion it may be noted that the racial composition of the population of New South Wales is fundamentally British; the population of the whole Commonwealth at the census of 1911 shoAved 97 per cent, to be of British extraction. At the census of 1921, when the first serious enumeration of full-blooded aborigines in Australia was undertaken, only some 1,501 natives were recorded in New South Wales. The total proportion of the non-European races recorded in the census of 1911 (excluding full-blooded aborigines) was only 1.1 per cent, of the total population of the State. There is, therefore, no native population in New South Wales in any way analogous to the Maori communities in New Zealand, amongst which, in the concurrent epidemic of 1913-14, some 1,778 cases of small-pox were notified with 55 deaths—a case-mortality rate of 3.1 per cent.

Type of the Disease.

The records of the clinical feature of the disease as it appeared in NeAV South Wales betAveen the years 1913-18 are complete, and are available in Quarantine Service Publication No. 4, “Small-pox in New South Wales,” by Dr. D. G. Robertson, and in the report of the Director-General of Public Health for New South Wales (Dr. W. G. Armstrong) for 1913 (Part III. “Outbreak of Mild Small-pox in Sydney, 1913,” pages 102 sqq.). Dr. Armstrong also contributed an informative article on “ The Recent Epidemic of Small-pox in New South Wales: Its Diagnosis and Prevention,” which appeared in the Australasian Medical Gazette for 2nd May, 1914, and in the Proceedings of the Royal Society of Medicine (Section of Epidemiology and State Medicine), Yol. VIII. (1914-15), Part II. Departmental reports by Dr. C. L. Park, Avho followed Dr. Robertson as quarantine officer in charge of the cases treated at the Quarantine Station, Sydney, have also been largely drawn upon in the folloAving record of the clinical features of the disease.

The presence of a mild form of variola in various oversea countries prior to and coincident with its introduction into New South Wales

lias already been commented on in chapter IT. (page 20). It will also be remembered that epidemics of a similar nature have from time to time been described, and that Jenner in 1798 drew attention to a species of small-pox which seven years before had spread through manv of the towns and villages of Gloucestershire. He states that it was of so mild a nature that fatal results were rarely heard of, and that he never saw or heard of an instance of its being confluent-. There is not sufficient data, however, to decide whether this epidemic was similar to the variety of small-pox which occurred in Hew South Wales or was merely a mild form of the more familiar type of the disease. Sydenham also states that “ small-pox has its peculiar kind* which take one form during one series of years, and another during another.” Van Swieten in 1759 described an outbreak which was “ so mild that secondary fever is not manifested, and constantly is wanting, convalescence coming on the eighth day of the eruption.” The type of small-pox which prevailed in Hew South Wales remained constant in all respects throughout the years of infection, and the clinical description of the disease can therefore be made along uniform lines throughout the epidemic.

Period of Invasion.

The period of invasion was usually ratheff gradual in jts onset, and was usually likened by most patients to an attack of influenza. Although the records were necessarily based for the most part on tlie statements of patients and friends, which were often not reliable, confirmation was available from the definite histories of those contacts who developed the disease whilst detained as contacts at the Quarantine Station, Sydney.

Initial Symptoms.—Although in some cases no symptoms whatever preceded the eruption, in the majority of cases the symptoms most frequently noted were headache, backache, shivering, vertigo, vomiting, and nausea, aches in the limbs and joints and abdominal pains. The most common combination of symptoms was headache, backache, shivering, and vomiting. An analysis by Drs. Robertson and Park of the histories of those cases treated at the Quarantine Station, Sydney, showed that the symptoms of onset were not recorded in a number of cases, and could not be elicited in the case of young children. Of 1,266 cases with reliable histories obtainable, 62 (or 5 per cent.) had no symptoms whatever prior to the appearance of the eruption. A number of cases, approximately 8 per cent, of the total, were not sufficiently prostrated to cause them to retire to bed, and many of them followed their usual occupation until discovery. The most common feature of the initial symptoms complained of was headache. which occurred in 1,064 cases (or 84 per cent.). The headache was usually frontal, but occasionally occipital, in some cases very slighr, and in some cases the only symptom present prior to the eruption.

Backache was present in 722 (or 57 per cent.) of the cases, and was usually referred to the sacrum or across the loins. Shivering occurred in 669 (or 53 per cent.) of the cases, and was usually merely an uncomfortable feeling of chilliness. Actual rigors were not common. Vertigo was complained of in 401 cases (or 32 per cent.), and was noted particularly by Dr. Robertson in the earlier cases as being very severe in some, and sometimes present without any headache. Vomiting and nausea occurred in 627 cases (or 50 per cent.) ; in very few did it continue after the first few hours; more often it was an early symptom not repeated, although in several cases vomiting came on a day or two after the appearance of a headache. Actual vomiting occurred in about 40 per cent, of the cases. Pains in the limbs was present in 471 cases (or 37 per cent.), many of the cases comparing the feeling as similar to “ having been beaten all over with a stick.’' Abdominal pains, usually referred to the epigastrium, occurred in 144 (or 11 per cent.) of the cases. In one case pain in the lower abdomen, which lasted half an hour, was followed on the same day by the eruption, and was the only initial symptom. Anorexia and insomnia were usually noted. Drowsiness was frequently noted, and in young children was the commonest initial symptom. Convulsions occurred in two children, one three and the other eleven years of age. Sore throat, coryza, pains in the chest, pains in the shoulders and in the back of the neck and diarrhoea were not uncommon. Delirium was not uncommon. Dr. Robertson noted that in some cases the spleen was definitely enlarged, sufficiently so as to be easily palpated. This subsided rapidly with the appearance of the eruption. These symptoms as a rule subsided as soon as the eruption appeared, but in some cases (approximately 5 per cent.) they continued afterwards, mostly for one day only, but some persisting up to four days. Backache and to a lesser extent headache were quite commonly complained of for several days after the appearance of the eruption.

In regard to the diagnosis given in regard to these initial symptoms, the most common mistake was to attribute them to influenza. Dp to the end of January eleven cases were admitted to wards in Sydney hospitals, five being diagnosed as typhoid fever, one as appendicitis, four as abdominal cases for observation, and one, seven months pregnant, was admitted into the Women’s Hospital under the impression that labour was setting in. Later several other cases were admitted to hospitals as cases of typhoid fever, and other with primary diagnoses of gastritis and appendicitis.

The Initial Fever.—There were naturally few occasions of observing the febrile condition of patients in the initial stage, hut it was apparent that in most cases the temperature was elevated during this period—the highest temperature recorded being 105 deg. F. In a number of children admitted to the Quarantine Station u feverishness ”

was said to have been present before the eruption appeared. Of the several contacts who developed the disease whilst under observation at the Quarantine Station, the majority were said to have had no rise of temperature at all, while four had n temperature, with the onset of symptoms, of 102 deg. to 104 deg. F., this latter in the case of a patient whose subsequent eruption consisted of only half a dozen lesions in all. In two of these cases the temperature dropped to normal on the day of the eruption, and in the other two on the day before the rash appeared.

Duration of Invasion Period.—The eruption most frequently appeared four days after the onset of symptoms, but it was undoubtedly delayed in some cases to as late as the tenth day. In the records of 1,240 cases at the Quarantine Station, Sydney, the following table shows the duration of the period from the onset of symptoms to the appearance of the eruption :—

Table 18.

In 16 cases the eruption appeared on the same day as onset of symptoms.

54

one day after the onset of symptoms.

173

,,

two days ,, ,. ,,

242

>> 99

three ,, ,,

318

four ,, ,, „

226

, ,,

five ,, % ,. ,, ^

119

six ,, „ ‘

63

,, ,,

,,

seven .. ,, ,,

15

,, 9 9

9 9

eight „

7

,, ,,

nine ,. ,,

3

ten .. ,, ,,

2

,,

eleven ,, ,,

2

99 ,,

,,

twelve ,. ,, „

Quiescent Period.—In a considerable number of cases there was a definite quiescent period between the subsidence of the initial symptoms and the appearance of the eruption; many patients who had been in bed for one or two days felt perfectly well, and returned to their work until the subsequent appearance of the eruption. In 1914 Dr. Armstrong considered that this period was usual, and in Dr. Kobertson’s series of 755 cases with definite histories 229 (or 33 per cent.) of the cases gave a history of such remission, 76 having a remission of one day, 78 of two days, 43 three days, 20 four days, 7 five days, 2 six days, 2 seven days, and 1 eight days. In the later stages of the epidemic this period of remission does not appear to have been so constant. In the cases treated at the Quarantine Station from February, 1914, to March, 1915, only 15 per cent, gave such a history as against 33 per cent, in the earlier series. In the case of a contact who developed the eruption whilst under observation at the Quarantine Station, a remission of two days was noted, although liis temperature did not reach normal until the rash appeared, relief, however, being obtained from symptoms.

Prodromal Bashes.—In four cases histories of prodromal rashes were given by patients admitted to the Sydney Quarantine Station. The histories of these cases are given hereunder:—

Case T. J., female, age five months.—On the 11th September, 1913, seemed feverish and restless. This lasted until the 15th. On the 16th September, 1913, the mother states, a rash “like measles, only smaller,” appeared on the back and nowhere else. It felt slightly rough to the touch. The spots were minute and red in colour (no white or yellow heads), and were thickly set all over the back. The rash became fainter the next day, 18th, when the small-pox eruption appeared on the face, buttocks, and back. On admittance to the station on the 23rd September, 1913, no trace of the first rash was visible. The child had a very slight eruption, the back only having a few lesions.

Case E. C., female, age 32.—On 26th September, 1913, patient complained of frontal headache, pains in back from the shoulders down, aching in the legs and arms, and shivering. The symptoms lasted five days. On day of onset a rash “ like prickly heat ” appeared on the back of the left hand, inner side of knees, and right round the back of the thighs (in this order). The rash was very itchy and rough to touch, and consisted of little red papules with no white or clear heads. This was probably vaccinal, as patient was vaccinated on 1st September, 1913, a “mulberry” reaction resulting. It lasted until 29th September, 1913, when it began to fade. On 30th September, 1913, a second rash appeared which looked just like “ measles,” but not so marked, not itchy, bluish-red in colour, not bright-red like the first rash, and consisting of macules, not papules. This rash was distributed over the whole of the arms, abdomen, back, and thighs down to the knees, but began to fade on the following day. No trace was visible on the 2nd October, 1913, wEen the patient was admitted. Her smallpox eruption was very slight.

Baby W., male, born 22nd January, 1915.-—No rash present, and apparently well. On 25th January the temperature rose to 101 deg. F., and the child was cross and fretful. On 28th January several very red papules appeared on the left cheek and the left forearm. These remained on 29th January, and on 30th January they had a papulovesicular appearance with a large amount of areola. On 31st January the vesicular appearance had disappeared, and on 1st February the lesions had practically disappeared. However, on 2nd February there were several small vesicles on the back and a few papules on the chin and left hand. On 3rd February the vesicles on the hack were typical of small-pox, and there was a small papule on the right knee. More lesions developed in the next few days until on 6th February there w7ere a number of discrete pustules over the body.

Case Mrs. W., female cet. 33 years.—Mother of Baby W. (Her history also shows what might have been a prodromal rash). On 13th

January she had suffered from headache, backache, but did not vomit. These symptoms were relieved on 15th January when a few “pimples ” were noticed on the chest. Later the same day these disappeared, and some spots were next felt under the skin of the forehead on the following day (16th January). She was admitted to the Quarantine Station on the 18th January with papular lesions on the forehead, which became vesicular on the next day. A semi-confluent rash developed, and on 22nd January, four days after admission, when eight and a half months pregnant, khe was delivered of a male child whose history is given above. At that time her rash was pustular all over the body. The puerperal period was quite normal.

The Eruption.

It is important to emphasize the fact that the experience of the epidemic showed that in general the eruption was identical with that of “ classical ” small-pox, and was influenced by the same conditions, the differences noted being those of degree and not of kind. For instance, the lesions generally were smaller and more superficial than those in Asiatic small-pox, the papules were less shotty on palpation and mildly discrete eruptions were the more common, but in regard to the all-important diagnostic feature of distribution the eruption complied with the dictum of Ricketts and Byles (Diagnosis of Smallpox, p. 16).    “ The rash prefers the upper part of the body to the

lower, it is a rash of the face and arms rather than trunk and legs. It is a rash of the distal ends of limbs rather than the- proximal, of the back of the trunk rather than the front, of exterior surfaces rather than flexor; it is a rash which shuns the most pronounced flexures.”

Classification of Eruptions.

Three groups of cases may be said to have occurred, those presenting mild discrete, discrete, and semi-confluent eruptions. Obviously the division into these groups is somewhat arbitrary, and the dividing line between the groups very broad. Generally, however, the classification adopted might be summarized as follows:—

(a)    Mild Discrete.—«This group comprised those in whom the eruption was very slight, consisting of a few scattered pustules. These cases often gave rise to great difficulty in diagnosis owing to sparsity of lesions. The period of onset in these cases was often as severe as in those with profuse eruptions.

(b)    Discrete.—These cotmprised those cases in which the eruption was moderately severe, but in whotm the lesions were discrete. They often had markd oedema of the face and nose, but secondary fever was very slight.

(c)    Semi-confluent.—These comprised those cases in which the lesions were so closely set as to leave little or no healthy skin visible between

them. Many of these ought more strictly to have been classed as confluent as the pocks in certain areas became confluent, especially on the nose and cheeks. These all had some secondary fever. Using this classification, and showing the types met with at the Sydney Quarantine Station amongst the vaccinated and the unvaccinated, Dr. Robertson and Dr. Park have recorded the following tables over two periods—

Table 19.—Cases Treated at the Quarantine Station, North Head, Sydney,

CLASSIFIED ACCORDINO TO TYPE OF ERUPTION.

Dr. Robertson : \st July, 1913, to 31s£ January, 1914.

Semi-confluent.

Discrete.

Mild Discrete.

Total Recorded

Cases.

Vaccinal Condition.

Not

Total

No.

Percentage

No.

Percentage

No.

Percentage

No.

Percentage

recorded.*

Cases.

of Total.

of Total.

of Total.

of Total.

Vaccinated . .

3

5’9

16

31-4

32

62‘7

51

100-0

2

53

Unvaccinated ..

44

4-7

376

40’3

514

55-0

934

100-0

50

984

Total ..

47

4’8

392

39-8

546

55-4

985

100-0

52

1,037

Dr. Park :

ls£ February, 1914, to 25tit March, 1915.

Semi-confluent.

Discrete.

Mild Discrete.

Total

Recorded

Vaccinal Condition.

Cases.

Not

recorded.*

Total

Cases.

No.

Percentage

No.

Percentage

No.

Percentage

No.

Percentage

of Total.

of Total.

of Total.

of Total.

Vaccinated ..

39

66-0

20

34-0

59

10O-0

59

Unvaccinated ..

21

4-1

285

55-7

206

40-2

512

100-0

10

522

Total ..

21

3-8

324

56-7

226

39-5

571

100-0

10

581

* These eases were those admitted in the convalescent stage.

Type of Eruption.

In regard to the type of eruption, Dr. Robertson fully described the lesions in the following :—

“ The lesions are smaller and more superficial than those in Asiatic small-pox. The papules are less definitely shotty on palpation. The vesicles are flat-topped, irregular in outline, and frequently have erenated margins. Often a small brown scab occupies the centre of a vesicle, giving an appearance of umbilication. Umbilication is exceptional. They are multiloculated and do not collapse on pricking. They lie definitely “ in ” the skin, not “ on ” it like varicella lesions. 'The pustules are typically dome-shaped on the limbs, but more irregular -on the face and trunk. They do not attain a large size, but occasionally on the extremities large blebs are formed, very often their -contents having a chocolate colour. On the limbs the pustules are

sometimes very thin walled, and present a milky translucent appearance. These dry up by absorption of the fluid contents and do not form definite crusts. The areola is very small in the papular stage, but increases rapidly and reaches its maximum when desiccation is commencing, after which it rapidly subsides.

On the lower limbs, haemorrhage frequently takes place in the areola, even when the lesions are only vesicular. This has been observed on other parts of the body, sometimes on the face. Haemorrhage into the lesions themselves has not been observed. Maturation is rapid, and the papular stage often only lasts a few hours; the pustulation maybe well advanced on the second day. In the severer cases the period is longer. Vesiculation may take 48 hours and pustulation another 48 hours. Crusting may be complete on the fourth day of eruption. By the ninth day even in semi-confluent cases the scabbing on the face is complete, and the crusts are beginning to fall off. Oil- the limbs maturation takes much longer, fourteen days being the usual time for all lesions to crust entirely. The crusts are quite distinct from those of varicella, being raised on the surface and not flush with the skin as in the latter disease. They are brownish in colour as a rule. In the case of unruptured pustules, as seen in the palms and soles, a brownish disc or seed is formed, which lies under the horny layers of the skin.    *

Many lesions abort, papules remaining papules and vesicles crusting without pustulation. This latter condition is common in children, the resulting crust being of a greenish-yellow translucent gelatinous nature. Vesiculation does not occur in one type of papule, which is very frequently seen on the face and body. It has a broad base, and develops a small bead of pus on the summit, which rapidly crusts.

The lesions come out in successive crops, even up to as late as the seventeenth day of disease, as recorded in one instance. In the majority of cases the lesions appear first on the face and forehead as dull-red spots or macules and on the neck, body, and upper limbs soon after.

It takes three days at least for the eruption to be complete in the limbs, and it was noted very frequently that the distal ends of the limbs were practically without any lesions for a day or two and then got a fairly profuse eruption. The wrists and forearms are, however, occasionally the first places for the eruption to appear.

Often the first site of eruption is around some place of irritation, such as vaccinal inoculation, sores, &c.

Frequently patients point to one or two lesions, and state that they appeared a day or two before the others. They occurred most frequently on the face and upper arms, and were always larger and ahead of the rest in development. The condition of the face is always more

advanced than that of the other parts of the body, frequently crusts having formed there whilst the distal extremities of the limbs were still vesicular.

Coming out in crops, the lesions in any one region are not necessarily in the same stage of development, and vesicles, pustules, and crusts may be seen side by side.”

Distribution of Eruption.

The characteristic distribution of the generalized eruption has been already noted as conforming to the diagnostic points laid down by Ricketts and Byles. This distribution remained constant throughout the epidemic, and is well described by Dr. Robertson.

The eruption was general, was identical with Asiatic small-pox, and was influenced by the same conditions. The diagnostic importance of the distribution might be emphasized by again quoting the description given by Ricketts and Byles prefacing the detailed description given by Dr. Robertson. “ The rash prefers the upper part of the body to the lower, it is a rash of the face and arms rather than trunk and legs. It is a rash of the distal ends of limbs rather than the proximal, of the back of the trunk rather than the front, of extensor surfaces rather than flexor; it is a rash which shuns the most pronounced flexures” (Diagnosis of Small-pox, p. 16).

“ The scalp was usually fairly affected, especially in the bald. The forehead, malar regions, and nose had the greatest eruption, the orbits and temples being spared. A few lesions occurred along the eyelid margins. Single lesions were observed, once in the ocular conjunctiva, just outside the cornea, and on two separate occasions on the palpebral conjunctiva. They appeared on the mucous membranes of the nose, mouth, and pharynx. The palate, tongue, uvula, pillars of the fauces, tonsils, and posterior pharyngeal wall were most frequently affected. No lesions were detected in the larynx. The ears on the exposed surface frequently suffered severely. On the neck, the posterior aspect and the projecting surfaces of the sterno-mastoids suffered most. The line of clothing was frequently strikingly demonstrated, very few lesions appearing upon the portion protected. The posterior triangle and episternal notch were always spared. The chest usually had a sparse eruption, the flanks particularly. The abdomen escaped most of all. The groins and hypogastrium were always spared. The back suffered more than the chest and abdomen, with the greatest eruption over the shoulders and least in the loins. The axillae were invariably spared, lesions being present in very few.

The Upper Limbs.—The upper arms had less than the forearms, the inner surfaces being always spared; the back of the elbow frequently suffered severely. The extensor aspects and the radial and ulnar borders of the forearms suffered more than the flexor surfaces,

where the tendons were a favorite site. The wrists and backs of the hands were more affected than the palms, where the hollow usually escaped. The fingers had more lesions on the extensor aspect. The ante-cubital fossa was invariably spared.

The Lower Limbsj—The ankles and feet suffered most; the front of the knees often had a profuse crop. The dorsum of the feet suffered more than the soles, and marked preference was shown for the tendons. The prominences of the soles and toes suffered more than the hollows. The eruption was always scanty in the popliteal space.

The penis and scrotum often suffered severely. Lesions were seen on the prepuce, glans penis, and sometimes inside the meatus. The vulva also had profuse eruptions in some cases.

The eruption showed great modification through the influence of attire, occupation, &c. Pressure and irritation patches were noted in numerous instances. The abdomen and chest often had a marked eruption in obese and pregnant women, due to the irritation produced by clothing. In babies the area covered by the napkin suffered severely in some cases, especially where the skin Avas excoriated. One well-marked binder rash occurred in a woman confined a couple of week-? before the eruption, a ring of lesions encircling the body.

A d river, who had followed his occupation during the prodromal stage of the disease, had an almost confluent eruption on the ulnar border of his forearm where it rubbed against his leg while driving. Ill-fitting boots caused numerous cltisters on the feet, the most favorite site being over the Tendo Achilles.

Bracelets, collar studs, sores, vaccinal inoculations, &c., all produced clusters at the points of pressure or irritation.

In the milder cases wlie«re the lesions were extremely few no particular distribution could be observed. In one case a single lesion only was present, and in two others four and twenty respectively. Frequently in such mild cases whole regions were skipped. The palms and soles had no lesions in numerous cases. In a few children the body was almost entirely skipped, whilst the face and distal extremities of the limbs had a profuse eruption. It was not unusual to find one side of the body having a greater eruption than the other, probably explained by posture. The lower limbs frequently had almost air equal eruption to that of the upper.”

Small-pox without Eruption.

Although many practitioners were inclined to regard the condition of variola sine eruptione as apocryphal, there were several instances observed of what appeared to have been cases of smallpox without a rash. In two instances the subjects were young women employed in a factory in which there had been several

cases of small-pox, and resident in districts in which at that time there was no small-pox. Neither had ever been previously vaccinated. Both suffered in a characteristic way from the symptoms of invasion of smallpox, and remained away from work as invalids at home. Both recovered, and were not afterwards the subjects of any rash. At periods, however, of seventeen and eighteen days after the onset of their respective attacks, other persons in their households became affected by the symptoms of invasion, and the persons so secondarily infected after recovering from the symptoms of invasion developed mild small-pox eruptions. Both the girls originally attacked were vaccinated subsequently on two occasions, and in both cases unsuccessfully.

Secondary Eever.

A striking feature was the relative or complete absence of the eruptive fever. In the later series of 544 cases at the Quarantine Station, secondary fever was only present in nineteen cases, or 3 per cent,., thirteen of whom showed semi-confluent and six discrete eruptions.

Even in the most severe cases the fever was very slight. In two of the earlier cases, however, a temperature of 104 degrees was recorded.

Prostration was practically absent, and, with one exception, no patient was at any period in a condition that might be regarded as dangerous. Stimulants were given very rarely.

Just immediately prior to the appearance of the eruption in severe cases a sensation of pricking or smarting was experienced.

During the height of pustulation a great amount of burning and smarting pains was experienced, especially in the face, hands, and feet. Actual itchiness was uncommon, but this was sometimes complained of after the rupture of pustules. In severe cases there was a great amount of swelling where the rash was profuse. The face looked very inflamed, the lesions standing out in relief. The face was puffy, the eyelids (edematous, the nose typically saddle-shaped. The features were obliterated. In the severest cases the patient presented a most revolting appearance. The mouth remained open and saliva trickled out. The teeth and gums were covered with sordes, and the tongue was harsh and dry. Swelling of the throat gave rise to considerable discomfort in swallowing. The hands and fingers were very swollen and stiff, and the hands held partly flexed. The feet were also very swollen. The pustules were extremely tender on palpation. The weight of the bedclothes and the pressure of the body on the mattress caused great distress. Backache was very commonly complained of. Insomnia was a frequent symptom, not only of the severe cases, but also of the milder ones, particularly during the pustular stage. Rigors occurred in four cases, in only one of whom was the rigor repeated, in this case—a female—there being a rigor with volmiting and backache on the following evening. This same case later became considerably excited, and talked at random, but in no case was there actual delirium. The pulse C.7279.—3

was often more rapid than the temperature would warrant, but 130 was never exceeded. In the earlier series of cases at the Quarantine Station adenitis was very common in severer cases, occasionally progressing to suppuration, but in the latter cases adenitis was not a marked feature, and suppurative adenitis was not met with. A characteristic putrid odour was noticed at the height of the pustular stage in three of the later cases, disappearing in 24 hours in two, hut persisting for two or three days in the other.

Stage of Convalescence.

A reddish-brown staining after the separation of the crusts was all that could be seen in the great majority of cases. In about 10 per cent, of the cases, numerous shallow pittings with staining were left, in some leaving the face rough and coarse, like a nutmeg grater, owing to the projections of newly-formed cicatricial tissues. The parts which suffered most were the nose, the forehead just above the root of the nose, and the cheeks. In some cases this condition quickly subsided, but in others it persisted, and was present on discharge. After the separation of the crusts, desquamation round the site of the lesion was well marked, much more than occurs in varicella. This soon cleared from the face and body, remaining longest on the palms of the hands and soles of the feet. The mildest cases were often quite free from desquamation within fourteen days after the appearance of the eruption, but the more severe cases continued to desquamate from six to eight weeks. Excrescences with firm-raised bases were commonly seen after to the projections of newly-formed cicatricial tissues. The parts which the 'separation of the crusts, these slowly subsided to pinkish macules level with the skin, but often further contraction took place, resulting in the formation of shallow pits. Warty granulomata also frequently occurred on the site of lesions, and persisted for prolonged periods.

Complications.

These were confined principally to skin and eye affections.

Shin Affections.—Particularly in the earlier stages of the epidemic boils and superficial abscesses were frequent, even in the mildest cases. The resisting power of the skin to bacterial invasions seemed to be very much lowered; sepsis, occurring in the slightest abrasions, often gave rise to unhealthy ulcers. An impetiginous condition frequently affected the lesions of the forearms, wrists, back of hands, legs, and feet, and occasionally the body. An effusion of fluid occurred around the dried crusts, undermining the epidermis, the margins extending to the size of a sixpence or more. This condition usually cleared up very quickly.

Eye Affections:—Conjunctivitis was prevalent, but very mild. Iritis occurred in six, and corneal ulcers also in seven cases, the latter being very intractable to treatment, and permanent opacities probably resulted. A suffusion of the conjunctiva immediately around the

cornea, and often limited to one or two quadrants, was a very common occurrence. Pterygium, if present, was always aggravated.

Otorrhea was noted on two occasions.

Respiratory System.—Ao complications recorded.

Influence of the Disease on Pregnancy.

Forty-two pregnant women were admitted with an eruption to the Sydney Quarantine Station. Premature labour or abortion took place in fourteen, in one of whom death occurred from Bright’s disease, 27 were not affected, and one died after giving birth to a healthy full-time child.

Premature labour occurred in six cases. Two gave birth to healthy eight-months’ children the day after the appearance of the eruption, which was mild discrete in both cases. A third was confined with six-and-a-half month twins nineteen days after a mild eruption. The twins were both slightly macerated, and showed traces of a mild eruption in the desiccated stage. The fourth was delivered of six-months’ twins a few weeks after the eruption, which was mild. One twin was still-born, without trace of an eruption; the other was alive, and was covered with a variola rash, and lived three weeks. The fifth case was eight and a half months pregnant on admission, and a healthy child was born on the sixth day of the eruption, which was of a severe semi-confluent type. The puerperium was normal, but the child had evidently been infected in utero, and developed the eruption nine days after birth, the onset having commenced six days previously. The sixth case of premature labour was in a woman seven months pregnant, who had the eruption five weeks prior to her admission on 13th May, 1914. A male still-born child was born on 23rd May, that is, almost seven weeks after the eruption. The child had a well-marked papular rash on the face, trunk, and limbs. 1 he skin was peeling, and there was some maceration, so evidently death had taken place some time previously.

Abortion took place in eight cases. Six were mild cases of the disease, the abortions occurring 19, 21, 24, 29, 30 and 35 days after the appearance of the eruption. The abortions occurred at 3^, 3, 5, 4, 4, and 5 months respectively. In four cases there was no evidence of disease in the foetus or placenta, in the fifth there was a profuse smallpox eruption in the pustular stage on the foetus, and in the sixth case no record was made of the placenta or the foetus. The seventh case was a woman four months pregnant, who had a severe attack of smallpox. Abortion took place on the twentieth day of the eruption, for some time afterwards the woman being in a state of collapse. The foetus and placenta were not diseased. In the eighth case the woman was six weeks pregnant, and had a prior history of Bright’s disease, from which she died, and which was probably the cause of the abortion, as her attack of small-pox was very mild.

I)r. Robertson records the histories of six babies who were born whilst the mothers were in an infective state. Four developed the eruption 5, 9, 11, and 15 days after birth respectively. Of the other two, one was successfully vaccinated when two days old, and the other three times unsuccessfully vaccinated, neither acquiring the disease. One baby in this series would thus appear to have been infected in utero.

Fatality.

During the course of the outbreak only four persons were recorded as dying from small-pox, in only one of whifch can this disease be ascribed as other than a contributory cause, and in that one case smallpox complicated labour. The particulars of these cases are as follows:—

I.M., female, cet. 29, was a semi-confluent case of small-pox who died two and a half hours after being delivered of a full-time, healthy, male child. She was a multipara, having had three children previously, all stillborn, but full-time. There was no history of miscarriages. Her eruption had appeared on 25lli August, 1913, being very nearly confluent on the forehead and face, and very profuse elsewhere. She was confined on 29th August, the labour being normal, apart from some adherence of the placenta, necessitating digital removal of the contents of the uterus. The patient collapsed an hour afterwards,' and failed to recover. Some post-partum haemorrhage occurred, but not enough to cause a fatal result. The results of post-mortem in this case were as follows :—

Uterus.—Firmly contracted, the mucous membrane clean and smooth. A little clotted blood was present.

Liver and Spleen.—Both slightly enlarged, but apparently healthy on section.

Kidneys.—Capsule slightly adherent over the right, otherwise both appeared normal.

Stomach and Intestines.—Healthy.

Lungs.—Healthy.

Heart.—In a condition of systole. The valves and endocardium healthy. Myocardium presented an appearance of cloudy swelling.

The degree of anaemia was not such as would be found in a case of fatal haemorrhage.

The report of the Microbiological Bureau on sections sent for examination was as follows:—

Kidneys.—Cells of some of the convoluted tubules are granular, with indistinct outlines and somewhat swollen apart from its normal.

Liver.—Normal.

Spleen:—Normal.

Skin.—Sections through vesicle show small spaces of varying size, larger nearer surface, but extending down to the rete malpi/ghi, due to the separation of the epithelial cells by transudation into lymph spaces. There is also considerable polymorphonuclear leucocytic invasion into the spaces thus formed. The nuclei of the pus cells often show fragmentation. numerous scattered bodies, dark, and with lighter ring to one side, and of varying size, are probably the remains of degenerated nuclei. In the deeper pustules the vesiculation has separated the malpigliian cells from the cutis vera, but does not seem to have extended deeper. There is some polymorphonuclear infiltration of the cutis vera below the vesicle, with fragmented nuclei in the pus cells nearest the surface.

Giemsa.—1STo definite parasitic bodies were detected.

Levaditi's Method.—Liver, spleen, kidney, skin—Ho spiro-chaetes or other parasites detected.

J.I., male, ad. 75.—Admitted to Quarantine Station, Sydney, on 8th July, 1914. Said to have been vaccinated in infancy, but no scars present. He had a moderately severe discrete eruption. He was suffering from carcinoma of the stomach, nourishment being taken fairly well, but he vomited frequently. His general condition on admission was bad, and he died on 31st July, i.e., 23 days after admission, the eruption being at that time in the stage of desquamation. The cause of death was gastric carcinoma, small-pox being only a contributory cause.

E.Gr., female, cet. 32, unvaccinated, was admitted on 28tli June, 1914, as a contact, but she developed a very mild eruption, and was admitted in a low condition into the hospital compound on 3rd July. She had a history of previous kidney trouble, and the urine on admission contained a good deal of albumen. She aborted whilst in hospital, being six weeks pregnant at the time. She suffered from retention of urine, and had diarrhoea and vomiting of dark-green matter. Death occurred on 12th July, the cause of death being Bright’s disease, with small-pox as a contributory condition only.

B., cet. 23 days, was a twin child of Mrs. B., cet. 27, who contracted small-pox when five and a half months pregnant, and was removed to quarantine, where she had a severe attack. Two days after returning home, whilst six and a half months pregnant, she was delivered of twins, both born alive. One child presented the remains of a copious smallpox rash. Most of the lesions had dried up, and were represented by stains, hut a few still had scales on,- and some were deeply pitted. This child lived three weeks. The other twin, which was entirely unmarked, died in twelve hours. The physician who attended the mother in her confinement and reported the case, was of opinion that prematurity was the cause of death of both children.

Incubation Period.

It is obviously difficult in an epidemic of a nature such as that of the small-pox which prevailed in Uew South Wales, to ascertain definitely the length of the incubation period. In some cases, however, it was possible to obtain histories of patients who had most probably been exposed to infection on only one occasion. As the experience both of the medical officers at the Quarantine Station at Sydney and of the State officers responsible for the administration of the control measures throughout the State indicated that in the later stages of the epidemic more cases were met with in which the incubation period tended to be prolonged, it is interesting to compare the records available from those cases at the Quarantine Station, who gave a history of one exposure. In two instances, newly born infants received infection, in one of these the eruption appeared on the eighth day after exposure, the shortest period recorded. This child was born on 11th August, 1913, and the rash appeared on 18tli August, 1913. The mother was perfectly healthy. She had been vaccinated not only in infancy, but also about five weeks before the birth of the child, the inoculations being successful in both cases. The father and daughter had been sent to quarantine suffering from small-pox, the one nine days and the other 27 days before the birth of the child, the house being disinfected on both occasions. ISTo onset of symptoms was noted in this case.»

Another child exposed during the first two days of life to infection from the father developed the onset when eleven days old, and the eruption when thirteen days old. The mother was healthy.

In the following table the experience is shown in the earlier period (1st July, 1913, to 31st January, 1914) in regard to fourteen cases (thirteen in respect of onset of symptoms) and in the later period (1st February, 1914, to 25th March, 1915) in regard to thirteen cases. All these cases gave a history of only one exposure to infection.

Table 20.

Number of Days after Exposure.

To Onset of Symptoms.

ToJAppearance of Eruption.

First Period.

Second Period.

First Period.

Second Period.

6 .. .. ..

1

8 .. .. ••

1

9 . . . • • •

2

10 .. .. . •

2

1

11 .. .. ..

2

1

12 .. .. ..

4

1

2

13 .. ..

2

1

14 .. .. .•

1

5

1

15 .. .. . •

1

5

1

1

16 .. .. ••

2

1

3

17 .. .. ••

4

2

18 .. .. ..

2

19 .. .. • •

1

20 .. .. .•

1

2

Total Cases .. ..

13

13

14

13

In connexion with the case in the later period in whom the eruption appeared ten days after exposure, this patient had onset of symptoms only one day before the eruption; while in the case who had onset of symptoms eight days after exposure, the eruption did not appear until fourteen days after exposure.

In cases where the exposure had lasted over several days the longest interval recorded from the last exposure was in the case of the first period sixteen days for onset of symptoms and nineteen days for the eruption; in the second period, the longest interval was seventeen days for the onset of symptoms and twenty days for the eruption. In regard to cases who developed onset of symptoms after nine days had elapsed from the last exposure, the following records were made in connexion • with 24 cases in the first period and 3S cases in the later period:—

Table 21.

Number of Days after last Exposure.

To Onset of

Symptoms.

To Appearance of Eruption.

First Period.

Second Period.

First Period.

Second Period.

9 .. .. ..

3

8

10 .. .. ..

5

6

11 .. .. ..

4

2

3

12 .. .. ..

4

6

3

4

13 .. .. ..

3

3

, .

5

14 .. .. ..

2

6

4

7

15 .. .. ..

2

3

6

4

16 .. .. ..

1

3

4

3

17 .. .. ..

1

3

2

18 .. .. ..

3

6

19 .. .. ..

. .

1

2

20 .. .. ..

2

Total Cases .. ..

24

38

24

38

The small number of cases recorded in these series, and the difficulty of fixing accurately on a given time of exposure, or even on the actual occasion of exposure, cannot be said to confirm as significant the observation that in the later stages of the epidemic "the incubation period tended to be prolonged. All that can he said is that these figures indicate that the incubation period was extremely variable throughout the course of the epidemic, ranging from six to seventeen days for onset of symptoms and from eight to twenty days for the eruption. It appears that the most usual period was between eleven and fifteen days for the onset of symptoms and fourteen to eighteen for the appearance of the eruption.

Infectivity.

Direct personal infection appears to have been responsible for most cases attacked during the outbreak. About 30 per cent, of the cases treated at the Quarantine Station, Sydney, had no knowledge of any such contact. The convection of infection by fomites wTas not much

m evidence. In one case an old man slept one night in a bed which had on the previous night been occupied by a small-pox patient; he developed small-pox about a fortnight later. One doubtful instance is that of a young woman who developed small-pox twelve or thirteen days after she had borrowed a handkerchief from an acquaintance who was suffering from a mild attack of small-pox. The report of the State Health Department alleges that infection remained in a house after the removal of a small-pox case, but the evidence, excluding other possibilities, is not given. One case was said to have been infected whilst attending to the disinfection of clothing, but in this capacity he might have easily come into contact with cases as well. Infection conveyed by a third person was the only method of infection elicited by inquiries from patients in a few cases.

It appeared that the patient was infectious throughout the whole course of the disease from the onset to the separation of the last crust. Dr. Robertson and Dr. Park at the Sydney Quarantine Station attempted to determine the period of greatest infectivity in 250 cases in whom the source of infection could be definitely traced. Amy onset of symptoms in the secondary case which coincided with the ninth to twelfth day of the eruption in the primary case was regarded as having received infection on the first day of the eruption in the primary case; secondary cases showing symptoms during less than nine days from the onset of eruption in the primary case were considered infected in the invasion period. In the other cases the onset was taken as twelve days. Taking these figures as a guide, it would appear that these 250 cases were infected by patients in the following stages of the disease:—

Table 22.

Stage.

Xumber of

Cases.

Per Cent, of Total.

Invasion Period . . .. . . . . . .

21 cases ..

8-4

First Day of Eruption . . . . . . . .

66 „ ..

26'4

Second ,, ,, . . . . . . ..

33 „ ..

13-2

Third ,, ,, .. .. .. ..

36 „ ..

14-4

Fourth ,, ,, . . . . ..

31 „ ..

12-4

Fifth ,, ,, ... .. .. ..

17 „ ..

6-8

Sixth ,, ,, .. . . .. ..

15 „ ..

6*0

Seventh ,, ,, ... .. .. ..

7 „ ••

2-8

Eighth ,, ,, . . . . .. • •

5 „ ••

2'0

Ninth „ „ and over . . .. ..

19 „ ..

7'6

Total . . . . . . .. ..

250 cases . .

lOO'O

This experience remained constant throughout the course of the outbreak. An instance of infection late in the course of the disease was shown by the case of R.K., whose eruption appeared on 18th January, 1914. He stayed at the house of O.I. from' 9th February to 21st February, 1914; on his arrival there his rash being 21 days old.

0.1. had onset of symptoms on 25th February, that is sixteen days after the arrival of R.H., and A.I. had onset of symptoms on 22nd February, that is thirteen days after the arrival of R.H. For the most part, however, it would appear that the first days of the eruption were the most infectious. This corresponds with the period in which lesions are present in the mouth and throat, and hence the virus could easily be conveyed in minute droplets of saliva. The period of onset was considered to have been infectious in some cases who were traced in the early period of the epidemic to a patient who supposedly had an attack of variola sine eruptions.

In some cases it would appear that the latent period was infectious. In families where one) member only had been exposed to infection and developed the disease, other members were observed to acquire it only a few days later, too short an interval having elapsed for the infection to have been conveyed by the first member after onset of symptoms, hut details of other possibilities of exposure are not recorded.

The infectivity of the disease remained low throughout the outbreak. Numerous examples occurred of one member of an unvaccinated family acquiring the disease, and in spite of exposure for a number of days, even in severe cases, none of the rest developed it. On the other hand, the disease in some cases attacked every member, even in large families. In 692 contacts admitted to the Sydney Quarantine Station between November, 1913, and March, 1915, only 64, or 9.2 per cent., developed the disease, although all had come into close contact with small-pox cases, several being exposed to severe cases for a number of days, and in many cases were not vaccinated for some days. Reference to Table 7 on page 40 will indicate that the behaviour of the epidemic in its spread to country localities was also indicative of low infectivitv. Although there were cases of definite outbreaks in these localities, for instance, the 66 cases reported in Warren in 1917, amongst a population of 1,200, for the most part the number of persons attacked were few, although missed and concealed cases undoubtedly occurred. It must also be remembered that in many instances, particularly in the country districts, there was definite carelessness on the part of both cases and contacts. Thus the medical officer of health at Newcastle records an instance in which he found a small-pox patient, whose face was covered v itli pustules, joining in a game of cards with three neighbours, and another in which a case living at Gloucester travelled to Newcastle by tiain and piesented himself at the Public Health Office to know whether he was suffering from small-pox. Another man, to prove his assertion that smalhpox was not infectious, kissed a particularly bad case of small-pox and developed the disease himself fourteen days afterwards.

Dr. Park analyzed the histories of 555 cases who were admitted to the Sydney Quarantine Station. In regard to the history of contact with previous cases and the extent of association, he obtained the results

shown hereunder. In every case personal contact appears to have caused the infection, with the possible exception of the one case who had been employed as a disinfector by the State Board of Health.

Table 23.

Contact or Association.

Number of Cases.

Per Cent, of Total.

Relative in same house .. .. .. ..

259

46*7

Non-relative in same house .. .. .. ..

39

7-0

Same camp (Coolahe cases) .. .. .. ..

13

2-3

Living next door .. .. .. .. ..

32

5-8

Living near by .. .. .. .. ..

16

2-9

Same place of employment .. .. .. ..

50

9-0

Same school .. .. .. .. ..

17

3-1

Hospitals—Nurses .. .. .. .. ..

3

•5

,, Patients .. .. .. .. ..

9

1*6

Association (Visiting, &c.)—Relative .. .. ..

23

4-1

,, ,, Friend or casual .. ..

65

11 -7

„ ,, Personal, not specified . . Engaged in control measures (Disinfector, State Board of

28

5-1

Health) .. .. .. .. .. ..

1

•2

Total .. .. .. .. ..

555

100-0

Influence of Vaccination.    »

In regard to the question of vaccination as a means of control of the outbreak it may be stated that all the available evidence in connexion with the prophylactic use of vaccination in regard to staff engaged in the control of the outbreak, and to the general public, pointed to the efficacy of vaccination in protecting against attack, and even in aborting or modifying the attack when performed shortly after exposure in the case of contacts. In regard to the history of previous vaccination in those cases who developed small-pox, the evidence of the value of recent successful vaccination is wholly in its favour.

Tables showing the vaccinal condition of those cases admitted to the Sydney Quarantine Station during the course of the epidemic have already been given (page 45). In a total of 1,628 confirmed cases, there were 106 who gave a history of previous successful vaccination. Hone of these latter cases were under the age of twenty, and none had been successfully vaccinated within thirteen years prior to attack.

Dr. Robertson has compiled a table of those cases vaccinated before the appearance of the small-pox eruption, and the records to the end of the epidemic have been completed by Dr. Park. Of the total of 1,628 cases treated at the Sydney Quarantine Station, 1,135 were not vaccinated at all, while 198 were successfully vaccinated and 295 unsuccessfully vaccinated prior to the appearance of' the eruption. Following the arrangement of Dr. Robertson in compiling these

histories of vaccinations, the following shows the distribution in regard to successful and unsuccessful vaccinations performed:—

Successful and Unsuccessful Vaccinations performed in 493 Cases Before the Appearance of Eruption.

Successful Vaccinations—(Total 198).

(1) Within the Incubation Period.—A total of 92, as follows :•—

1

day before eruption . .

Cases. . . 1

2

r>

r> ' '

. . 1

3

V

v • •

. . 4

4

»

v • •

. . 1

5

»

r> • •

. . 3

6

n

r> ' '

. . 10

7

??

v • *

. . 6

8

??

v • •

. . 10

9

r>

r> • •

. . 9

10

•n

?? • •

.. 12

11

V

• •

. . 15

12

?? • •

.. 7

13

T)

v • •

.. 7

14

v •

. . 4

15

r>

» • •

.. 1

16

r> '

.. -

17

»

>5 • •

.. 1

Total within incubation period . .    92

Five of these had been previously; recently unsuccessfully vaccinated.

In the four cases in which the eruption appeared on the fourteenth day after vaccination, the onset of symptoms occurred in one case four days, in one five days, in one nine days, before the eruption, and in the other case no symptoms of onset were noticed. In those cases in which the eruption appeared on the fifteenth and seventeenth days after vaccination, the onset of symptoms occurred four days and eleven days prior to the eruption respectively.

(2)    During infancy, or more than thirteen years prior to attach. A total of 106. Two x)f these were vaccinated successfully a second time more than thirteen years before, one twenty years before; sixteen were subsequently vaccinated without success during the incubation period, and six without success a few weeks before the eruption.

(3)    Between these two periods.—FTil.

Unsuccessful Vaccinations.— (Total 295).

(1)    Within the Incubation Period.—-One hundred and fifty-

two, of whom seventeen were vaccinated without success a second time in the incubation period, and one a third time.

(2)    During Infancy.—Nineteen cases, who gave a history of

infantile vaccination, but showed no cicatrices. Three of these were vaccinated subsequently in the incubation period without success.

(3)    Betiueen Infancy and the Incubation Period.—One

hundred and nine, of whom 70 were recorded as having been unsuccessfully vaccinated within live months preceding exposure to infection, another 38 within eighteen months, and one seven years before. Twenty-four were vaccinated a second or third time unsuccessfully.

Vaccinations performed after the appearance of the eruption.— Seven hundred and twenty-seven patients were vaccinated for the first time at varying periods after the appearance of the eruption. In all these cases vaccination was unsuccessful, with the exception of one case in which the inoculation was performed oi^ the second day of the eruption, and of another case who was admitted as ‘a contact and vaccinated the same day. She gave a history of headache, shivering, and vomiting seven and a half weeks before, which had been followed in a few days by a skin eruption, the staining of which was still apparent on the feet on admission. Live days after admission, the vaccination had taken.

It will be seen from the preceding tables that a single vaccination successfully performed does not confer lifelong protection, but that it certainly has a prophylactic effect for a number of years. It is a significant fact that no case occurred in a vaccinated person under twenty years of age, or less than thirteen years after vaccination, whereas in the unvaccinated no less than 590 contracted the disease in the first twenty years of life. Over 50 years of age, as many vaccinated as unvaccinated persons were attacked. The influence of vaccination in modifying the severity of the eruption was not emphasized in this epidemic owing to the fact that so many cases of an extremely mild nature occurred in the unvaccinated. An analysis of the earlier cases at the quarantine station shows that the vaccinated really suffered as severely, as 6 per cent, of the former and only 5 per cent, of the latter had semi-confluent eruptions. Later, however, no semi-confluent cases were present among the vaccinated. One of the severer cases in the earlier series occurred in a woman who had been twice successfully vaccinated, although over twenty years had elapsed since the second vaccination.

It seems beyond doubt that a recent successful vaccination is an absolute protection against this disease, and that the protection conferred lasts some years, thirteen years appearing to be the limit.

In connexion with the staffs employed at the Quarantine station and by the State Health Department, it may be stated that of these large staffs who came into intimate contact with cases, and who were protected by recent successful vaccination, not one became infected, the only exception to this statement being a disinfector who had by some means evaded vaccination and developed the disease.

It is claimed that a successful vaccination performed two days after exposure to small pox will ward off the disease. Two cases developed the eruption, one fourteen and one fifteen days after the inoculation, the onsets occurring on the tenth and eleventh days after inoculation respectively. If the incubation period were definitely twelve days, then the preceding claim could not be held established. In this epidemic the incubation period was very indefinite, in some undoubted instances being as long as fifteen and sixteen days. Both these patients were exposed a few days to infection, and probably were incubating the disease at least three days before being vaccinated. This is supported by the fact that amongst a number of cases which were vaccinated successfully after one exposure, in none did the disease develop when the inoculation was performed before three days after that exposure.

In several cases where women patients had young children, these were vaccinated and admitted to the hospital with them. Also, several mothers were sent to the hospital as contacts of their young children who had the disease. It was found that of these contacts who did not develop the disease—

2 had been vaccinated successfully 1 day after exposure to the rash

2    tt    tt    2    f>    tt    „

q    q

ft    tt    °    tt    tt    tt

2    4

tt    tt    ^    tt    tt    tt

In each of these last two cases, one other contact did contract the disease, one having been vaccinated two days after exposure and the other four days after.

Errors in Diagnosis.

The errors in diagnosis in the initial stage have already been referred to on page 50. In connexion with diagnosis after the appearance of the eruption, varicella was obviously the most common mistake, and this was complicated by the unusual prevalence and severity of varicella coincident with,the prevalence of the small-pox epidemic. During 1913 over 3,000 cases of chicken-pox were seen and diagnosed by the medical officers of the Health Department, and, with few exceptions, the experience of these officers served to differentiate between these two

diseases without difficulty. Twenty-seven cases of eruptions were sent foi admission to the Quarantine Station at Sydney, which were found on examination to have been diagnosed in error. These cases comprised—

Cases.

Impetigo    . .    . .    . .    5

Acne vulgaris    . .    . .    . .    5

Secondary syphilis    . .    . .    4

Varicella    . .    . .    . .    4

Vaccinia    . .    . .    . .    2

Vaccinia urticaria with impetigo . .    1

Erythema multiforme    . .    . .    2

Herpes Zoster    .    .    .    .    .    .    1

Furunculosis    .    .    .    .    .    .    1

Mosquito bites    .    .    .    .    .    .    1

Insect bites    .    .    .    .    .    .    1

small-pox eruption for an iodide rash. Lesions on the fauces were mistaken for diphtheria, and one patient was informed by a medical practitioner that the lesions on the glans penis were chancres.


Other mistakes which had occurred had been mistaking the

Laboratory Finding^.    4

Drs. J. Burton Cleland and E. W. Ferguson have recorded the results of microbiological findings and of animal inoculations in the Report of the Director-General of Public Health for Hew South Wales, 1913, page 114; in the Australasian Medical Gazette, Vol. XXXV., Xo. 18 (2nd May, 1914), page 388; and in the Proceedings of the Royal Society of Medicine (Epidemiology and State Medicine), Vol. VIII. (1914-15), Part II. From the microbiological data obtained in these investigations, they give it as their opinion that the disease prevailing in Hew South Wales was a form of true variola. They based their conclusions on the following grounds:—

1.    Such a modified variola was what, on microbiological grounds,

might have been expected to arise.

2.    The disease, in some of its features, seems to be intermediate

between ordinary variola and vaccinia, though so close to

the former as to be in most respects indistinguishable.

3.    Bodies resembling the Cytorrhyctes variolae have been seen

in material from cases.

4.    The appearance of sections of tissues from cases accord with

those described from small-pox patients.

5.    The disease is convey able to calves by inoculation.

6.    The condition thus produced behaves as does inoculated

vaccinia.

7. The inoculated disease and vaccinia are mutually more or less completely protective against each other, provided that a sufficient area be inoculated.

Spread of the Disease between Different Localities.

Personal infectivity and personal spread of the infection have already been discussed, direct personal infection seeming to have been responsible for most cases attacked. The spread of the infection from the original focus in Sydney throughout the whole metropolitan area and later to different localities in the country was obviously difficult to trace, 'but sufficient evidence was collected to indicate the actual transference of infection in several instances. Of the 28 country towns or districts which were invaded by small-pox in 1913, in all but six the first person, or the only person attacked, had come from Sydney, where he had been infected. In five instances the evidence of the source of infection was doubtful, and in one instance the person attacked had been infected in Hew Zealand. In 1914, well defined and circumscribed, but more or less extensive, outbreaks occurred in six localities. In each case where the links in the chain of evidence were established, the sequence of events was identical. Infection was introduced into the locality by a new arrival from Sydney who had been infected some days before leaving the metropolis, but in whom the characteristic illness and rash had not developed until he had reached his new domicile. Wilfulness or ignorance on the part of the patient led to concealment of his attack, and the first information of the introduction of infection which reached the medical practitioners of the district was the occurrence of a crop of cases among those persons who had been most in contact with the new-comer. Sometimes when the early cases were unusually mild, even for this mild type of small-pox, a second crop of cases occurred before a doctor was called in, and the radius of infection thereby greatly increased. A typical instance of the spread of infection is recorded in the case of an outbreak at Moree in July,

1914. Moree is a town of 3,000 inhabitants, situated near the Queensland border, distant 350 miles from Sydney.

On 15th June, 1914, H.H., a journeyman barber, who resided at St. Peters and was employed at a hairdresser’s shop in Hewtown (both suburbs of Sydney), left the metropolis and went to Moree, where he had obtained employment at his trade in a local hairdressing establishment. He appeared to have had an attack of illness resembling influenza just before leaving Sydney. Two days after his arrival in Moree he developed a rash, and was off work for a week, during which time he was under the treatment of a local chemist. He saw no doctor. He returned to work on 26th June, and continued regularly to attend to his duties in the barber’s shop.    He occu

pied a furnished bedroom with two fellow-tradesmen, and had

liis meals at a boarding-house. He had never been successfully vaccinated. By the middle of June nine persons, all of whom either frequented the premises where H.H. was employed or resided in the same lodging-house with him, had become ill, and developed rashes which aroused the suspicion of the medical profession in the district. I he State health authorities were communicated with, and a medical officer was sent to Moree. He proved the cases to be small-pox, and, despite immediate isolation of cases and vaccination of contacts and I he general public, eight more persons (four of whom were members of one family) had become infected.

Variation in Type of the Disease During the Course of the

Outbreak.

The type of the disease remained constant throughout the five years of prevalence, there being no change, either sudden or progressive, in either the character or severity of the symptoms. In reviewing the clinical records of those cases who were treated at the Quarantine Station, North Head, Sydney, there has not appeared any significant difference between those cases treated in the early period of the epidemic and those subsequently received into hospital there. The incubation period in the latter stages of the epidemic appeared to be somewhat prolonged in a larger percentage of cases, bui the number of cases in which a history of one exposure could be obtained are few, and the difficulty which exists in definitely attributing infection to a recorded exposure renders the records in this question indecisive. In regard to the clinical findings there appear to have been no definite differences during the progress of the epidemic. In the earlier cases, vertigo appears to have been a more common symptom of the period of onset, and with the pustular stage of the rash, adenitis, going on to suppuration, appears to have been more prevalent. But in the essential features of onset, eruption, and course of the illness, there do not appear to have been any variations. In regard to the age and sex distribution of persons attacked, the incidence remained constant throughout the épidémie. Similarly, the influence of vaccination as a protection against attack did not vary. In regard to those cases with a history of a successful vaccination more than thirteen years before exposure to infection, the question as to whether such vaccination modified the attack is raised by the earlier records of the Quarantine Station, when it was shown that 6 per cent, of those cases had a semiconfluent attack as compared with 5 per cent, of the entirely unvaccinated. In the later series of cases, however, no semi-confluent cases occurred amongst those with a history of an old successful vaccination. As the 6 per cent, in the earlier series is based on three cases only, it is of doubtful significance, more particularly as obviously the classification of the eruption is an arbitrary distinction liable to variations through the personal factor.

Comparison with Oversea Types of Mild Variola.

Tlie world distribution of a mild grade of small-pox with certain definite variations from the classical type of small-pox has already been discussed. Dr. Robertson gives a comparative table of the Amaas or Kaffir milk-pox which has prevailed in South Africa, the so-called varioloid varicella of the West Indies, and the mild variola which was present in New South Wales and has prevailed in North America for some time. This table is given hereunder:—

Table 24.

Amaas.

Varioloid Varicella.

Variola, New South Wales Epidemic.

Incubation . .

Ten-fourteen days . .

Ten-fifteen days ; uncertain

Thirteen days ; uncertain

Effects of vaccination and previous attacks of variola

Sure preventive. Only one case occurred, in a woman, aged 63 years, who had suffered from smallpox 60 years previously, and bore unmistakable evidence of the attack

Of 312 cases reported on, 28 were recently successfully vaccinated ; 4 within 1 year ; 8 within 3 ; 4 within 4 ; and 11 within 8. Twelve cases of second attacks occurred one to seven months after complete recovery

Sure preventive

Effects of vaccination during convalescence

Modified vaccinia ..

In 185 cases, fifteen were successfully vaccinated

Out of 675 patients, one was successfully vaccinated on second day of eruption

Date of eruption

Third day ..

Usually fourth day. Rarer between first day and eighth day

Most common fifth day. Varies between first and eleventh days

Distribution of rash on body

The body generally, not uniformly ; always most markedly on the face, front of the legs, extensor surfaces of the forearms, palms of the hands, and soles of the feet

As for amaas • . .

As for amaas

Initial rashes . .

Were not observed ..

Were not observed . .

Only two cases reported, and these of doubtful nature

Evolution of

In from 36 to 48 hours

As for amaas ; but

As for varioloid vari-

pock

the macule, with its small conical centre, has passed through the papular stage, and has become a fully developed flat-topped vesicle. The vesicles are partially divided by fine tra-beculee. In 96 hours the vesicle is pearly and in 100 hours is

stages of maturation are very irregular. Rash invades the body in separate crops. Frequently well-formed vesicles seen on the first day of rash. True umbi-lication is exceptional

cella

Table 24—continued.

Amaas.

Varioloid Varicella.

Variola, New South Wales Epidemic.

Evolution of pock—continued.

waxy-white in appearance. The polynuclear lymphocytes are losing staining re-actions and becoming pus cells. A number of pustules are without areolae. Um-bili cation and pseudo-umbilication are present

Fever ..

Defervescence with first appearance of eruption. No secondary fever

Defervescence with first appearance of eruption. Mild secondary fever in 5 per cent.

Defervescence with first appearance of eruption. Only semi-confluent cases show secondary fever of mild type

Race and age..

Predilection for individual negroes in unvaccinated community, also individual Europeans, but in much lesser degree. Disease mild in sucklings and children, often aborting in former. Fatality for all ages is low

Europeans spared. Age period 20-30 most affected. Fatality for all ages low

%

Age period 20-30 most affected. (In United States of America appeared to start among the southern blacks, but later in other portions of tlie country the whites constituted the great majority of cases.) Fatality for all ages low

Initial Symptoms

Headache, slight cold in the head, slight sore throat, glands of the neck enlarged. Vomiting and occasional backache

General muscular pains, fever and headache in most cases. Backache most constant. Vomiting in 25 per cent. Symptoms varied from headache and slight pyrexia to high fever and delirium

Occasionally none.. Headache most constant ; backache, shivering, vertigo, vomiting, general muscular pains. Often quiescent period between symptoms of onset and appearance of eruption

Hæmorrhagic

cases

Unknown .. ..

Unknown .. ..

Unknown

h

It would appear that amaas, varioloid varicella (Trinidad), and the mild variola existing in Horth America and Hew South Wales were the same disease. Varioloid varicella (Trinidad) differs from the other two by showing greater incidence amongst the recently vaccinated and the occurrence of second attacks in persons who have recently recovered from the disease. Both amaas and varioloid varicella differ from the mild variola by reason of the frequency with which successful vaccination can be performed during convalescence.

Administrative Measures Adopted for the Control of the

Outbreak.

The epidemic in the metropolitan area was formally declared to be small-pox at a meeting of the State Board of Health on 1st July, 1913, and arrangements were initiated for the hospitalization of cases and the isolation of contacts at the Quarantine Station, ISTorth Head, by arrangement with the Comjmonwealth Quarantine Service, the provision of free vaccination facilities to the public, the disinfection of premises on which cases occurred, and the informing of the Premier of the State with the view to publicity being given to the outbreak in the press.    On 2nd July arrange

ments were confirmed between the State Health Department and the Commonwealth Quarantine Service for the treatment of cases at the Quarantine Station, the State Department providing the necessary medical and nursing staff, but the station remaining under the general supervision of the Chief Quarantine Officer (General). On 25th August the Commonwealth Quarantine Service took over the whole control of the station. Patients were removed to the station by launch from Woolloomooloo Bay, and at first all contacts were also transferred to the Quarantine Station for observation.

A special visiting medical staff was organized by the State Department, every case of suspected small-pox being visited whether the case was reported by a medical practitioner or by the public. With the extension of infection into country districts, arrangements were made that a member of the State departmental staff visited the infected district, and remained in the district if such a course appeared desirable, until it appeared that control over the outbreak was established.

Quarantine Measures.

In order to guard against the extension of the outbreak to the other States of Australia, the Commonwealth Government, under the powers derived from the Commonwealth Quarantine Act, on 4th July declared Sydney, within an area of 15 miles from the General Post Office, to be a quarantine area. The effect of this was to prohibit persons in the area who had not been successfully vaccinated within the previous five years, from travelling to another State. The public health medical officers of each State were proclaimed quarantine officers under the Commonwealth Act on 5th July. On 26th November, as the result of a conference at Melbourne, at which the Commonwealth and State Health Departments’ representatives discussed the position, the declaration of Sydney as a quarantine area was repealed, provided that every person travelling out of New South Wales, either by sea or land, should give a written undertaking to report the occurrence of any illness occurring within 21 days in himself or in persons under his charge to the health authorities of the State in which he happened to be.

V accination.

Public vaccination dépôts were early established, lymph being first obtained from the Commonwealth Serum Laboratories, and later on also from the State Microbiological Laboratory. As public demand lor vaccination died down towards the end of 1913, these public dépôts were closed, by that time (31st December) it having been estimated that about 500,000 persons had been vaccinated, including 225,674 in the public dépôts in the metropolis and some 6,000 who were adjudged to be contacts. On 5th July the State Board of Health passed a resolution recommending the State Government to pass immediately a Compulsory Vaccination Act. A draft Bill was prepared, but was rejected on its third reading on 10th October. Measures were adopted tor the vaccination of hospital staffs, police, postmen, and public officials, and announcements through the press urged the public to avail themselves of this protection. In 1914 there was a marked decline in the number of those availing themselves of public vaccination, the recorded number of public vaccinations, exclusive of those performed by private practitioners, being only 6,628. The vaccine lymph then being used was obtained frdm the Hastings Vaccine Station, Hawkes Bay, Hew Zealand. In 1915, 10,159 persons were recorded as having been vaccinated, the majority of these being contacts of cases, inmates of Government asylums and charitable institutions, aiid prospective travellers to the Pacific Islands—that is, these were for the most part compulsory vaccinations, voluntary vaccination, except during the outbreak in the Newcastle district, having become practically a “ dead letter.” In 1916 only 2,618 official vaccinations were recorded throughout the State, but in the Newcastle and North Coast districts there were considerable numbers vaccinated by private practitioners. In 1917, 4,663 official vaccinations were recorded, and in 1918, with the cessation of the outbreak, the number of vaccinations dropped considerably, although no records are available of the actual number of vaccinations performed.

Isolation and Treatment of Cases.

In the metropolitan area, as already stated, provision was made at the onset of the outbreak for the isolation and hospitalization of cases at the Quarantine Station, North Head, whence they were removed by launch after examination and confirmation of diagnosis by a medical officer of the visiting staff of the State department. This arrangement continued until 25th March, 1915, when the last case was discharged from the Quarantine Station. The seventeen cases which subsequently developed during that year were removed to the Coa.st Hospital at Little Bay.

In the country districts, owing to the difficulties of conveyance, this practice could not be observed, although in some cases patients were so removed; for instance, in October, 1914, 40 persons were admitted from Yass, where an outbreak had occurred in September amongst workmen on the railway deviation works, at first a temporary hospital and medical officer having been provided) , locally by the railway authorities. As a rule, therefore, country cases were treated in the isolation wards of their local district hospitals, the authorities, in view of their experience in the infectivity of the disease, judging that this procedure was quite satisfactory. In the Newcastle district, however, as this is a populous district around a busy seaport, it was considered advisable to construct a temporary isolation hospital at Stockton, a small suburb of Newcastle on the northern shore of the Hunter River. To this hospital all persons were removed who were found to be suffering from small-pox in' the district surrounding Newcastle during the outbreaks in that locality. In the early part of 1915, when there was an outbreak among miners at the coal mines at Cessnock and Kurri Kurri, these patients were treated in the isolation wards of the Kurri Kurri Hospital, where temporary additions were effected for their accommodation. The legal powers for the removal and detention of patients were derived from the Commonwealth Quarantine Act 1908-1912, the exercise of these powers by State medical officers being provided for by constituting all such medical officers quarantine officers by a proclamation dated 5th July, 1913.

Control of Contacts.

The measures considered necessary for the control of contacts, with the exception of compulsory vaccination, varied during the outbreak according to the available facilities of the locality and the experience gained as to the infectivity of the disease.

In the metropolis, at the onset of the outbreak, the visiting medical staff of the State Health Department offered vaccination to all contacts, who were then removed to the Quarantine Station for observation, the powers for removal and detention being derived from the Commonwealth Quarantine Act, and the State medical officers being proclaimed quarantine officers for the exercise of these powers. Later on, owing to the impossibility of housing all the contacts at the Quarantine Station, this practice was modified, only those contacts who refused vaccination being so removed. At a still later period, when the daily number of cases had fallen to two or three, the practice of removing all contacts to the Quarantine Station was revived. The following

were the admissions of contacts to the Quarantine Station, North Head, Sydney, during this period :—

Table 25.—Contacts Admitted to the Quarantine, Station, in each Month during the Period July 1st, 1913, to 25th March, 1915.

Year.

Month.

Males.

Females.

Total.

1913 .. ..

July .. .. ..

46

57

103

August .. ..

7

17

24

September .. ..

12

14

26

October .. ..

4

12

16

November .. ..

58

65

123

December .. ..

32

29

61

1914 .. ..

January . . ..

20

16

36

February .. ..

11

21

32

March .. .. ..

13

15

28

April .. .. .. May .. * .. . .

15

34

49

J une .. .. ..

84

78

162

July .. .. ..

72

49

121

August .. ..

9

6

15

September .. ..

13

9

22

October .. ..

11

22

33

November .. ..

3

3

December .. ..

1

1

1915 .. ..

January .. ..

1

1

February .. ..

9

3

12

March .. .. ..

Total .. ..

416

452

868

In the Newcastle district, that is, within the area of the Hunter Eiver combined sanitary districts, under the administration of a fulltime Medical Officer of Health, the arrangement in regard to contacts was that the house in which a case occurred was at once quarantined, disinfected on the removal of the patient, all contacts vaccinated, and the quarantine of the premises maintained for fourteen days after removal of the patient. Such quarantines were maintained in cooperation with the State Police Force. So far as possible, inspection of these quarantined contacts was made daily, and in any case they were instructed to report through the police or a neighbour on the appearance of any of the prescribed symptoms. If the contacts refused vaccination, the quarantine was extended to 21 days. If any contacts had been successfully vaccinated within ten years and were revaccinated on the visit of the Medical Officer of Health, after removal of the patient and the disinfection of the premises, they were permitted to leave and reside elsewhere. If, owing to unforeseen circumstances, the patient could not be removed to hospital, any persons qualifying under this provision were allowed to leave the house after revaccination and disinfection of effects. Vaccination was arranged for in regard to all persons at places where cases or contacts had been employed.

In other country districts, the measures employed were adapted to local circumstances, isolation of cases and vaccination of contacts being in the main the measures relied upon, with a general vaccination of the public in the vicinity of each focus of attack.

Continuance of Administrative Aleasures of Control.

With the continuance of the epidemic over several years, the question naturally arose as to whether the health authorities of the State were justified in maintaining an expensive campaign of compulsory segregation against a disease which was no more deadly than chicken-pox. In his report on the outbreak for the year 1916, Dr. Armstrong summarizes in the following terms the principal arguments which justified such a continuance of the efforts being made to stamp out the disease: —“ In many instances the effects of this mild form of small-pox have been very disfiguring. Except in the mildest cases the complexion and features of women who have undergone attacks have been permanently disfigured to a greater or less degree. The disease also tends to produce abortion when it attacks pregnant women. Add to these facts that the eruption is a very loathsome one, and that a great deal of pain and discomfort precede and accompany an attack, and a fairly good case emerges for the enforcement of strong repressive measures. Finally, the attitude of the adjoining States of the Commonwealth has no little bearing upon the question. They have all apparently escaped infection so far (probably because they are better vaccinated than Hew South Wales), and they are naturally apprehensive of invasion from this State, and would strongly resent any slackening of the precautions which are being taken to check and limit the spread of infection here.” To Dr. Armstrong’s statement there might he added, in regard to the quarantine aspect, that the extension of the disease to the Pacific Islands which are in intimate trade relationship with Sydney, would have been fraught with disastrous results. The experience of the similar and concurrent epidemic in the Horth Island of Hew Zealand showed that amongst the Maoris a case mortality rate of 3.1 per cent, prevailed. The establishment of an endemic focus of infection in the South Seas is obviously to be prevented, and Australasian quarantine systems are required to give due regard to this matter.

CHAPTER IV.

SMALL-POX IH VICTORIA.

During the period under review, small-pox appeared in Victoria only durmg one year, 1921, when a total of seven cases were officially reported, two cases in Melbourne and five cases in Geelong. In addition there were presumably at least two other cases in Geelong.

The cases in Melbourne definitely originated from a lascar seaman landed in the pre-emptive stage to the Melbourne Hospital. Although coincident in point of time, there is no other evidence that the two groups of cases, in Melbourne and Geelong, had a common source of infection. The outbreaks can be conveniently discussed separately and then reviewed in regard to origin of infection.

The Cases at Melbourne.

On 9th April, 1921, a lascar firemen’s cook, A. J., was admitted to the Melbourne Hospital from the steamship Gracchus, then in port. He had suffered from fever since 7tli April, was delirious on 8th April, but somewhat improved and showing no temperature on admission to hospital on 9th April. A provisional diagnosis of malaria was made. On 10th April a vesicular rash appeared and a diagnosis of varicella was made. On 11th April a diagnosis of variola was established and the patient immediately removed to quarantine, where he developed a severe confluent eruption and died on 17th April. On admission to the Melbourne Hospital at midday on 9tli April he had been placed in a general ward (Ao. 28), from which he was removed to an annexe three hours later, where he remained until taken to quarantine on 11th April. Immediate steps were taken to vaccinate all contacts at the Melbourne Hospital. All passengers landed from the vessel were traced, and with all persons who had boarded the vessel whilst in port were vaccinated and subjected to surveillance. The detailed history of the vessel from the quarantine aspect is given on page 166.

On 26th April, Mrs. O’A., cetatis 40, who had been an inmate of the Melbourne Hospital from 7th to 16th April, was sent to the Infectious Diseases Hospital as a case of measles. A diagnosis of variola was made and she was removed to quarantine the same day. She developed a severe confluent eruption and died on 30th April. Whilst in the Melbourne Hospital she had been an inmate of Ward 26, which is in the same block as Ward 28, to which the original case, A.J., had been admitted. It was stated that this patient had been vaccinated in infancy, but on examination the profuse eruption obscured any marks that may have been present.

On 29th April, Miss T., cetatis 26, of Collingwood, was reported as a case of variola, and was removed to quarantine the same day. She had become ill on 22nd April with headache, backache, and vomiting, and the eruption appeared about 27th April. When seen on 29th April, the rash was in the vesicular stage, and was present on the face, markedly on the back and also present on the forearms and legs with some lesions in the mouth and on the palms and soles. She had four good marks of infantile vaccination and the disease ran a modified course to recovery. On 10th April Miss T. had visited her father, who was a patient in Ward 28 at the Melbourne Hospital. There is some doubt as to whether Mr. T. and the case A.J. were in the main Ward 28

together or in the special annexe ward. The records of the State Health Commission state that Miss T. only passed the door of the annexe within 6 feet of the patient A.J., but Miss T. is reported to have stated that her father and the black man ” A.J. were in a ward together.

Ho cases developed amongst the passengers landed from the s.s. Gracchus, nor amongst those who had boarded the vessel in port. dSTo further cases developed amongst hospital contacts. In each case, these contacts had been traced, and after vaccination subjected to surveillance.

The Cases at Geelong.

(1). On 5th May, a case of variola was reported in a male H.C., cetatis 25, living in South Geelong. He had become ill with “ influenzal1” symptoms on 27th April, hut proceeded to work until 29th April. On 30th April he had a few “ spots ” on the forehead, head, and chest. On 1st May his temperature was 102 deg., and he had “ water blisters on the face, arms, and back. On 2nd May his temperature was normal and the vesicles had become turbid. On 4th May his temperature was 99.4 deg., and the pustules had developed, his face was swollen, but the general condition remained good. On 5th May he had pustules over the face and head, and the nose swollen. On the body, there were a few dried-up lesions and odd pustules and vesicles. On the arms, there were a few vesicles, some ruptured, and on the flexor surfaces the lesions.had dried. The thighs showed vesicles and ruptured lesions, some very superficially placed. The rash was prominent on the buttocks and consisted of some new vesicles and some ruptured lesions. More rash was present on the shoulders than on the small of the back. On the back of the neck there was a definitely vesicular eruption, and passing down the back of the trunk, dried legions and scabs. On the top of the head, some lesions have become pustular and some were drying up. On the ears both vesicles and pustules were present. On the face some lesions were pustular and some showed scabs; and on passing down to the front of the neck, there were vesicles and small pustules mixed. A diagnosis of variola was made, and confirmed by Paul’s Test. He was immediately removed to quarantine.

Dr. C. L. Park, Chief Quarantine Officer for Victoria, who investigated the outbreak in co-operation with officers of the State Health Commission, reported in regard to this case as follows:—u The appearance and history of this case differed in no way from the cases seen at North Head during the Sydney outbreak of 1913-14. The patient was in good condition at the time that his rash become pustular, and was able to eat well, although the size of the rash, on the face and head particularly, was considerable. The rash on the face had that characteristic appearance as if the scabs had been 1 stuck on the surface. There were successive crops of vesicles, giving the mixed appearance to

the eruption. Seen on the eighth day, when the scabs had fallen off, there was the same bumpy ’ condition of the face and forehead so common in the Hew South Wales cases.”

1 his patient had two good scars of infantile vaccination, the eruption ran a modified course, and the patient made a good recovery.

The origin of the infection of tins case was Inot determined. He iad worked for three weeks at the Government Brick Works, at Worth Geelong, and prior to that for eight months at the local railway goods sheds. He had not been away from Geelong during the year, and had no known contact with any person suffering from any skin eruption. Fie had not been in contact with any ships, or, so far as he knew, with any one connected with shipping.

There had been in Geelong during the three months preceding the outbreak seventeen vessels from oversea—five in February, four in March, and eight in April. All had been subjected to quarantine medical inspection and on none had any illness been reported or detected.

1 )r. Park came to the conclusion, based on both clinical and epidemiological grounds, that infection in this case was entirely unconnected with the infection introduced from the s.s. Gracchus.

(2) . On 16th May, Mrs. C., cetahs 46, th^ mother of the case H.C., was found to be suffering from variola. She had two good scars of infantile vaccination, and had been unsuccessfully vaccinated on 6th May. She was removed to quarantine, where the course of illness was mild, and she recovered.

(3) . Mrs. A., cctatis 38, was not recognized as a case of variola during the course of her illness. She became ill with headache and epistaxis on 26th June, and was sent to a private hospital as a case of typhoid fever. The temperature fell gradually until normal on 29th June. On the 29th June a skin eruption appeared on the face and exposed parts of the body and later became pustular “ like small boils.” The appearance on 16th July of a variola eruption in a nurse at the hospital (Worse W.) called attention to her condition, and on examination on 17th July there was staining of lesions on the face, shoulders, and back, and on forearms and feet. A few deep-seated “ seeds ” were still present in the soles of the feet. She had four plain marks of infantile vaccination. ho connexion could be traced between this case and any other known or suspected case except a suggestion that a child of this patient had suffered from a similar condition, but nothing more definite was ascertainable.

(4) . Wurse W., cetatis 23, was a nurse attending Mrs. A. at a private hospital. She became ill with headache, backache, prostration, and fever (103 deg.) on 12th July. On 13th July there was an erythema on the chest. On 15th July there was a papular eruption on the face and body. On 17th July the rash became vesicular; on 19th July the

rash was becoming pustular on face and semi-confluent on hands and back.. On 20th July the rash was pustular on face, becoming pustular on chest ; while the back was a confluent, pustular mass. The rash was confluent on the face, hands and back on 23rd July, and the patient died on 26th July. She had never been vaccinated. Her infection was definitely due to contact with Mrs. A., the contact being close and continuous.

(5) . On 1st August, E.S., cetatis 58, undertaker’s assistant, was reported as a case of variola. On 2'9th July he had felt dizzy with “ influenzal ” symptoms, but went to work on 1st August, on which day a rash appeared on his forehead, becoming papular on 2nd August. He suffered from a severe attack, and the rash was profuse, hut his general condition remained good, and he made a good recovery. He had been vaccinated in infancy, but showed only one poor mark. He had driven a mourning coach at the funeral of Hurse W. on 27th July, but his illness developed only two days later than this. A list of all persons with whom his work brought him into contact showed no history of possible €*xpo3iire to infection. He had not been away from Geelong for two months. In connexion with this case, Dr. Park noted that “ this case bore close resemblance to the Hew South Wales cases, and showed clearly that the extent of the eruption was not a definite indication of tlie severity of the disease.”

(6) . Hurse M. was a nurse at the Geelong Hospital, and at the hospital, and subsequently at quarantine, had attended JSTurse W. from 16th July till the death of the latter on 26th July. On 29th July, one day after leaving quarantine, she had a “shivering” attack, and on 30th July her temperature reached 102 deg., and there were a few spots on her chest, back, and face about 1st or 2nd August. She remained in bed for a week, being attended by her mother, and was not seen by a medical man. She accompanied her mother to Adelaide on 8th August, returning on 18th August, and on 22nd August the' appearance of a papular eruption in her mother called attention to her history. She had three good scars of infantile vaccination, and had been unsuccessfully vaccinated on 1/th, 20th and 23rd July—-on the latter occasion there was some reaction, itchiness and reddening, without vesicular or pustular formation, but showing later some slight scaling.

(7) . Mrs. M., cetatis 54, was the mother of Hurse M., and had nursed her during her illness from 30th July to 5th or 6th August. Between 8th and 18th August both she and Hurse M. had been in Adelaide, returning to Geelong on 18th August. On 19th August she felt “out of sorts,” and on 21st August was seen by a doctor, her temperature being 103 deg. On the afternoon of 22nd August, a papular eruption appeared on her forehead. On 24th August the papular rash was present on the face, trunk, and limbs, on the hack rather more than on the front of the body, and sparse on the limbs. There was a tendency

to vésiculation about tlie neck and at tlie base of tlie right thumb. She had three marks of infantile vaccination, and had refused revaccination whilst her daughter was attending Nurse W. She had a mild modified attack, and made a good recovery.

Measures of Control.

The measures of control adopted in connexion with the quarantine of s.s. Gracchus are detailed on page 166. The cases in Melbourne did not develop beyond the original institutional spread, and vaccination and surveillance of all contacts were effected. The action taken by the State Health Commission in connexion with the outbreak at Geelong may be summarized as follows :—

(1)    All cases immediately removed to quarantine at Coode

Island.

(2)    Isolation and vaccination of all house contacts.

(3)    Vaccination and surveillance of all other contacts.

(4)    Establishment of vaccination dépôts and public vaccination

urged.

(5)    Medical practitioners urged to report all cases of eruptive

disease in any way resembling small-pox.

(6)    All persons suffering from rashes advised to report to the

Officer of Health.

(7)    Investigation of source of infection by medical officers of

the Commission in co-operation with the local Medical

Officer of Health.

Review.

The course of the infection in Melbourne and Geelong presents some striking features which will be discussed later in dealing more fully with the epidemiology of small-pox in Australia (Chap. XIII.). In connexion with the cases in Melbourne, the history of origin and association is clear, but the surprising feature is the limitation of the outbreak, whilst in neither of the two cases was contact close or continuous. Contact with, the original case A.J. by Miss T. may have been more or less direct, but the contact by Mrs. O’X. must have been indirect and through a third person. Granted that all the hospital staff in close association were protected by vaccination, and that immediate vaccination of all contacts was instituted on confirmation of the diagnosis, the capricious spread of infection in the two cases that did occur would indicate an expectation of a far higher incidence of secondary cases. The Melbourne Hospital is a modern institution, well staffed and under efficient administration, and conditions are such as would reduce to a minimum the possibility of cross-infection by the medium of nursing staff or physicians.

In regard to the Geelong cases, the origin of the infection is obscure. Granted that the outbreak might appear coincident in point of time with the Gracchus cases, this is really negatived on analysis of the actual dates. The first Geelong case, H.C., became ill on 27tli April. Taking the extreme variation of the incubation period of variola as between a minimum of six days and a maximum of fifteen days, it is obvious that if the infection of the case H.C. was related to the Gracchus, then the infection was direct, since it is most unlikely that sufficient time elapsed for the development of an intervening case. The relevant dates are brought together here for reference:—

7th April, 1921.—Gracchus arrived Melbourne.

9th April, 1921.—Case A.J. landed from Gracchus.

11th April, 1921.—Case A.J. removed to quarantine.

17th April, 1921.—Case A.J. died.

26th April, 1921.—Mrs. O’X. (Melbourne) developed rash.

27th April, 1921.—Case H.C. became ill.

30th April, 1921.—Case H.C. developed rash.

The most minute inquiry failed to indicate any possibility, however remote, of direct association between the case H.C. and the Gracchus.

On clinical grounds, also, the infection showed a definite variation as between the Melbourne and the Geelong cases. Dr. Park’s remarks on the cases H.C. and E.S. at Geelong have already been recorded, and notwithstanding the severe confluent and fatal case in Hurse W. at Geelong, the cases there were (in .distinction from the true Asiatic or “ classical ” variola present in the Melbourne cases) analogous to the cases seen at Sydney during the course of the mild or “ alastrim ” type of infection prevalent in 1913-14. It must,, therefore, be accepted, although not definitely proven, that the outbreaks in Melbourne and Geelong were not coincident in origin of infection.

CHAPTER V.

SMALL-POX IX QUEENSLAND.

When small-pox was ascertained to be epidemic in Xew South Wales in July, 1913, immediate action was taken by the State health authorities to supplement the preventive measures against the introduction of infection already initiated by the Commonwealth quarantine service. Eree vaccination was offered, and a considerable number of people availed themselves of the opportunity. However, in July and August, 1913, five cases of a mild type of small-pox were discovered in Toowoomba, Ipswich and Brisbane. The diagnosis in each case was confirmed by

unsuccessful vaccination with lymph of proven potency. The particulars of the cases, all of whom recovered, were as follows :—-

Table 26.

Case.

Address.

Sex.

Age.

Occupation.

Date of Onset of Eruption.

Date

reported.

Vaccination History.

(1) J.C.A. ..

Craig End, Too-

M.

27

Farm

15-7-13

18-7-13

Faded, doubtful

woomba

labourer

scars, dating from

(2) W.O’B.

Roma-street, Bris-

M.

23

Police eon-

19-7-13

19-7-13

infancy

Never successfully

(3) E.A.C.

bane

stable

vaccinated

Limestone - street,

F.

21

Draper’s as-

23-7-13

23-7-13

(4) J.A. ..

Ipswich

sistant

(circa)

Brunswick - street,

M.

39

Fruiterer

26-7-13

26-7-13

Faded, doubtful

(5) R.T.C.

Brisbane

Limestone - street,

(circa)

scars, dating from infancy

M.

19

Clerk . .

8-8-13

8-8-13

Never successfully

(brother to Case 3)

Ipswich

(circa)

vaccinated

Additional particulars of the outbreak are recorded in a report by Dr. J. S. C. Elkington, Chief Quarantine Officer (General), which is quoted here practically verbatim.

Nature of the Illness.—The disease was identical with that then prevalent in Sydney, and diagnosis was con^rmed by consultants with experience of these Sydney cases and of small-pox in the East.

Coincident Cases of Suspicious Eruptions.—A number of cases presenting very suspicious and curious skin eruptions were reported from Brisbane and several other parts of Queensland during this period. Several were isolated pending application of the vaccination test, but all reacted successfully. A form of severe chicken-pox, with a pronounced tendency to secondary septic infection of the skin lesions, certainly coincided with the earlier part of the local outbreak. The vaccinal reaction afforded the only method of establishing a diagnosis from variola. After about the middle of August, these troublesome and puzzling cases ceased.

History and Source of Infection.—-The sources of infection from which these cases arose were carefully searched for, but with one exception (R.T.C., who was evidently infected from his sister, E.A.C.), no definite conclusion as to origin could be arrived at. Despite minute inquiry, no connexion with Sydney could be established, and, with the exception of the case J.A., the dates of onset negative any probability of infection having been introduced to Queensland after the quarantine regulations were in working order. It is, however, possible that a source of infection existed in Ipswich towards the end of June and in the earlier part of July. The first case, J.C.A., was in Ipswich from 24th June-to 11th July, and developed the eruption on 15th July. The second case, W. O’B., was in the Ipswich district, at Esk, prior to 8th July, and passed through Ipswich on that date. He developed the

eruption on 19th July. E.A.C., the third case, resided at Ipswich, and developed the eruption about 23rd July. The most minute inquiry failed to establish the identity of the supposed infectious source, but allowing an incubation variation of eleven to seventeen days from infection to outcrop, the three cases referred to would fall, as regard date of infection, between 28th June-4th July, 2nd-8th July, and 6th-12th July respectively. The latest date at which the presumed source of infection could possibly be regarded as operative was 12th July, the earliest 28th June. Allowing the average incubation period of fifteen days from infection to outcrop, the dates of operation would be 1st, 4th and 8th July. A second and subsequent source of infection for the last case is very improbable, and it may therefore be reasonably concluded that the same cause operated in all. Border inspection was begun on 6th July, and Sydney vessels were first examined on 7th July. In the case of J.A., no definite history of any conceivable source of infection could be obtained, but both he and his people were difficult to get information from, and were probably unreliable.

Action Taken to Control the Outbreak.—The Epidemic Diseases Regulations 1913, under The Health Acts 1900 to 1911, were gazetted on 31st July. In all cases where circumstances appeared to warrant it, the sufferer was isolated and vaccinated for diagnostic purposes. The contacts were located and vaccinated, and either kept under daily surveillance or isolated. Precautionary disinfection was effected as early as possible. Where children attended a school from any premises where a suspicious case occurred, the school was inspected by arrangement with the medical inspecting officers of the Department of Public Instruction. The general precautions taken were those which would have been adopted in the case of an outbreak of a virulent and fatal form of small-pox—no other course was deemed justifiable under the circumstances.

CHAPTER YI.

SMALL-POX IX SOUTH AUSTRALIA.

During the period under review only one case of small-pox occurred amongst the shore community in South Australia, in connexion with the infection on the steamship Runic in December, 1914 (see page 135). In this instance a passenger of this vessel contracted infection from a fellow-passenger who had joined the vessel at Cape Town, after travelling from Rhodesia, where the mild type of small-pox known locally as Amaas was very prevalent. This case, who contracted the infection on the vessel, passed through a mild attack, and since infection was not recognized on the vessel on arrival at either Albany or Adelaide, he was

permitted to land at Adelaide on 28th December. That afternoon he spent an hour at an hotel near the Glanville railway station in association with a local resident G. He had drinks again with this man G. during an hour on the following afternoon. G. subsequently contracted small-pox. The infection on the vessel being discovered on arrival at Melbourne, the contacts were traced, the missed ” cases segregated, and on the appearance of the eruption in the case G., prompt and energetic measures were adopted. There were no subsequent developments.

CHAPTER VII.

SMALL-POX IX WESTERN AUSTRALIA.

During the period under review, small-pox was introduced into Western Australia in 1914, and resulted in an outbreak of seven cases at I!unbury, a seaport town of 4,000 inhabitants, situated 120 miles south of Fremantle. On 4th May, 1914, a lascar seaman was reported sick on the steam-ship Kilcliattan, which had arrived from Bombay, via Busselton, on 24th April, 28 days out from Bombay. (For quarantine of this vessel see p. 134.) When examined om 4th May, this lascar had a temperature of 102.8 deg., and on the following day (5th May) was removed to the local general hospital. On 6th May his temperature was normal and remained so until 9th May, when a vesicular rash was discovered on his forehead, arms, and hands, and the temperature rose to 99 deg. He was removed that day (9th May) to quarantine for observation, with a provisional diagnosis of varicella. He had two small scars of vaccination which he stated had been done “ a long time ago.” On 11th May his temperature was 102 deg., and small-pox was suspected, and confirmed on consultation the following day (12th May). The rash was characteristic in distribution and development, and especially persisted in the thickened soles of the feet. His subsequent history shows that the general condition remained good, with evening fever only, until 24th May. He had recovered by 29th July, and left the State for oversea on 31st July.

On confirmation of a diagnosis of small-pox (12th May), the general hospital was quarantined, and efforts were made to trace all contacts known to have visited the hospital during this period. These contacts were placed under surveillance, but on 22nd May a hospital patient was found to present suspicious symptoms, and on 24th May a patient who had been discharged from hospital on 12th May, and who had not subsequently been traced, was sent into quarantine by a doctor at Donnybrook, 16 miles out of town. Both these cases proved to be small-pox, and altogether seven cases developed, the last case on 3rd

June. Particulars of these cases are summarized in the following table and then discussed in detail:—

Table 27—Small-box at Bunbury, 1914.

Case.

Age.

Sex.

Oci) pation.

Date of Onset.

Date of Appearance of Rash.

Date of Discharge.

Date of Death.

Previous

Vaccination

History.

Type « f Disease.

0 I-M.

25

M.

Lascar seaman, ex s.s. Kil-chattan

4th May

9th May

3lst July

Two small old scars

Severe

discrete

() J.G.

34

M.

Sleeper-cutter (hospital patient)

20th May

23rd May

17th July

Never vaccinated

() E.S.

34

M.

Shop assistant (hospital patient)

22nd May

24th May

Two infancy scars

() E.A.

49

F.

Matron of hospital

25th May

20th July

Vaccinated, infancy, 1891; 1901

Haemorr

hagic

[) P.S. . .

29

F.

Nurse ..

26th May

22nd July

Vaccinated,

1903

Moderately

discrete

) A.B.W.

25

F.

30th June

Vaccinated, infancy, and 1913

Very mild, modified by vaccination

() H.W.M.

10

M.

Hospital

patient

23rd May

25th May

7th June

Never vaccinated

Confluent'

() E.H.

32

F.

Nurse ..

3rd J une

7 th June

22nd July

Vaccinated,

1913

Very mild, modified by vaccination

The particulars of the cases are recorded in detail by Dr. J. W. Hope, Commissioner of Public Health, in his annual report for 1914 (Appendix M, page 56). These records are here quoted practically verbatim.

(Case 2.) J.G. was discharged on 12th May from the hospital, where he had been treated for influenza, and was not mentioned in the list of those exposed to infection. After leaving the hospital on the morning ot the 12th, he went to a boarding-house in Bunbury; next morning he went to where his work lay, a timber mill at East Kirupp, about 45 miles from Bunbury. He joined this camp of about 45 people, who were living in tents and working at timber felling, &c. His tent was built up against another man’s. Up till about the 20th he did a little work, then felt unable to do much as he suffered from pains in the head, back, &c., and on the 23rd found that he had a rash on him, and himself thought that he had caught the disease the Lascar had. He made his way from East Ivirupp on Saturday morning, the 23rd, m the company’s train, associated with some of his companions, who were playing cards at a public-house there. Then he proceeded to Donnybrook. 16 miles away. Went to a lodging-house there that night, and the next morning C.7279.—4

(24tli) sought a doctor, who pronounced him to be suffering from smallpox. He was at once brought into the quarantine station at Bunbury by motor. 1 he lodging-house was quarantined, with the occupants.

The rash was mainly distributed on the face, limbs, and back; but the neck, especially below the collar mark, and the anterior surface of the body were free. The course was typical but mild, with a moderate degree of pitting. General symptoms were not marked; the patient ate and slept well. Photophobia and soreness of throat were present for some days, also a marked swelling of the neck, but all soon subsided. 1 emperature was only 100 deg., and dropped to normal after the first couple of days. He was discharged from hospital on 17th July, 1914. This patient had occupied the next bed to Case 1 in the Bunbury Hospital.

(Case 3.) E.S. had been operated upon for appendicitis and was in the Bunbury Hospital; developed a prodromal rash on Friday, 22nd May, and was transferred to the isolation ward on that day. On Sunday, 24th, symptoms developed which clearly indicated the nature of the disease, and he was removed to the Quarantine Hospital the same day.

The rash was widely distributed, especially thick on the face and extremities; a good number on the soles and palms. Mainly discrete, but some confluence on the face and a good deal of subsequent pitting. During pustulation the odour was characteristically unpleasant. Delirium, at first violent and afterwards muttering, continued for some days. Photophobia and conjunctivitis for the first couple of weeks; also sore throat and a number of lesions in the mouth and throat. Temperature at onset ran to 103 deg. or 104 deg. F., but became normal on 26th. There were subsequent slight rises on 28th May, and on 1st and 2nd June. The pulse was soft and feeble, necessitating a strychnine mixture. Recovery was only interrupted by a discharging sinus appearing for some days in the operation wound. He was discharged 17th July, 1914.

This case had occupied the next bed to Case 1 in the Bunbury Hospital.

(Case 4.) E.A., matron of the hospital, presumably contracted the disease on 9th May, when she was present at the examination of the Lascar patient, previous to his isolation as suspicious. Vomiting and rise of temperature occurred on evening of 22nd May, and by 25th the characteristic rash had appeared. (She was removed from her room to infectious block on 26tli.) The rash was widely distributed, but the lesions seemed small and discrete, with the result that the subsequent pitting was not great. The lesions became haemorrhagic, especially on palms of hands and soles of the feet, but cleared up well.

Photophobia, conjunctivitis, pains in the head and back, as well as insomnia, were all marked in the early stages. There was one pustule on the conjunctiva, and several on the buccal mucous membrane, with

coughing of blood-stained mucus. A hypodermic injection of morphia to relieve the pain and insomnia resulted in such a purpuric patch at the site of injection that subsequently veronal for the insomnia and aspirin for the pain were relied upon.

Temperature dropped after the appearance of all rash. Pulse was very soft and irregular during the illness, but this was probably due to antecedent myocardial trouble. Stimulants were administered constantly on this account. Even during convalescence this tendency to heart, attacks manifested itself on the slightest over-exertion. She was discharged from hospital on 20th July, 1914.

(Case 5.) P.S. was a nurse on duty at the General Hospital when the Lascar patient was there. Taken ill on 22nd May, with vomiting and temperature of 102.2 deg. On 26th, she was removed to the isolation ward, where a characteristic variola rash, hut of limited distribution, developed. The pain in the back was severe for the first few days, and the temperature was slightly above normal for some days. Apart from these, recovery was good.

This case showed the typical tendency of the rash to prefer elevations to hollows; on the hands the extensor tendons were picked out by the few lesions developing there. She was discharged 22nd July, 1914.

(Case 6.) A.B.W. was a trained nurse brought direct from Perth, and took charge of the Lascar patient at quarantine station on 14th May, after he had been there in charge of orderly since 9th. She continued to perform all the duties, domestic and nursing, until 26th May, though feeling ill from the evening 22nd. She had several chills, and on 26th her temperature was 103.8 deg., and she was vomiting. Spots appeared on her forehead, with only a few lesions developing characteristically on other parts. Backache and headache were marked ; temperature gradually subsided, and disease ran a normal and mild course. She was practically convalescent in a week, and in another fortnight she had finished exfoliating. Only one lesion appeared on the sole of the foot, and only one on the face pitted. She was discharged 30th June, 1914.

(Case 7.) H.W.M. was discharged from the hospital on the 12th May, after five weeks’ suffering from rheumatic fever with cardiac complications, and was living with his family in Bunburv, and mixed freely with people, attended a picture show, and assisted his father as a bottle collector. He felt iill on the 23rd May, and was seen by his doctor on the 24th. On the 25th May, he had a prodromal rash and general symptoms of small-pox. Removed to the Quarantine Station on the same day.

The characteristic rash developed and was well distributed. By the 27th the rash had become distinctly papular with a tendency to vesicu-lation, but still somewhat resembling the rash of measles. The body was covered except for a patch or two on the abdomen towards the

groins; even the armpit had some lesions on it. Vomiting after admission was severe. The sputum was blood-stained, there being lesions in the mouth and throat.

The lesions during development were fairly] discrete and surrounded by a distinct zone of inflammation. They showed characteristic umbili-cation. On the face, arms, and thighs they became confluent, and later haemorrhagic, with areas of sloughing at all points of pressure.

Temperature went up to 103.6 deg. on day of admission, but fell gradually to normal on 29th. It gradually rose again to 101.2 deg. on 61st, and dropped to normal on 1st June. On 2nd June it rose to 103.6 deg., and continued above normal until death, with an intermission to 99 deg. on 6th June.

The pulse was rapid and irregular throughout; stimulants—cham-agne, brandy, and strychnine—were administered on this account. There were photophobia- and conjunctivitis and constant pain in the head and back. The skin irritation was such as to necessitate the hands being muffled in the second week to prevent scratching during sleep. Nourishment was taken fairly well though hindered by soreness of mouth and swelling and dryness of lips.

There was slight delirium on admission* but subsequently he was normal until the second week, when with increased septic absorption, muttering, delirium, and insomnia supervened. Tie died 7th June, 1914.

The patient had had unusually close contact with Case 1 in the hospital.

(Case 8.) E.II. was a nurse brought direct from Perth who took charge at Quarantine Station on 26th May (to relieve Nurse A.B.W., who was down with the disease), and was vaccinated the same day. She fell ill on the 3rd June, and was again vaccinated that day. During the next three or four (jays there were a number of rigors, also some vomiting. On 7th June papules were discernible on face and arms. Subsequently they developed in other situations, but not in great numbers. Some of them went through the typical stages, but the majority appeared to abort without going through the pustular and desquamation stages.

The temperature continued above normal for some days, but with improvement in the condition of the arm from vaccination she also improved. There were pains in the back and limbs, but the most unpleasant symptom was a severe and persistent headache, which was accompanied by enlargement of the posterior cervical glands. She was discharged on 22nd July, 1914.

Vaccination History of Cases and Hospital Contacts.

The detailed vaccination history of each case was as follows :—

(1)    I.M.—■ Says he was vaccinated a long time ago. Two small scars resulting were visible.

(2)    J.G.—Unvaccinated. He had left the hospital on the morning of 12th May, prior to the confirmation of diagnosis.

(3)    E.S.—Vaccinated in infancy, two scars -|-in. diameter each. Recovering from appendicectomy, and was not vaccinated at the hospital.

(4)    E.A.—Vaccinated in infancy, also in 1891 and 1901. Scar area, \ inch, f inch, and f inch. She stated that the last two vaccinations produced little local reaction—only one scar was plainly marked.

(5)    P.S.—Vaccinated eleven years ago. Scar area, -§ inch, \ inch, quite plain.

(6)    A.B.W.—Vaccinated in infancy. Well-marked scar area, 1 inch and \ inch. Revaccinated eleven months previously, two scars well defined.

(7)    H.W.M.—Unvaccinated. His father said he thought the hoy was vaccinated in infancy, but no scars were visible. His father objected to the lad being vaccinated as a contact of the Lascar, probably because he had heart disease. He was vaccinated on the 24th May without result.

(8)    E.H.—Vaccinated eleven months previously. Three scars almost invisible. Revaccinated 26th May, unsuccessful. Revaccinated 3rd June, five places, which took well, developing with variolous eruption.

The vaccination condition of the patients in hospital who were not infected is as follows    '

Patients.—Vine were revaccinated, the second vaccination in each case having been done less than two years previously. In five cases the vaccination condition is unknown. In one case there was a history of a previous attack of small-pox.

Nurses.—Three were vaccinated only in infancy and one twice vaccinated, the second occasion being five years previously.

Control Measures Adopted.

On confirmation of the diagnosis of the original case on 12th May active control measures were initiated. The hospital was quarantined and all staff and patients vaccinated with the exception of two or three seriously ill. This first vaccination was unsuccessful, and revaccination was effected. Arrangements were made to trace and keep under surveillance all contacts who had been known to have visited the hospital. When the case J.G. was admitted to the Quarantine Station

from East Kirupp on 24th May, and the case H.W.M. fropi Bunbury on 25th May, the town of Bunbury was quarantined under the State Health Act as from 25th May, and free vaccination offered. It was estimated that 3,000 of the population of 4,000 submitted to vacccina-tion, so that with the 400 who had been vaccinated in 1913 on the announcement of the presence of small-pox in Sydney, the community became fairly well protected. The stevedores working the vessels in port were vaccinated, and vessels were handled under quarantine restrictions by vaccinated stevedores and the jetty closed under guard. All roads into the town were guarded, and permits to leave Bunbury only granted to successfully vaccinated persons, who proceeded under quarantine surveillance. By co-operation with the manager of the timber mill at East Kirupp, the police, and the Railway Department, all the contacts of the case J.G. at East Kirupp, Kirupp, and Donny-brook were located and brought by special train to a camp on the quarantine reserve. All contacts of the case H.W.M. in Bunbury were also removed to this camp. The bulk of the contacts freely submitted to vaccination. Disinfection of all possibly infected articles in relation to these two cases was effected; the tent and contents at the camp at East Kirupp at which J.G. had stayed were destroyed by fire, as well as the bedding and linen used by him at the lodginghouse at Donnybrook.

%

On 9th June, since no further outbreak had occurred either in Bunbury or along the route taken by J.G., the quarantine was raised after having been maintained for fifteen days. By 15th June all the contacts at the quarantine camp had been released.

The cost of the outbreak amounted to £2,066 2s. lid.

Features of the Outbreak.

1 he striking epidemiological features of this outbreak can be more conveniently discussed on a comparative basis in relation to other Australian outbreaks (see Chapter XIII.). It might be well, however, to summarize here some important points.

(1) Introduction of Infection.—-The vessel left Bombay on 8th April, and the eruption developed in the Lascar seaman on 9th May, 30 clear days intervening between these dates without the occurrence of any other known case. This is-more fully discussed in dealing with the quarantine of the vessel (isee page 134). It will also be noted that the case was landed in the febrile pre-eruptive stage to a general ward of the local hospital, where he remained four days (5th to 9th May) before the appearance of a rash, when he was isolated as a case of varicella. Small-pox was suspected on 11th May and confirmed on 12th May, the eighth day after admission to hospital.

(2) The period from infection to development of disease in the secondary cases was variable, as indicated in the following table:—

Table 28.

Case.

Dates of Exposure.

Date of Onset of Symptoms.

Date of Appearance of Rash.

Period from Infection to Onset of Symptoms.

(2) J. G. ..

5th-9th May ..

20th May

23rd May

11-15 days

(3) E. S. ..

5th-9th May . .

22nd May

24th May

13-17 days

(4) E. A. ..

5th-9th May . .

22nd May

25th May

13-17 days (probably 13 days)

(5) P. S. ..

5th-9th May . .

22nd May

26th May

13-17 days

(6) A. B. W. ..

14th May onwards. .

22nd May

26th May

8 days or less

(7) H. W. M. ..

5th-9th May . .

23rd May

25th May

14-18 days

(8) E. H. ..

26th May onwards. .

3rd June

7th June

8 days or less

In the cases of the two nurses who contracted the infection at the Quarantine Station, the period was only eight days ; in those cases which contracted the infection at the General Hospital there avrs a period of from eleAmi to eighteen days. The infection of the cases in hospital points to infection contracted during the pre-eruptiA'e stage or the very early eruptive stage of the primary case.

(3)    The capricious striking of infection from the original case is indicated by the high infectivity evident in the hospital and the Quarantine Station, whereas the case J.G. mixed freely with a camp community after the eruption had appeared, yet no further case developed from him of from any of the other secondary cases. The only record of the vaccination condition of the hospital population is that “ all were not so protected ” prior to the general \r"accination on 12th May.

(4) The effect of vaccinai ion is evident in that in those cases recently and successfully vaccinated, when infection did occur the course of the disease Avas mild, convalescence rapid, and disfigurement nil, AA'hereas in cases not so protected the converse held good.

(5)    The epidemiological records of the outbreak are incomplete, although Dr. Hope’s report covers completely the clinical and administrative details. For example, the complete vaccination histories of the exposed hospital population would provide material for a closer study of the behaviour of the infection in the hospital. Since the conditions in an institution and on shipboard are in many AAmys analogous, the schedule of records suggested for the use of ships’ surgeons (see Chapter XV.) -provides an indication of a form

of record which a hospital administration can adapt for purposes of control and of record for future reference or publication.

The one feature of this outbreak, however, which does arrest attention, is that each of the cases had had close personal contact with the original case.

CHAPTER Vlli.

IMMUNITY OF TASMANIA.

During the period under review, no case of small-pox occurred in Tasmania.

CHAPTER IX. %

VACCINATION IN AUSTRALIA.

The position as regards vaccination in each State in the Commonwealth up to the year 1909 has been fully reviewed in the previous volume. At that time, 1909, there was no Vaccination Act in NewSouth Wales. In Victoria, infant vaccination wms compulsory under the Health Act. In Queensland, provision was made for compulsory vaccination under the Health Act 1900, but the section was never proclaimed. In South Australia a conscientious objection clause nullified the compulsory provisions of the Vaccination Act, although, in the case of small-pox prevailing in the State, power was given to vaccinate contacts. In Western Australia, compulsory vaccination rvas in force under the Vaccination Act of 1878. In Tasmania, there wras a conscientious objection clause to the Vaccination Act of 1898. The position in 1909, therefore, was that compulsory vaccination was enforced only in the States of Victoria and Western Australia.

In 1911 a conscientious objection clause was inserted in the Health Act of Western Australia, and of Victoria in 1919. In South Australia an Act to suspend compulsory vaccination was passed in 1917. The position as regards vaccination in comparison with the number of births in each State for each year of the period under review is indicated in the following table :

(Number of Vaccinations reported by Public Vaccinators only.)

State.

New South Wales.

Victoria.

Queensland.

South Australia.

Western Australia.

Tasmania.

Census Population, 1911

1,646,734

1,315,551

605,

813

408,558

282,

114

191,211

,, ,, 1921

2,100,371

1,531,280

755,072

495,160

332,

732

213

780

Vaccina

tions.

Vaccina-

Vaccina-

Vaccina-

Year.

Births.

tions per 100

Births.

Vaccina

tions.

tions per 100

Births.

Vaccina -tions.

Births.

Vaccina

tions.

tions per 100

Births.

Vaccina

tions.

Births.

Vaccina

tions.

Births.

Birt lis.

Births.

1909

43,782

11

■02

31,549

21,344

68

15,552

10,004

1,477

14-7

7,002

-e ~

5,500

1910

45,444

280

■6

31,437

(b)

69

10,109

10,540

1,800

17-1

7,585

^ ^ o

5,586

1911

47,537

20

•04

33,044

(b)

62

10,984

11,057

1,431

12-9

8,091 (d)

5,437

1912

51,801

35

■06

35,817

(b)

60

18,738

12,079

1,035

8‘6

8,689

120

5,853

1913

52,180

10,159 (a)

19-5

35,978

(b, c)

69

19,731

12,027

1,493

11-8

9,218

37 (/)

5,886

. Ó 3

1914

53,041

0,028

12-4

30,225

(b)

66

19,882

12,905

940

7-3

9,204

6,017

1915

52,931

4,080

7 • 7

35,010

24,180

69

20,103

03

11,798

854

7 ‘2

9,017

5,845

ce!

1910

52,080

2,018

5-0

34,239

20,910

61

18,912

t>

11,857

587

4-9

8,563

5,642

1917

52,448

4,003

8 ■ 9

33,035

19,759

60

19,787

11,320

251

9 -9.

7,882

¡3

5,376

o3

1918

50,709

(b)

31,001

15,300

48

19,530

4—'

o

11,357

38 (e)

0-3

7,106

5,280

O

1919

48,532

324

0 ‘ 7

31,021

14,031

44

18,699

5^

11,060

8

o-ol

6,937

iS

5,310

£

1920

53.942

377

0 ■ 7

30,214

4,327 (d)

12

20,256

12,028

20

0-17

8,149

5,740

1921

54,030

1)

35,593

3,915

11

20,329

11,974

Nil

7.807

O

5,755

1922

55,170

(b)

30,288

2,750

8

19,987

12,001

Nil

8,131

5,817

1923

54,009

(b)

35,876

2,149

6

19,982

11,092

Nil

7,854

5,657

(a)    Small-pox outbreak in New South Wales, and probably 500,000 were vaccinated

(b)    Not available.

(c)    Also 130,000 adults during New South Wales outbreak.

(d)    Introduction of “ Conscience clause.”

(e)    Act to suspend compulsory vaccination passed in 1917.

(/) Exclusive of Bunburv, where 3,400 were vaccinated during the local outbreak.

The position in each State can be now reviewed, but it might be here recorded that the decline of vaccination was not allowed to pass unnoticed by Conferences of the Health Officers of the various States. In 1904 the Conference which had met to discuss the draft legislation which initiated a Federal system of quarantine, resolved in regard to “ some matters3 in connexion with which it seems to the Conference that Commonwealth legislation should deal,” that “ as regards public vaccination the Conference desires to affirm most emphatically that vaccination and revaccination afford to the individual the only defence against infection by small-pox; and that if vaccination and revaccination were compulsory throughout the Commonwealth, and were uniformly carried out, quarantine as against small-pox would become unnecessary. Accordingly, this Conference is of opinion that an Act providing for compulsory vaccination and revaccination would be of the utmost benefit to the Commonwealth.”

The Conference of 1909 again called attention to “ the present unsatisfactory condition of the greater part of the Commonwealth in regard to protection by vaccination from the risk of epidemic smallpox,” and in view of this did not recommend any> abatement of the maritime quarantine restrictions.

After the Conference on Food and Drugs^ Standards, which met at Melbourne in June, 1913, and at which the permanent heads of the Health Departments of the six Australian States and the Acting Director of the Commonwealth Quarantine Service were present, opportunity was taken to discuss the situation in Australia with regard to the possible introduction and spread of small-pox. Amongst the suggestions submitted were the following in relation to vaccination:—

(1)    That effective vaccination be made compulsory.

(2)    That every registered medical practitioner be made a public

vaccinator.

(3)    That only Commonwealth vaccine be used for vaccination.

(4)    That all vaccination be free.

(5)    That a fee of 2s. 6d. be paid for each vaccination.

(6)    That four marks be required at each vaccination.

(7)    That the Health Department of each State supervise the

organization of the service, so as to ensure satisfactory inspection of vaccination.

The Conference of 1913 met to consider the position in regard to the proclamation of Sydney as a quarantine area and the nature of joint action of the Commonwealth and States in relation to similar epidemics in the future. As such, the question of vaccination was not

raised at this Conference, but as has been already noted in Chapter III., the legal powers for the vaccination and detention of contacts in the epidemic at Sydney were derived from the Commonwealth Quarantine Act, the State Health Officers being appointed quarantine officers for the exercise of these powers.

The requirements of, and the standard adopted in regard to vaccination under the Commonwealth Quarantine Act and Regulations have already been referred to (page 10) in discussing the procedure in connexion with the maritime quarantine in relation to small-pox in Australian ports.

Hew South Wales.

In Hew South Wales there has never been any statutory provision for compulsory vaccination, but public vaccinators are appointed and receive a fee of 2s. 6d. for each vaccination performed and reported. The available statistics of reported successful vaccinations have been shown in Table 29.

An indication of the vaccination condition of the community in 1913 is given in a return shown by the Government Statistician in his report on vital statistics for the year 1911 :—

Table 30.—Persons Vaccinated by the Government Medical Officers from the Year 1902 to 1911.

Age Groups.

1902.

1903.

1904.

1905.

1906.

1907.

1908.

1909.

1910.

1911.

Under I .. . .

22

2

3

1

2

3

1-4 .. .. ..

128

43

2

5

10

2

2

3

59

5

5-9 .. .. ..

393

251

9

12

14

16

11

5

122

9

10 years and over . .

353

309

9

15

15

20

29

3

97

3

Total, All Ages ..

896

605

20

32

42

39

42

11

280

20

On the outbreak of small-pox at Sydney in July, 1913, a Compulsory Vaccination Bill was drafted and submitted to the Government on the recommendation of the State Board of Health. The Bill, however, was rejected on its third reading on 10th October, 1913.

In a report of the Principal Medical Officer of the State Education Department, it is stated that out of 55,740 school children medically examined during 1919, 2,149, or about 6 per cent., had been vaccinated. Since this would include many children vaccinated during the 1913-17 prevalence of small-pox, it must be concluded that the percentage at the present time is considerably below this figure.

Victoria.

The continuance of infantile vaccination in Victoria up to the year 1917 is indicated in Table 29. During the years 1914-15 a Select Committee inquired into and reported upon the efficiency of vaccination and upon the operation of the vaccination laws of the State. The recommendations of the Committee were incorporated in a report on 27th October, 1915. The Committee, in recognizing “ the claims of those who for good and valid reasons oppose the compulsory vaccination of infants," considered that “the Victorian legislation should he brought into line with that of the other States, New Zealand, and Great Britain, and that what is usually termed The conscience clause,’ similar to that contained in the English Act of 1907, should be enacted forthwith." Further recommendations were:—

(1)    That vaccination under the age of two years be prohibited,

except in the presence of an epidemic.

(2)    That vaccination be required before the age of five years.

(3)    That arm-to-arm vaccination be made illegal.

(4)    That the use of calf vaccine prepared under proper pre

cautions be legalized.

(5)    That various amendments in corresponding sections of the

Health Act 1915 be made in accordance with the findings of the Committee.

The Health Act of 1919, incorporating the provision of the conscientious objection clause, came into force in 1920.

. *. . . . *

This provision for a statutory declaration of conscientious objection

to the vaccination of a child is included in section 134 of the Health

Act 1919, the section reading as follows:—

134. (1) Notwithstanding anything in this Part, a parent of any such child shall not be liable to any penalty under the last preceding section if a parent of such child—

(a)    makes within four months of the birth of the child a

statutory declaration that he conscientiously believes that vaccination would be prejudicial to the health of the child ; and

(b)    within seven days after the making of the declaration gives

or sends by registered letter through the post the said declaration to the registrar for the district in which the birth of the child is registered.

(2) Upon receipt of the declaration the said registrar shall give or send by post to the person making the declaration a certificate according to the form in the Seventh Schedule or to the like effect.

(3)    When the said certificate of the registrar has been received by the parent he shall thenceforth not be required to cause the child to be vaccinated.

(4)    The said certificate shall without further proof be admissible as evidence of the making of the statutory declaration.

(5) In the application of this section to a child born before the commencement of this Act, there shall be substituted for the period of four months from the birth of the child the period of four months from the commencement of this Act.    , ^

Section 135 provides for the notification of the police and the institution of inquiry and proceedings for all cases in which at the commencement of each quarter certificates of vaccination or statutory declarations have not been received during the preceding six months.

The form of certificate mentioned in section 134 is as follows:—

Seventh Schedule.

I, the undersigned, hereby certify that (insert name of parent), the parent of (insert name of child), whose birth was registered on the day of    ,19    , has, within four

months of the birth of the said child, made a statutory declaration that the said (insert name of parent) conscientiously believes that vaccination would be prejudicial to the health of the said child, and has within seven days from the making of such statutory declaration delivered the same to me.

Dated this    day of    19    .

(Signed)    C. D.

Registrar of Births and Deaths for the District of    ,

The effect of this measure is evident in the following table, shown in the Second Report of the State Commission of Public Health, 1924, page 10:—

Table 31.—Vaccination in Victoria, 1918-1923.

Year.

JBirths.

Vaccina

tions.

Percentage

of

Vaccinations to Births.

Con

scientious

Objectors.*

Parents

Fined.

Total Cost to State.

Cost to State of each Vaccination.

1918 ..

31,601

15,311

48-4

5,752

£

2,326

£ s. d. 0 3 0

1919 ..

31,621

14,031

44'4

7,852

2,476

0 3 6

1920* ..

36,214

4,396

12-1

22,633

2,865

2,224

0 10 1

1921 ..

35,593

3,915

11-0

21,464

4,488

2,002

0 10 2

] 922 ..

36,288

2,756

7-6

24,062

2,949

1,946

0 14 1

1923 . .

35,876

2,149

59

24,917

2,364

1,833

0 17 0

* Conscience clause came into operation at the beginning of 1920.

The comments of the Commission in regard to these figures are as follows :—

“ During the period 1875 to 1900, 72 per cent, of children born were vaccinated. Since this period there has been a gradual decline in the number of vaccinations. In 1918 the percentage had declined to 48.4, and in 1919 there was a further reduction of 4 per cent, The ‘ conscience clause7 came into operation in 1920. Its effect is clearly shown by the figures for the succeeding years.

The effective return that the State gets for its expenditure in relation to vaccination may he gauged by the number of children immunized against small-pox.

As the State is not getting adequate value for its expenditure, the Commission recommends that vaccination should either be made compulsory or entirely optional.”

Queensland.

Part VII. of the Health Act 1900-1922 provides for compulsory vaccination in Queensland, but its operation has never been proclaimed. Vaccination being purely voluntary, medical practitioners do not notify vaccinations, so that, excepting comments by the Commissioner of Public Health in his annual reports, no exact data of the proportion of the population vaccinated is available, but it is undoubtedly low.

In his report for the year ended 30th June, 1911 (page 9), Dr. J. S. C. Elkington, Commissioner of Public Health for Queensland, in noting the danger of cases of small-pox landing in the incubation period from vessels coming from infected ports oversea, comments on the limitations of maritime quarantine in this regard, and states that “ The only real defence against the spread of epidemic exotic disease is to be found in the organization and powers provided by the State. In respect of small-pox this implies compulsory and closely enforced laws for vaccination and revaccination such as exist in Sweden and Germany.” In regard to the practicability of such legislation in Queensland, Dr. Elkington continues: “nevertheless, I am not at present prepared to recommend the universal application of such statutory power securing vaccination as is available under the Health Act of 1900. Experience has shown that a widespread inability exists amongst a large section of the public to recognize the facts in this particular case and to make the correct deductions from them. Public opinion cannot be driven, and a considerable official relationship with Australian people in three States has convinced me that unless smallpox becomes epidemic, or unless conipulsory vaccination and revaccination are uniformly enforced in every State, enforcement throughout any one State is impracticable as a general measure. Popular education, or the ghastly disease itself, may some day remove this curious and dangerous prejudice.”

In his report for the year ended 30th June, 1912 (Appendix 5, page 21), Dr. Elkington reports on an inspection of the Torres Straits Islands and vaccination of the islanders. The danger of the introduction of small-pox into these islands had already been stressed, and Dr. Elkington’s records are of sufficient interest to be quoted in full.

Vaccination.—One thousand two hundred and seventy-nine natives in all were vaccinated, representing some 71 per cent, of the total estimated population. The absence of a number of young adult males employed in the pearling boats in the Straits accounted in a considerable part for the un vaccinated remainder. The work at Murray Island was hampered somewhat by the uncontrolled enthusiasm displayed in dinghy racing, a recently introduced sport, of which the charms could not be wholly counterbalanced even by Mr. Bruce’s influence in favour of vaccination. (Mr. Bruce was Government teacher at Murray Island.) At Darnley Island the Council disappeared incontinently from the scene of action directly it became apparent that some work would be required for landing supplies for the new school, and vaccination also suffered from this cause. In all other islands visited, practically the whole population came in, and evident enthusiasm was displayed in securing the benefit of the operation, or the honorable and distinguishing mark of a white bandage.

The number of vaccinations according to islands and estimated populations was as follows :—

Table 32.

Island.

Popula

tion.

Number 1 Males

accinated.

Females.

Darnley . . . . . . . . . . . .

320

72

56

Murray . . . . . . . . . . . .

449

136

145

Stephens .. . . . . .. . . ..

30

8

13

Yorke . . .. .. .. .. ..

80

44

31

Cocoanut .. .. .. .. . . ..

70

29

33

Yam . . . . . . .. . . . .

75

30

39

Saibai . . . . . . . . . . . .

300

98

115

Dauan . . .. . . . . .. . .

60

22

22

Boigu . . .. . . . . . . . .

97

46

38

Nagheer . . . . .. . . . . . .

30

13

11

Badu . . .. . . .. .. . .

230

117

91

Moa (Adam Village) .. . . . . . .

70

23

36

The age distribution of persons vaccinated was as follows:—

Table 33.

1-5

Years.

6-10

Years.

11-20

Years.

21-4-0

Years.

Over 40 Years.

Total.

Darnley . . . . . .

19

24

37

36

12

128

Murray . . . . . .

37

46

78

87

33

281

Stephens .. .. ..

9

1

2

7

2

21

Yorke . . . . . .

16

5

8

37

9

75

Cocoanut .. .. ..

14

12

6

19

11

62

Yam . . . . . .

18

14

14

25

9

80

Saibai . . .. . .

58

37

34

56

28

213

Dauan .. . . . .

10

8

11

10

5

44

Boigu . . .. ..

23

14

14

33

11

84

Nagheer .. . . ..

5

6

3

7

3

24

Badu . . . . ..

54

24

40

60

30

208

Moa (Adam Village) . .

19

12

6

17

5

59

282

203

253

394

147

1,279

In no case were any serious results reported to have followed the operation. A few “ bad arms ” doubtless occurred, but this was practically inevitable under the conditions. The site of vaccination was cleaned with water and spirit prior to operation. An antiseptic dressing was applied, and the necessity for cleanly treatment of the vaccination site was impressed on each person. A supply of dressings and ointment was left at each island with instructions for use. The vaccine was supplied from the Melbourne vaccine farm of the Federal Quarantine Bureau, and yielded excellent results. Re-inspection was made at Darnley and \ am Islands only, owing to the weather conditions causing delay in transit, but natives seen at other places enabled an approximate idea to be formed of the results for most of the other islands.. I he case successes appear to have been well over 95 per cent., at a low estimate. The keeping qualities of the vaccine are shown by the fact that after being carried on deck, packed in sawdust and covered with wet bags, in an average atmospheric temperature of over 83 deg. F., an unimpaired reaction of four insertions was obtained in an unvaccinated European from the last vial opened.

One drachm of vaccine was found to afford material for from 150 to 180 persons.”

Amongst the recommendations of Dr. Eikington as a result of his tour in the following {Ibid. p. 26) :—    *

“ (1) An inspection by a medical officer versed in sanitation and tropical medicine should be made on the inhabited islands at least once yearly, with a view to vaccinating children and adults not already protected, assisting the Government teachers with advice and backing in sanitary matters, and keeping the disease question under active observation. If weather conditions permit, this should be made during the north-westerly season, when malaria and dysentery are at their maximum seasonal prevalence.”

The appearance of small-pox in Sydney in July, 1913, provided a stimulus to vaccination, and in his report for the year ended 30th June, 1914, Dr. J. I. Moore, the Commissioner of Public Health, records the control measures adopted and vaccination facilities provided in Queensland :—

‘‘    •    •    • During July of last year, owing to the presence of

this disease in Sydney, stringent measures were immediately taken to protect this State, and, with this end in view, public vaccination dépôts were established at the principal centres, and steps were taken for securing the immediate notification of any suspicious rash illness, such as chicken-pox. The Epidemic Diseases Regulations, which provide ample power for dealing with emergencies, were made applicable to the whole of the State, and materially assisted the Department to cope successfully with the occurrence.

The main gateways of entry into the State were closely guarded by stationing officers at the border, as well as by keeping a close surveillance over traffic arriving by sea, passengers being compelled to produce vaccination certificates and to report at a central dépôt at fixed periods.

The public at the various centres freely availed themselves of vaccination while the scare lasted ; the dépôts were rushed, and all willing hands enlisted; in fact, at times the crowds awaiting vaccination became so unwieldy that the services of the police had to be requisitioned, a course which acted admirably and prevented confusion. ... As the measures taken against the disease continued to prove efficacious, public interest, however, began to wane, with the result that the dépôts, which up to then had been a scene of activity, were practically deserted, and were merely kept open for the convenience of travellers visiting the southern States with the intention of returning to Queensland, and also for the examination of travellers arriving from the southern States.

It is a matter of regret that only about 30,000 people were vaccinated in this State out of a population of 625,555, i.e., less than 5 per cent. .    .    ."

This waning public interest is further evidenced in the report of the Brisbane health officer for the year ended 30th June, 1915 (contained in the Annual Report of the Commissioner of Public Health) :—

With the exception of a few individuals and groups of individuals occasionally who seek the services of this Department in quest of the above previous to proceeding to Hew Guinea and the islands, this prophylactic against small-pox has virtually dropped into abeyance as regards the general population in the metropolitan area. The fact that the precautionary measures established in Hew South Wales against small-pox have been recently raised, all help to nurse and foster the usual self-complacency and false security indulged in by the public when they think that all source of imme-mediate danger has been removed from their midst, and as the popular mind is always swayed by immediate events, and not by possible ultimate consequences, nothing would be gained here by belabouring the point, except to remark in conclusion that it is a regrettable incidence, viewed from the public health point of vantage, should the disease appear in a more virulent form at any time, where it would find an almost non-immune population eminently suitable as a medium for the establishment and development of the causative virus, with speedy infection of susceptible units, the far-reaching results of which would not be pleasant to contemplate.”

These comments may be said to be applicable throughout the period under review up to the present time.

South Australia.

< ompulsory vaccination in South Australia ended with the 1901 Act to abolish compulsory vaccination, which was extended to 1906, again to 1911, and again to 1916, by granting the right to the parent of lodging a declaration of conscientious objection. In 1917, an Act to suspend compulsory vaccination was passed.

I he decline in vaccination reported is shown in Table 20, there being no vaccinations reported in 1923, and only an annual average of five for the past five years.

Western Australia.

In 1909, the \ accination Act of 1878, which made vaccination compulsory, was revised, and the administration and details brought up to <iate. In that year a Bill was introduced to remove the compulsory clauses of the Act, but after passing the Lower House it was rejected by the Upper House. The Legislature struck out, however, the item from which the salary of the compulsory officer was derived, and the services of this officer had to be dispensed with.

In commenting on this in his Annual Report for 1909, the President of the Central Board remarks, “ As it is, only about 10 per cent, of those born in recent years in this State have been vaccinated.”

In the Health Act of 1911, which came into force on 1st June, 1911, the “ conscience clause ” in regard to vaccination was adopted in the following terms :—

Section 231. (1) No parent or other person shall be liable to conviction or to any penalty for neglecting or refusing to have any child vaccinated, or to take or to cause any child to be taken to be vaccinated as a protection against any infectious disease if, within four months from the birth of the child he makes a statutory declaration that he conscientiously believes that vaccination would be prejudicial to the health of the child, and within seven days thereafter delivers the declaration to the district registrar of birth and deaths in the registry district within which the birth of such child was registered.

(2)    A statutory declaration made for the purposes of this section shall be exempt from stamp duty.

(3)    A statutory declaration for the purposes of this section shall be made in the form set out in the Third Schedule to this Act or in a form to the like effect.

THE THIRD SCHEDULE.

Form of Declaration.    .

I;    > °f    , in the State of Western

Australia,    being the parent (or person having the custody)

of a child named    , who was born on    day

of    ,19 .do solemnly and sincerely declare that I

conscientiously believe that vaccination would be prejudicial to the health'

of the child; and I make this solemn declaration by virtue of section one hundred and six of the Evidence Act 1906.

Declared at    this    day of    19

Before me,

Justice of the Peace,

(or as the case may he).

In 1912, only 120 vaccinations with 8,689 births were notified. In

1914,    during the “scare” which arose from the presence of an epidemic ill Sydney, some 400 metropolitan vaccinations were effected, and 3,000 in a population of 4,000 at Bun bury during the local outbreak. For the remainder of the State in that year, however, only 37 vaccinations were reported. Since that date, vaccination has remained practically a “ dead letter,” although all district medical officers are public vaccinators but without fees.

Tasmania.

Under the Vaccination Act of 1898 all infants are nominally required to be vaccinated before the age of twelve months, unless either (a) a statutory declaration of conscientious objection is made, or (b) a medical certificate of unfitness is received. No information in regard to vaccination in recent years is available.

The Extent to which the Australian Community is Protected by Vaccination.

Consideration of the extent to which vaccination has been carried out in the several States during this period indicates that for practical purposes the Australian community is, as a whole, unprotected by vaccination. It is difficult to assess the proportion of vaccinated persons in the community, even in terms of infantile vaccination, without any consideration of the revaccinations necessary to ensure a more complete immunity. In the previous volume, page 132, an approximate estimation was given that, in*1910, some 30 per cent, of all persons in Australia had been vaccinated. During the period 1909 to 1923 the Australian population increased from 4,274,617 to 5,688,903. The reported vaccinations performed by the Government vaccinators have been shown in Table 29. Records of vaccinations performed by general practitioners are not available, but presumably such vaccinations are not numerous. The records of vaccinations performed during the prevalence of smallpox in New South Wales are not complete, but in New South Wales some 500,000 official vaccinations were performed in 1913, 10,000 in

1915,    2,600 in 1916, and 4,600 in 1917. In Victoria, some 160,000 official vaccinations were performed in 1913, and in Queensland some 30,000. No records are available for South Australia or Tasmania. In Western Australia, some 8,000 vaccinations were performed in 1913, and, during the Bunbury outbreak of 1914, 3,000 at Bunbury and 400 at Perth. In addition, during this period there must be included the 270,000 troops who returned from oversea after service in the Australian Imperial Force. That is, as a crude estimate, some 720,000

no

official vaccinations have been performed in addition to those infantile vaccinations regularly reported by Government vaccinators. The proportion of 30 per cent, already given for 1910 may he calculated as approximately the present percentage. The influence of vaccination in its relation to the course and control of epidemic small-pox in Australia is reviewed in Chapter XIII.

CHAPTER X.

VESSELS ARRIVING IN AUSTRALIAN WATERS WHICH HAVE BEEN INFECTED WITH SMALL-POX DURING THE VOYAGE, OR WHICH WERE INFECTED ON ARRIVAL.

In order to bring together the records of vessels quarantined in Australia for small-pox during the period under review, it is necessary to group these vessels in categories which will present the epidemiological circumstances in a more or less comparable manner. In order to do this, a classification has been made according to whether a vessel actually arrived with a case or cases of small-pox on hoard, either developed or incubating, or whether a vq^sel had landed a case at an oversea port or buried a case at sea prior to arrival. In addition, one vessel not handled in quarantine was subsequently shown to have been concerned with the introduction of small-pox into Australia. Vessels trading coastwise and infected locally during the presence of small-pox in Australia, as well as vessels held temporarily on account of the existence on hoard of cases definitely suspicious of small-pox, are listed separately. The arrangement is chronological, and a departure has been made from the classification used in the previous volume (Chapter X.), where vessels are listed according to the ports at which quarantine was enforced. Under the existing quarantine procedure, as already detailed in Chapter I., vessels are permitted to continue the voyage along the Australian coast in quarantine, whilst under Commonwealth control a uniform quarantine practice is adopted and uniform records are compiled at each port called at. Under the special geographical circumstances of Australian oversea traffic, this means that before the arrival of a vessel at the terminal port of the voyage, the quarantine period has practically expired, measures of vaccination and disinfection have been effected, and the time lost by the vessel on the coast is reduced to a minimum. It will be shown that the menace of small-pox is greatest from the north and the west, and vessels using these routes usually make Melbourne or Sydney a terminal port, so that in many cases vessels may call at three or even more ports at which they are handled in quarantine—a procedure in which uniformity could only be attained under a system of Comlmonwealth control.

Ill

Table 34.—Vessels Quarantined in Australian Ports for Small-pox, 1909-1923.

Year.

(A) .

Vessels which have arrived in Australian Ports with Small-pox on Board.

(Total, 60.)

(B)

Vessels which have arrived in Australian Pf rts, having landed one or more Cases at an Oversea Port, or having had Cases on Board who Died and were Buried at Sea.

(Total, 22)

(C)

Vessel not Quarantined, but subsequently shown to have been concerned with the introduction of Small-pox into Australia.

(Total, 1.)

(D)

Coastwise Vessels which have had Small-pox Cases developed on Board.

(Total, 6.)

(12)

Vessels which leave been Quarantined, having©» Board one ©r more Cases: suspected to he Small-pox.

(Total, 12.)

1909

1.    Paroo . .

2.    Redbridge

61. Empire

1910

1911

1912

3.    Otway . .

4.    Kazemke.

5.    Mooltan

6.    Narrung

7.    Van Lins-choten

8.    Eastern

9.    Taiyuan

10.    Malwa ..

11.    Changsha

12.    Yawata

Mara

13.    Prinz

Sigismund

62.    Charon

63.    Prinz Wal

demar

64.    Empire

65.    Mon toro

66.    Montoro

Navarro

1913

14.    Matararn

15.    Eastern . .

16.    Barr along

17.    E. J. Spence

18.    Brunner

19.    Malwa

67.    Pera . .

68.    Snow-

donian

83. Zealandia

84.    Karoo la

85.    Mongolia

Baron Fair It*

1914

20. Orsova ..

86. Caledonian

Prinz Stgtt-

21.    K ilchattan

22.    Runic

87. Karoola

mund

1915

23.    Urlana . .

24.    Umballa

25.    Gregory

A pear

26.    Chanda

27.    Transport

H. 2

28.    Morea

29.    Lord Derby

30.    City of

Baroda

69.    Knight

Templar

70.    Chindwarra

88. Wodonga

1916

31. Clan Mac-

71. Willochra

89. Yulgilbar

Orsova

Corquodale

72. Katuna

Uganda

1917

i

1919

32.    Nikko Maru

33.    Eastern

34.    St. Albans

35.    Argonne

36.    Eastern

37.    St. Albans

38.    War Ar

mour

39.    Eastern

40.    Khyber

41.    Rio Pardo

73.    Port Sydney

74.    Ulimaroa

75.    Euripides

76.    Karoa

77.    War Ar-mour

1

Empire

Table 34.—Vessels Quarantined in Australian Ports for Small-pox, 1909-1923—continued.

Year.

(A)

Vessels which have arrived in Australian Ports with Small-pox on Board.

(Total, 60.)

(B)

Vessels which have arrived in Australian Ports, having landed one or more Cases at an Oversea Port, or having had Cases on Board wrho Died and were Buried at Sea.

(Total, 22.)

(0)

Vessel not Quarantined , but subsequently shown to have been concerned with the introduction of Small-pox into Australia.

(Total, 1.)

(I>)

Coastwise Vessels which have had Small-pox Cases developed on Board.

(Total, 6.)

(E)

Vessels which have been Quarantined, having on Board one or more Cases suspected to be Small-pox.

(Total, 12.)

1920

42. Ceramic..

78. Roggeyeen

St. Antoine Y arroppa Maru

1921

1922

43.    Ventura..

44.    Kanowna

45.    Gracchus

46.    Niagara

47.    Victoria . .

48.    Teespool

49.    Clan Mur

ray

50.    CAerie

51.    Banna

52.    Shelley

53.    St. Albans

54.    Montoro

55.    Clan Mac

William

56.    Huntress

79.    Montoro

80.    Changsha

*

Wonganella

1923

57.    Victoria. .

58.    Eastern

59.    Taiyuan

60.    Sussex

81.    Eastern . .

82.    Maicura

Esperance Bay

Rotenfels

Gracchus

The quarantine histories of these vessels can now be considered in detail, in chronological sequence according to the serial number allotted to each vessel in the above table. In a subsequent chapter (Chapter X.), the epidemiology of small-pox as it occurred on these vessels can be reviewed on a comparative basis.

A.—Vessels which Arrived in Australian Ports with Small-pox on Board.

No. 1.ParooT

1909.—On 17th February, 1909, the steamer Paroo arrived at Broome with one of the crew, a quarter-master, suffering from smallpox. I he vessel had left Singapore on 10th February, having on board mails, cargo, and 66 Asiatics proceeding to Broome under engagement to the owners of the pearling fleets. The patient became ill one day out from Singapore, 11th February. The rash appeared on 15th, and two days later fhe temperature was normal. (This patient had a temperature of 105 at Sourabaya, and had not been identified as suffering from small-pox.) The ship’s crew and the 66 contract labourers were all certified at Singapore as having been recently successfully vaccinated. On 19th February, tlie 66 Asiatics were transferred to a schooner anchored in the harbour at Broome, and the}7 all remained there in quarantine until released. The patient was landed on 19th February with two attendants, and died on the 21st. The attendants were then, after disinfection measures, re-embarked in isolation on the Faroe. The whole of the ship’s company—officers, passengers and crew—were vaccinated on 21st February, and on 22nd February the Paroo left Broome, and proceeded in quarantine to Fremantle. The mails had been landed at Broome on the 19th, and all cargo was carried on to Fremantle, the vessel never having come alongside. These Asiatics, who had been transferred to the schooner at Broome, were all vaccinated, the majority of them bearing marks of recent efficient vaccination. On 7th March, one of these Asiatics became ill, and was landed within, the quarantine compound on suspicion. On 10th March this case was diagnosed as variola benigna, and the Asiatics on the schooner were again vaccinated. No further cases developed amongst these Asiatics, and all were released from quarantine and landed from the schooner on 27th March. On 8th April, the patient was discharged from the quarantine hospital. The evidences of previous vaccination of the Asiatics, who had been removed on the 19th, may be summarized as follows:—1 ive of the men showed marks which could be described as good, and 23 marks could be described as slight. Twenty-six of them showed the remains of vaccination which had. been performed at Singapore, while all the others showed good recent marks. No further cases developed either on the schooner or in Broome.

The Paroo continued her journey and arrived at Fremantle on 28th February, not having touched at any port except Geraldton, and then only in strict quarantine, for the purpose of discharging some cargo.

On arrival at Fremantle there were no cases of small-pox on board. The vessel was placed in quarantine and sent to Owen’s Anchorage. On 2nd March, three of the crew were isolated on board on account of their being ill. On 4th March, one case of small-pox was landed from the boat at the quarantine station, and on 5th March, three more cases were landed. The passengers for Fremantle and the Quarantine Officer, who had been on board supervising, were all landed at the quarantine station, and the vessel, after fumigating at Fremantle, proceeded in strict quarantine to Singapore (calling at Cossack Boads for some cargo).

No further cases were reported, either at the station or on board. On 19th March the contacts, and on 28th April the patients, were released from quarantine.

There were no deaths among the patients at Fremantle, but the first case died at Broome.

i he vaccination at Broome could not have been effective in those cases which developed at Fremantle, but there is no record to this effect.

No. 2.—“ Redbridge.”

1909.— The steamer Redbridge arrived at Bunbury, 27th February, 1909, with one case of small-pox on board, and reported the death of the captain during the voyage. The steamer left Calcutta on 6th February. The captain became ill on the 8th, complaining of very severe headache, and he died on the 11th, only a few spots having been noticed on his face. The man who was sick on arrival at Bun bury was a fireman, a European, wdio first became sick on 15th February (that is, the tenth day from Calcutta). The spots first appeared on the 17th, and on arrival at Bunbury the rash was beginning to disappear. He had been vaccinated in early adult life. These twro—the captain and the fireman—were the only two of the ship’s company affected, and as the boat had been 21 days at sea when she reached Bunbury, there had been time tor other, even secondary, cases to arise, and although the whole ship s company ivas vaccinated at Bunbury, this vaccination cannot have played much part in preventing the spread of the disease. The origin of the small-pox on this ship is very obscure. The vessel had been for some weeks at Calcutta before leaving for Bunbury, to which port she came direct, and it is clear that the captain and the fireman contracted the disease before leaving Calcutta, and it is therefore probable that the two cases arose from two different sources of infection. (As the ship carried no doctor it must remain uncertain whether the captain died from small-pox or not.) The patient was isolated on shore at Bunbury, and no further case arose.

No. 3.—“ Otway/'

1910.—This vessel arrived at Fremantle on 22nd March, 1910, from London via Suez Canal and Colombo (12th March).

At Fremantle the vessel was boarded by the local quarantine officer. Preliminary inquiries elicited no information as to the presence of any disease on board, nor did the ship’s papers or the health report reveal anything of a suspicious character. The subsequent quarantine inspection disclosed the presence of a convalescing case of small-pox in the isolation hospital. The vessel wras ordered into quarantine, and the patient was removed to the Quarantine Station at Woodman’s Point, together with the whole of the Western Australian passengers, 136 in number, who were straightway vaccinated. Three cases of small-pox (infected prior to the arrival of the vessel at Fremantle) subsequently developed in quarantine among the third-class passengers at Woodman’s Point.

The disinfection ot the ship's isolation hospital was ordered by the Quarantine Officer, and was undertaken by the ship’s surgeon. No vaccination had been carried out during the voyage, and only a few tubes of lymph were carried. Sufficient lymph to vaccinate 1,000 persons was therefore placed on board, and general vaccination was urged by the Deputy Chief Quarantine Officer.

The vessel left Fremantle for Adelaide on the evening of the same day (22nd), and reached Adelaide early on 26th March. No further cases of small-pox had occurred, but two days after leaving Fremantle a girl who had developed sores on the face, neck and arms was placed with her mother in the isolation hospital previously occupied by the original case of small-pox. The girl was seen by the Quarantine Officer on arrival at Adelaide, and the case was diagnosed as one of impetigo; there was at that stage apparently nothing suggestive of small-pox.

The Adelaide passengers, 17 in number, were landed in quarantine, and those found to be properly vaccinated were released under quarantine surveillance after proper disinfection. No case of small-pox occurred amongst these passengers.

On arrival at Melbourne (Hobson's Bay) on 28th March no developed cases were found, but several passengers were under suspicion, and on the following day the Otway proceeded to the Quarantine Station at Point Nepean to land these cases together with the Victorian passengers. A heavy fog prevented the arrival of the vessel until the morning of the 30th. One hundred and fifty-four passengers were landed in quarantine pending a complete investigation of tlieir vaccination history and of the evidence of contact with the first case. Three cases of small-pox were placed in the isolation hospital, and other suspicious cases were kept under observation. During the next eight days five more cases of the disease occurred. With the exception of one, a third class stewardess who had waited on the first case during the first few days of his illness, all were third class passengers, and the infection could be dated to the period prior to the arrival of the vessel at Fremantle in every case but one. This case, which proved fatal, was that of the mother of the girl who had been placed in the isolation hospital on the Otway two days after leaving Fremantle. Of the eight cases, three died from haemorrhagic small-pox.

The Otway left Point Nepean for Sydney on 30th March; two further cases developed before arrival there. These and other suspicious cases were isolated in hospital at the Quarantine Station, North Head; the remaining passengers (about 500) with some of the crew were placed in quarantine at the station, and the rest of the ship’s company (between 200 and 300) were placed on board a steamer chartered for the purpose. Four cases of small-pox, with one death, occurred, all being third class passengers.

Quarantine was raised in the several States on the following dates:— Adelaide on 16th April, Sydney on 13th May, Fremantle on 17th May, and Melbourne on 15th June. In all, seventeen cases of smallpox occurred, with four deaths. Four of the seventeen cases presented no evidence or signs of vaccination, and of these two were fatal. The remaining thirteen showed signs of more or less satisfactory primary vaccinations, and one had been revaccinated 23 years ago. Of the thirteen cases two were fatal, one being that of a passenger who was, when attacked by small-pox, already seriously ill from another cause, fn all but four of the vaccinated patients the disease was very mild (varioloid), and in the only child affected there was no constitutional disturbance and, not more than 50 spots.

Origin and Evolution of the Outbreaks.

I he outbreak evidently originated with a boy who with his mother (both from Bombay) joined the vessel at Colombo on 12th March, 1910, as third class passengers. The boy was ill when he went on board, having a high temperature, headache, and other symptoms of fever. W ith his mother he was accommodated among the other third-class passengers. During the evening the fever appears to have risen considerably, and the disease was diagnosed as “ sun fever ” and treated by cold (iced) baths. The mother states that a rash appeared on the 13th March, and was seen on the 14th by the ship’s surgeon, who attributed it to the cold baths. The eruption developed and became pustular. The boy and his mother were removed to ^ie isolation hospital. The date on which the boy was placed in the hospital is uncertain, as contradictory statements have been made on this point; it was, however, not later than 17th March. It is clear that isolation was far from complete, for the mother and other passengers state that while the boy was confined to the hospital the mother, who occupied the hospital with him and nursed him, visited the third class lavatories and went to and from the dispensary, coming in contact with other third class passengers. The mother states that she was furnished with a needle and carbolic lotion, being instructed at the same time to empty the pustules and to swab them with the lotion. The ship’s surgeon visited the patient from time to time, as also did the surgeon’s orderly, who, it is stated, attended a third class passenger in connexion with another illness, who subsequently developed small-pox and died (case jST.). The stewardess who attended to the boy in the cabin during the first few days of his illness, carrying out at the same time her ordinary duties, subsequently developed small-pox, apparently contracted on 14th March, 1910.

On arrival at Fremantle, the boy from Colombo, then convalescent, was found by the Quarantine Officer at the door of the isolation hospital.

From the information available it would appear that the third-class passengers were exposed to infection from the first case during the greater part if not the whole of the voyage between Colombo and Fremantle; the development of subsequent cases proves that some at least were so exposed.

The following statement shows the order of development of the secondary cases, and the probable date of infection in each case:—

Date of Onset.

Probable Date of Infection.

Primary Case.

A. (W.G.) Ill when he went on board the Otway at Colombo

Secondary Cases.

March 11-12

B. (E.N.) Stewardess attending to A and waiting on other Third Class Passengers

March 26-27 . .

March 13-14

C. (K.C.) Third Class Passenger . . . .

. .

D. (J.S.) „ „ „ .. ..

March 27 ..

March 14

E. (S.F.) „ „ .. ..

99 . . '

,,

F. (C.K.) „ „ „ .. ..

March 28 . .

March 15

G. (G.C.) „ „ „ .. ..

H. (T.W.) „ „ „ .. ..

I. (E.S.) „ „ „ .. ..

J. (J.G.) „ „ „ .. ..

K. (N.W.) „ „ „ .. ..

. .

L. (V.N.) „ „ „ . . ..

March 29 . .

March 16

M. (C.L.) „ „ „ .. ..

March 30 . .

March 17

N. (A.S.) „ „ „ .. ..

April 2 . .

March 20

0. (S,C.) „ „ „ .. ..

P.    (H.S.) „ „ „ .. ..

Q.    (O.H.) Third Class Passenger who was placed

with her daughter on March 24 in Isolation Hospital on the Otway previously occupied by Case A

April 4 ..

March 22

April 6-7 . .

March 24-25

The vaccination condition of the patients may be summarized as follows :—

Case A, œt. 10.—dST.o evidence of vaccination in infancy. Had been vaccinated nine months previously without result. Severe attack.

Case B, œt. 27.—Good primary vaccination in infancy. Light attack.

Case C, œt. 20.—Primary vaccination in infancy. Alleged revaccination without any signs of success. Modified attack.

Case D, œt. 32.—Primary infantile vaccination, fair results. Not revaccinated. Modified attack with mild constitutional reaction.

Case, E, œt. 29.—Vaccinated in infancy, two scars. Not revaccinated. Mild attack.

Case F, œt. 36.—Vaccination in infancy, one large shallow cicatrix with poor foveation. Bevaccinated 23rd March, 1910, with typical reaction. Mild attack.

Case G, œt. 17.—Vaccination at the age of ten years. Very mild attack.

Case H, cet. 45.—Vaccination alleged at the age of 38, result doubtful. Haemorrhagic small-pox. Fatal.

Case I, cet. 32.—Vaccinated in infancy, one good scar. Not revaccinated. Mild case.

Case J, cet. 24.—Vaccinated in infancy. Not revaccinated. Severe attack.

Case K, cet. 2|v—Unvaccinated.    Mild attack.

Case L, cet. 25.—Vaccinated in infancy. Moderate attack.

Case M, cet. 42.—'Vaccinated in infancy. Revaccinated 23 years ago. Well-marked cicatrices for both vaccinations. Vaccinated again 23rd March, 1910, with good result. Very mild attack.

Case N, cet 35.—Unvaceinated. Haemorrhagic small-pox. Fatal.

Case O, cet. 4.—Well vaccinated in infancy. Very mild attack.

Case P, cet. 35.—Vaccinated in infancy. Haemorrhagic smallpox. Fatal. This patient had not been in good health for previous eleven years.

Case Q, cet. 36.—Vaccinated in infancy. Haemorrhagic smallpox. Fatal.

The history of this outbreak is peculiarly instructive. In the first place there is the fact that the disease was introduced to the ship by a passenger who, previously resident in India, boarded the vessel at Colombo in such a condition that the suspicions of the ship’s officials should have been aroused. In fact, with a perfect system of international control, the patient should not have been allowed by the shore officials to join the ship.

The greatest interest attaches to the limitation of the outbreak. During the voyage from Colombo to Fremantle the ship’s company consisted of 1,129 souls distributed throughout the ship as follows:—

First class . . . .

. . . . 69

Second class . . . .

. . . . 90

Third class . . . .

. . . .' 644

Crew . . . . . .

.. .. 326

Amongst this large company there developed altogether sixteen cases in addition to the original case. There occurred no case amongst either the first class or the second class passengers, and amongst the crew only one stewardess was affected. The epidemic was limited to the third class, amongst whom fifteen cases occurred. There were in all 644 third class passengers, all confined within a very restricted space, and all in constant mutual contact, yet the spread of infection was limited to one stewardess and fifteen secondary cases. In only one of these cases was the probable date of infection later than thq day of the removal of the patient from the ship at Fremantle. This exception was case Q, who was placed in the isolation hospital after the patient had been removed. It has been already stated that the stewardess had been especially exposed to infection.

Can any reason be assigned for this limitation of the infection to a comparatively small number of cases? Two factors might be postulated as possibly concerned, The ship’s company might have been protected by vaccination, or some special degree or kind of contact might have been necessary for successful infection.

hfothing is now known, as records are not available, of the vaccination condition of the ship’s company generally. It may be presumed that there was a certain proportion of the ship’s company quite unprotected by vaccination. But as there were fourteen persons amongst the sixteen secondary cases who had been vaccinated, it can hardly be thought that the incidence of secondary cases was determined by the distribution of non-immunity amongst the ship’s population.

The degree of contact with the initial case is naturally difficult to establish, but one of the present writers (J.H.L.C.) made careful inquiries at the time, and, so far as could be ascertained the only cases which showed any degree of known contact with case A were cases B, I, J, and Q, and the contact in cases I and J was of an indefinite kind. Case I occupied a cabin in the same passage as, and just opposite to, the cabin occupied by case A ; and case J slept on deck 2 yards away from case A the first night out from Colombo.

It has been stated above that vaccination was very incomplete, even after the case had been discovered at Fremantle, while prior to reaching Fremantle no attempt at vaccination had been made.

It is also definite that no attempt at isolation was made for the first few days after the first case came on board, and that even after isolation was nominally begun there is reason for grave doubts as to its completeness. It may be assumed that there was no effective limitation to the spread of infection for the greater part of the time.

Taking all the facts into consideration there is a certain amount of justification for the hypothesis that in this epidemic the virus of the disease was characterized by a short range of infectivity ; and it is further legitimate to say that the factors upon which the selection of secondary cases depends are not certainly evident.

The virus was potent enough, as witness two severe cases, and four-fatal haemorrhagic attacks; and as witness also the high incidence on vaccinated persons. Nevertheless, with every opportunity for dramatic and widespread extension, the disease was limited to the third-class passengers, and to only 2.3 per cent, of these. As protection by vaccination cannot be invoked, nor special exposure proven in explanation, it must be admitted that the epidemiological factor which determined the incidence is uncertain.

No. 4.—“ Kazembe. '

1910.—This vessel left Singapore on 17th August, 1910, in ballast, and arrived at Port Pirie on 4th September. There were on board a crew of 63, consisting of 9 European officers and 54 lascars, who had joined the vessel at Calcutta prior to the departure of the vessel for Singapore. Fumigation had been carried out at Singapore. When twelve days out from Singapore (29th August) a lasear fireman reported sick, and being diagnosed by the master as a case of small-pox he was isolated with an attendant in one of the empty holds. On arrival at Port Pirie on 4th September the case presented scabbing from a pustular eruption on the face, arms, and legs. The vessel was quarantined and ordered to return to Port Adelaide, where the case and two immediate contacts were landed to the Quarantine Station. The remainder of the crew were vaccinated, and personal disinfection carried out, and the vessel disinfected. The vessel with the crew under surveillance returned to Port Pirie on 8th October. On 13th September the health officer at Port Pirie discovered two fresh cases on board amongst lasear firemen. Both had been vaccinated some years before, and the attacks were’ mild in type. The vessel returned to Port Adelaide on 14th September, and the two cases and seven of the crew who were “ imperfectly protected by vaccination ” were landed to the quarantine station. All contacts who had boarded the vessel at Port Pirie were vaccinated. The vessel returned to Port Pirie on 24th September, and after loading proceeded to Sydney. On arrival at that port on 3rd October one fireman was found to be suffering from fever, and the vessel was detained at the quarantine anchorage till the following day when the case was diagnosed as not small-pox, and pratique was granted. The cases and the contacts quarantined at Adelaide were released on 26th October to rejoin the vessel on her outward voyage. In this vessel, as in the case of the Otway, there is an incidence of infection for which the reason is not quite apparent. Amongst 54 lascars exposed to infection there were two secondary cases, both of whom had been vaccinated some years before, and at least seven of the crew who were “ imperfectly protected by vaccination ” who did not develop the disease.

No. 5.—“ MooltanT

1911.—This vessel arrived at Fremantle on 11th April, 1911, from London via ports, the last oversea port of call being Colombo (1st April). There were on board a crew of 317 (121 European, 196 lascars), and 248 passengers. No sickness was reported at Fremantle, and pratique was granted; twelve oversea passengers landing at that port. On the evening after leaving Fremantle (11th April), IT.J.B., a second class passenger, reported sick with a temperature of 101.6 deg., headache, and vomiting, and stated that he had been feeling sick for

two or three days. On 12th April he was removed to the hospital, which was situated on the spar deck between the after entrance to alley-ways, and situated between the engineers’ quarters and the barber’s shop. Although strict supervision and care was exercised by the surgeon, it is probable that traffic past the hospital was considerable. A diagnosis of typhoid fever was suspected, and on examining the abdomen for rose spots, one or two quite atypical spots were found between the umbilicus and pubes. On the morning of 13th April a rash was apparent around the mouth, quite distinct from a pre-existing acne. On 13th April the temperature was 104 deg. This fell on the 14th April, when the rash had developed and small-pox was diagnosed. The father of the patient stated that he had not been vaccinated in infancy, but had a doubtful vaccination result in India three years previously. The patient with his father had come from Poonah, India, and embarked at Bombay on 25th March on s.s. Assaye, transhipping at Colombo on 1st April to Tt.M.S. Mooli an,. On confirmation of a diagnosis of small-pox on 14tli April the surgeon proceeded to vaccinate all passengers and crew. The crew had for the most part been vaccinated throughout a year previously.

On arrival at Adelaide on 15th April the diagnosis was confirmed, and the vessel ordered into quarantine. The case wTas landed to quarantine together with immediate contacts and 80 local passengers. The vessel proceeded in quarantine to Melbourne, where persons unsuccessfully vaccinated were revaccinated, and 94 local passengers landed to quarantine. On arrival at Sydney on 22nd April the remaining passengers and all the crew excepting an anchor watch were landed to the Quarantine Station. On 26th April after disinfection the vessel was handed over to a scratch crew from the shore, and taken to a berth. On 27th April all crew and remaining passengers were released at Sydney; at Melbourne and at Adelaide twelve remained at that date pending completion of the vaccination period, and six who had refused vaccination.    All were released on expiry of the quarantine period on 3rd May.    The case was discharged recovered on 10th

June.

Kecords of the vaccination histories of the immediate contacts are not complete, but amongst the second class passengers with whom the case mixed from onset of illness (about 9th April) till hospitalized on 12th April, of the total of 137, only eleven appear to have been sufficiently protected to warrant release under surveillance on arrival. By 27th April an additional 120 had been released, apparently on a successful vaccination carried out on board or revaccination on arrival at the quarantine stations. The crew were apparently well protected from vaccination effected a year previously. The saloon passengers would presumably be unlikely to come into direct contact with the case, although the proximity of the hospital to the barber’s cabin made possible some degree of exposure. Of the saloon passengers apparently 109 were sufficiently well protected to be released under surveillance immediately after disinfection on arrival.

No. 6.—“■ Nauru,\g.”

1911.—This vessel of the Peninsular and Oriental branch line arrived at Adelaide on 15th May, 1911, from London (29th March! via Cape Town (24th April). There were on board a crew of 100 and 278 one-class passengers (19 for Adelaide, 91 for Melbourne, and 168 for Sydney). On arrival the ship’s surgeon reported that there had been during the voyage a sequence of cases diagnosed as varicella and one case, possibly, variola. The cases were as follows:—

N.D., female, cet. 6, passenger, onset 31st March.

C.D.L., male, cet. 19, steward, onset 14th April.

M.N., female,    cet.    1,    passenger, onset    16th April.

M.M., female,    cet.    6,    passenger, onset    16th April.

W.M., female,    cet.    6,    passenger, onset    1st May.

Each case had been isolated on onset and quarters fumigated. The case C.D.L., who was considered as a possible case of variola, was isolated in a cabin on the upper deck, next to a case of varicella. The attendant, a stowaway, revaccinated severa^ times in the Army, slept by himself in a cabin on the well deck, and left his overalls behind him on each visit. The history of the case showed that he had reported sick on 14th April with severe headache and backache, and a rash which had appeared the previous day on palms of hands, face, neck, trunk, and limbs. The rash was polymorphous, but mostly vesicular. He was better on 15th April, but the rash was present in all stages, papules, vesicles, and pustules. His vaccination history was not recorded. On arrival at Cape Town on 24th April the port health officer would not commit himself to a diagnosis in regard to the case C.D.L., but recommended vaccination of all on board. This was effected by the ship’s surgeon, 90 per cent, successful vaccinations being recorded. On arrival at Adelaide on 15th May the cases were all convalescent. In the cases of the children the quarantine officers concurred in the diagnosis of varicella, confirmed in one case by the disease appearing after a good vaccination result, and in another by a subsequent successful vaccination. The case C.D.L. still- showed fading spots of the eruption on the body and pitting of the face, forehead, and malar prominences, and a diagnosis of variola was made. The vessel was ordered into quarantine, the case and the attendant landed to the Quarantine Station, from which he was subsequently released on 16th June. Local passengers were landed to the Quarantine Station, but released after disinfection. The vessel left Adelaide on 20th May, arrived at Melbourne on 22nd May, when 111 passengers were landed and released after personal and baggage description, on

an undertaking to report any sickness tkat might occur amongst them or their families. Cargo was lightered for the port, and the vessel proceeded to Sydney, where 147 passengers wTere released after disinfection, and the crew disinfected and released on 31st May. JNTo further sickness occurred. Detailed records of exposure, close contacts, and vaccination histories are not available. The 90 per cent, successful vaccinations claimed by the surgeon would imply a poorly protected population. Yet no other case occurred amongst other stewards or passengers, although the steward did not report until the following day after appearance of the rash. From the time of his reporting sick isolation was probably effective.

Yo. 7.Van LinschotenV

1911.-—This vessel left Batavia on list August, 1911, and arrived at Brisbane on 30th August via Semarang (12th-13th August). Soura-baya (13th-14tk August), Thursday Island (22nd August), and Port Moresby (24th August). There were on board a crew of 111 (14 Europeans and 97 Javanese) and 32 passengers (25 saloon and 7 steerage).

On 26th August Madame de S., cet. 27, saloon passenger, who had joined the vessel at Batavia on 11th August, took ill with vomiting, which she attributed to drinking flat wine. On 27th August vomiting continued, the temperature was 102 deg., but there was no pain or malaise. On the morning of 29th August a rash was noticed about the neck and then spread over the body. On 30th August, on examination by the quarantine officer at Brisbane, her temperature was 102.5 deg., pulse 116, she was vomiting frequently, and there was a diffuse erythematous rash about the face and back, more discrete on the body. The hands were involved, but not the feet or legs. There were no definite papules, but some vesicles about the neck. The patient had been taking quinine gr. x for several days. Vaccination had been done in infancy, showing two scars, one poor. Revaccination was said to have been done ten years previously. The patient had had two attacks of measles. A diagnosis of general erythema was made, and confirmed by a second quarantine officer. Pratique was granted for Brisbane, but the master of the vessel was instructed to isolate the patient and to report the case to the quarantine officer at Sydney immediately on arrival. The vessel left the same day for Sydney. The patient was not isolated, but continued to occupy her cabin on the saloon deck, almost at the foot of the companion way to the boat deck.

The vessel arrived in Sydney on 1st September. On examination of the case the rash was found present on the face, body, and extremities, the face being suffused and full. There were numerous papules on palms of hands and a few on the soles of feet. There were vesicles under a bangle on the right arm. Temperature was 100.2 deg. After consultation a diagnosis of variola was made, and the vessel C.7279.—-j    '

ordered into quarantine. The case was at once isolated, and landed to quarantine the following day. Vaccination of all on hoard was proceeded with, and passengers were landed to the Quarantine Station, where personal and luggage disinfection was carried out. The vessel was disinfected. Brisbane was notified of the circumstances, and all local passengers and contacts traced, vaccinated, and quarantined. Passengers were released under surveillance on showing successful vaccination, and all except the immediate close contacts were released by 19th September. The vessel with the crew under surveillance left for Melbourne on 14th September, and remained under surveillance until expiry of the quarantine period on 26th September. The case developed a high secondary fever on 6th September. Dysentery, from which the patient had suffered in Java nine months previously, was troublesome from 9th to 14th September. Severe pain over the liver region set in with tenderness and distension of the abdomen. By 19th September a pyaemic condition with several crops of boils supervened, and on 25th September the patient died, probably from a portal pyaemia.

The vaccination histories of the 31 passengers (excluding the patient) showed that 22 had scars of infantile vaccination, twenty showing good scars. Of these fifteen had been revaccinated, one two months before, three others under five years,, three six years, three nine years, two under fifteen years, and two thirty years previously. Of the nine passengers not vaccinated in infancy, five had been vaccinated at various periods previously, one under one year, two under three years, and two at eleven years previously. Three passengers had never been vaccinated, and one showed no record. On revaccination on board, of the 22 vaccinated in infancy:—

Of the 15 who had been re vaccinated, three were successfully vaccinated on the first occasion, and eleven were reported as successfully vaccinated on a second insertion, one infant was not revaccinated.

Of the seven who had never been revaccinated, all were successfully vaccinated on the first insertion.

Of the five wdio had been vaccinated later than infancy, three were successfully vaccinated on the second insertion, one was not successfully, and one child was not revaccinated.

Of the three who had never been vaccinated all were successfully vaccinated in four places on the first insertion on board.

Although isolation on board was in no wise complete, and probably considerable traffic from the saloon deck to the boat deck passed the door of the patient’s cabin, there was no extension of infection.

No. 8.—“ Eastern.”

1911.—This vessel left Kobe on 8th September, 1911, and arrived at Darwin on 29th September, via Moji (9th September), Shanghai (llth-12th September), Hong Kong (15th-20th September), and

Timordilly (27th September). There were on board a crew of 87 (14 Europeans and 73 Asiatics) and 288 passengers (23 saloon, 30 second class, 144 steerage (Asiatics), and 91 deck (Malays)).

On arrival at Darwin (29th September) the surgeon reported that a Chinese fireman, cet. 36, had complained of illness on 27th September. On arrival this patient showed a temperature of 101 deg. and indefinite symptoms. A provisional diagnosis of typhoid fever was made, and limited pratique granted to the vessel. The vessel left the same day for Thursday Island, and that evening the patient developed a papular rash, temperature 104 deg., with severe constitutional symptoms. The papules became haemorrhagic, and delirium set in, and the patient died at midnight on 30th September. He was buried at sea, his effects thrown overboard, and the hospital fumigated. This man’s quarters had been in the port alley-way immediately opposite the engine-room and stokehold, and so were not convenient for isolation. On his becoming sick he was placed in a temporary structure on the main deck, which was removed after his death to the after awning deck after thorough washing.

The surgeon proceeded to vaccinate all on board. On arrival at Thursday Island, on 1st October, the vessel was ordered into quarantine, vaccination completed of all on board, disinfection effected, and the vessel ordered direct to Sydney on 4th October. The vessel arrived at Sydney on 11th October. Ho further cases of suspicious illness had occurred, but a Chinese fireman had died just prior to arrival. He had suffered previously from pulmonary tuberculosis and heart failure. The vessel after disinfection was handed over to a scratch crew from the shore on 16th October. Passengers were released on 20th October. The 91 Malay deck passengers were detained and placed on board for return to Thursday Island on the outward voyage of the vessel.

The detailed contact and vaccination histories are not complete, but of the vaccinations carried out at Thursday Islajnd only fifteen were successful. Of the vaccinations carried out at Sydney, of 363 vaccinated, 250 (or 68.9 per cent.) proved successful. As giving some indication of the vaccination status of each group on board, the following data were recorded, showing the successful vaccinations per cent, of those vaccinated :—

43.75

per

cent.

33.33

per

cent.

30.0

per

cent.

77.1

per

cent.

76.92

per

cent.

46.15

per

cent.

66.7

per

cent.


Passengers, European, Saloon    . .

Passengers, European, Second Class Passengers, Chinese,    Second Class

Passengers, Chinese,    Steerage    . .

Passengers, Malays,    Deck    .    .

Crew, European    . .    . .

Crew, Asiatics . .    . .    . .

No. 9.—Taiyuax.

1912.—This vessel arrived at Darwin on 2nd January, 1912, from Hong Kong (22nd December, 1911), via Manila (26th December), and Zamboanga (28th December). There were on board a crew of 72 (12 Europeans, 2 Malay quartermasters, and 58 Chinese), with 63 passengers (5 Europeans in saloon and 5 second class, 3 Chinese second class, 8 Japanese third class, and 42 Chinese steerage).

On 28th December a Malay quartermaster, cst. 32, fell sick. On the appearance of a rash on 20th January he was immediately isolated in the surgeon’s cabin on the starboard side at break of poop, being situated off a blind alley-way adjoining secon'd class accommodation, but opening only to the lower deck. He was attended by a recently vaccinated quartermaster who slept on a hatchway outside the cabin. Previously to isolation the patient had occupied a cabin with three other quartermasters.

On arrival of the vessel at Darwin on 2nd January, the case was diagnosed as small-pox, and the vessel quarantined. All on board were vaccinated, but all insertions proved subsequently unsuccessful. The vessel left the same day for Thursday Island, carrying on the passengers booked for Darwin. During the voyage the surgeon was lost overboard on the night of 5th January. On arrival at Thursday Island on 6th January the patient and his attendant were landed to quarantine. All the crew and passengers were revaccinated. The surgeon’s cabin occupied by the patient was fumigated and disinfected; the cabin occupied by the quartermasters was similarly dealt with, and all bedding thrown overboard. The vessel proceeded in quarantine to Sydney, carrying on all passengers. On arrival at Sydney on 14th January all were well, the crew and passengers were landed to quarantine, leaving an anchor watch only on board. Personal and baggage disinfection and vaccination where required were effected. All were released without any further sickness having occurred on 25th January. The patient made a good recovery, and rejoined the vessel on the outward voyage at Thursday Island. The attendant remained well, and also rejoined the vessel.

Of the close contacts of the patient, the surgeon was lost overboard, the quartermaster who attended him was recently and effectively protected by vaccination, and of the other two quartermasters who had shared a cabin with the patient, one aged 39 had one good scar of infantile vaccination, and was said to have had small-pox 23 years before; the other, aged 31, had two good scars of infantile vaccination, and one good scar from a vaccination seven years previously. Neither gave a successful reaction to the vaccinations performed at Thursday

Island and Sydney. Of tlie remainder of the crew, the following particulars are recorded of their vaccination status :—

Eleven European officers, all except two had good scars of infantile vaccination, one had poor scars, and one no evident scar. Eive had been revaccinated at periods of two, three, three, five, ten years previously, and one ten times in the last 26 years without success. On vaccination at Sydney, this latter gave a positive reaction, and the two officers with poor and no scars of infantile vaccination were successfully vaccinated, together with one other vaccinated in infancy 25 years before.

Of the nineteen deck crew (excluding the three quartermasters) with whom the patient would have more or less associated, the following particulars summarize the vaccination status :—

Twelve had good scars said to be of infantile vaccination carried out from 24 to 40 years previously.

Eour had evidences of having had small-pox.

Two had scars of vaccination carried out three and a half years previously.

One had no scars of infantile vaccination, and did not successfully react to vaccination at Thursday Island or Sydney.

Only two reacted successfully in one insertion each to the vaccination carried out on board.

Of the sixteen Chinese! stewards thirteen had good scars, said to be of infantile vaccination, two had evidence of having had small-pox, and one had poor scars of infantile vaccination. Only one was successfully revaccinated on board. Of the 23 firemen, fifteen had good scars, said to be from infantile vaccination, one had evidence of having had small-pox, two had scars of revaccination three and six years previously, one had poor scars of infantile vaccination, four had no scars. Three of those already showing scars of infantile vaccination were successfully vaccinated on board.

Of the five saloon passengers, four had scars of infantile vaccination, and the other had evidence of having had small-pox three years before. One with poor infantile scars gave a successful reaction to vaccination on board. Of the five second class Europeans, all had scars of infantile vaccination, two had been successfully revaccinated one and 28 years before, and one had had small-pox 24 years before. Of the 53 Asiatic passengers, 39 had good scars, said to be from infantile vaccination, and fourteen had evidence of having had small-pox. Twenty of these passengers gave a successful reaction to vaccination on board.    4

It must be noted that the age of vaccination scars as stated by Asiatics cannot be accepted as in any way definite, and probably many of those stated as from infantile vaccination were in many instances cases of shipboard vaccination in early manhood. It is evident that the ship’s company was comparatively well protected by vaccination, In addition, the patient as a Malay quartermaster would not associate intimately with the remainder of the crew, and his immediate cabin mates were well vaccinated, whilst isolation Avas effected immediately on discovery of the rash.

No. 10.—“ Malwa."

1912.—This vessel arrived at Fremantle on 9th April, 1912, from London, via Marseilles, Port Said, Suez, Aden, Bombay (29th March), and Colombo (1st April). There were on board a crew of 329 (130 Europeans and 199 Asiatics) and 151 passengers (69 saloon, 82 second class).

On the morning of 9th April a male saloon passenger from Bombay reported sick to the surgeon. He had felt ill, with pains in the back, on 6th April, and that morning had noticed a rash on his forehead, palms of hands, back, and soles of feet. He was at once isolated in his own cabin, there being no one else in that block. On arrival at Fremantle the case was diagnosed as small-pox, the vessel ordered into quarantine, the case and his steward landed with five local passengers to the quarantine station. Vaccination of all on l^oard was commenced.

The vessel proceeded in quarantine to Adelaide, Melbourne, and Sydney (19th April), being handled in quarantine at each port, local passengers landed for disinfection, and, where vaccination was efficient, released under surveillance. The vessel Avas released after disinfection on 23rd April with 128 of the creiv under surveillance. The remainder of the crew and passengers were released on 27th April. The patient made a good recovery, and was discharged on 15th June.

The degree of exposure of this patient was limited after appearance' of the rash. He occupied a cabin by himself, and the other cabins in the block were vacant. His immediate contacts gvere, therefore, only his steward, who was landed to quarantine with him, and his seven table companions. These seven had been successfully vaccinated four months, four months, six months, six months, two years, seven years (and revaccinated recently) previously, whilst the seventh contact had had small-pox. The records relating to the vaccination histories of the remaining passengers are not complete, hut would indicate a comparatively high proportion of recent vaccinations. Of the crew, all officers were well vaccinated, and a majority of the Asiatic crew had been recently revaccinated.

No. 11.—“ Changsha.”

1912.—This vessel arrived at Thursday Island on 5th May, 1912, from Hong Kong (22nd April), via Manila (25th April) and Zamboanga (28th April). There were on board a crew of 72 (11

Europeans and 61 Asiatics) and 81 passengers (18 European cabin passengers and 63 Chinese on deck), with 11 stowaways. On inspection by the quarantine officer at Thursday Island, a Chinese steerage passenger, who had joined the vessel at Hong Kong, presented an eruption on the face, body, and extremities, with slight fever. The vessel was ordered into quarantine, and the case isolated on the starboard side of the forecastle head beneath a winch cover and tent. Prior to isolation the passenger occupied a bunk in ’tween decks, adjoining bunks being occupied by another Chinese passenger and a cook, both of whom were recorded as being well protected by vaccination. The vessel was ordered south in quarantine, calling at Cairns (7th May) and Townsville (8th May). Vaccination of all on board was commenced by the surgeon on 9th May. The vessel arrived at Sydney on 12th May, when the patient showed a well-marked small-pox eruption on the palms of hands and soles of feet. Mo other sickness existed on board. The patient was landed into quarantine. Passengers were landed for personal and luggage disinfection and detention. The vessel was subjected to fumigation and disinfection. On 18th May the vessel was released, to be taken to Melbourne by a European crew from the shore, and seven European officers and three Chinese firemen who had been recently vaccinated were also released. All remaining passengers and crew were released on 29th May. The patient was discharged on recovery on 11th June. Mo other sickness occurred amongst the ship’s company.

The vaccination records of this vessel are not wholly complete. The immediate contacts of the patient in his sleeping quarters were recorded as being “ well protected by vaccination.” Of the other Asiatic deck passengers, and the eleven stowaways, none -reacted successfully to vaccination by the surgeon. Eifteen and two stowaways were successfully vaccinated on 9th May. Of the eighteen European cabin passengers, seven had recently been successfully vaccinated at Manila. These seven passengers were accordingly released under surveillance on 15th May, but other passengers, both cabin and deck, were detained and released later—six on 20th May, thirteen on 27th May, and 101 on 29th May— thus indicating a comparatively low proportion of recent vaccinations.

Although the case was not detected and isolated until arrival at Thursday Island, no further case occurred on board. The difficulty of ascertaining age of vaccination scars amongst Asiatics has been noted in connexion with the quarantines of other vessels, and it is probable that the deck passengers were relatively well protected by vaccination, by analogy of those recorded for other vessels.

Mo. 12.—“ Yawatu Maru.”

1912.—This vessel arrived at Thursday Island on 21st May, 1912, from Yokohama, via Hong Kong (10th May) and Manila (14th May). All were well on board on inward medical inspection. There were on board a crew of 102 with 109 passengers (26 Europeans saloon, 5 Europeans second, 24 Europeans third, and 54 Asiatics deck). On arrival at Townsville on 24th May, it wras reported that a female saloon passenger, aetatis 26, never vaccinated, had complained of headache, but had no temperature, on the evening of 20tli May. On 21st May she went ashore at Thursday Island, but that evening had headache and backache, temperature 101.5 degrees. On 22nd May the temperature was 103 degrees, but dropped to 100.4 degrees on 23rd May, when two papules appeared, one on the forehead and one on the left palm. The patient was isolated that morning on the poop deck with her husband and a second-saloon Japanese waiter as attendant. The vacated cabin and adjoining cabins were disinfected. The patient had joined the vessel at Hong Kong on 10th May, having arrived there on 6th May, so infection was probably contracted at that port. On arrival at Townsville on 24th May, the patient had a well-marked small-pox eruption. A supply of lymph was placed on board, and the vessel ordered in quarantine to Sydney. Vaccination of all on board was commenced by the surgeon on 25th May. On arrival at Sydney on 28th May, the patient showed a typical confluent small-pox rash, the eruption on the face becoming pustular. The patient was landed to the quarantine station. The two immediate contacts were landed separately from the remainder of crew and passengers on 29th May. On 4th June, the vessel, after disinfection, was released with a skeleton crew under surveillance. On 9th June, after picking up the remainder of the crew, the vessel sailed for Melbourne, where, on arrival on 11th June, all were well on board. All passengers, with the exception of the close contacts, were released under surveillance on 14th June, the quarantine ending on 26th June. The patient recovered, and was discharged on 30th July.

The vaccination histories of the passengers on this vessel are not complete^ The crew, in accordance with a Japanese instruction, were subjected to re-vaccination every six months, and were accordingly well protected.

JSTo. 13.—“ Pkinz SigismundV

1912.—This vessel arrived at Brisbane on 6th July, 1912, from Yokohama (7th June), via Kutchinutsu (9th June), Hong Kong (14th and 15th June), Manila (18th June), Angau (22nd June), Yap (23rd June), Friederick Wilhelmskaven (27th June), Rabaul (29th-30th June). There were on board on arrival a crew of 96 (19 European, 60 Chinese, and 17 Malays) and 28 passengers (10 European saloon, 12 European second class, and 5 Chinese and 1 New Britain boy on deck).

On 28th June, a Malay quartermaster, cetatis 30, reported sick with malaise, temperature 100.2 degrees. He was isolated in a cabin on the starboard side of the foredeck under the forecastle head. This

was abreast of Ho. 1 hatch, so there was probably considerable traffic past the door. On 29th June, the temperature of the patient was 100.6 degrees, and a rash appeared on the scalp, face, body, and extremities. He had had a previous attack of small-pox twenty years previously.

On arrival at Brisbane on 6th July, the case was diagnosed as varioloid ” and the vessel quarantined, and crew and passengers waccinated. Four local second class passengers were landed to quarantine. The vessel arrived at Sydney on 8th July, and the diagnosis of small-pox being confirmed, was handled in quarantine. The patient was landed. Passengers and all the crew, with a relieving anchor watch, were landed. Disinfection of the vessel was effected and the vessel handed over to a shore crew on 11th July. Twenty-four passengers and 36 of the crew were released under surveillance on 20th July and the remainder on 24th July, when the quarantine expired. Ho further illness occurred. The patient recovered and was discharged on 14th August. Vaccination histories are incomplete, but would indicate that recent vaccinations amongst the ship’s company were not numerous. It will be noted that the patient was isolated on appearance of fever, but that isolation was not complete, since probably considerable traffic passed the door.

Ho. 14.Mataram.”

1913.—This vessel arrived at Darwin on 10th January, 1913, from Singapore (30th December, 1912), via Batavia (1st January, 1913), Semarang (2nd-4th January), and Sourabaya (5th January). There were on board a crew of 87 (14 Europeans and 73 Asiatics) and 57 passengers (29 Europeans and 21 Javanese for Hew Caledonia on deck).

On arrival at Darwin on 10th January, the surgeon reported that a Javanese deck passenger, who had joined the vessel at Batavia on 1st January, had developed an erythematous rash on that date, prior to wdiich he had felt sick for three days. The rash became papular, then pustular, scabbed over, and the scabs were falling off by 6th January. The case was said to have come from inland in Java to a dépôt on 29th December, where he was examined on arrival and on embarkation, and was vaccinated with two successful insertions on °9th December. The surgeon considered the case to be one of vaccinia. On arrival at Darwin, the patient showed no constitutional symptoms, and the quarantine officer considered the case as corresponding to a scratched “ prickly-heat ” rash. Ho passengers landed at Darwin. On arrival at Thursday Island on 13th January, the quarantine officer obtained, through an interpreter, a history from the patient somewhat • divergent from that previously obtained by the surgeon. According to this history, the man had become suddenly ill on 9th or 10th December with pains all over the body and fever for three days, when a rash came out in the situations where scars were then showing. The rash was

stated to have been lumpy, tbe lumps filled with water, and later dried, leaving scabs which fell off. He stated that this occurred twenty days prior to going to the immigration depot at Batavia, whilst he denied that he was ever examined by a doctor at the depot.

The quarantine officer considered that this history was possible, and that the healed rash was characteristic of a small-pox distribution. This is confirmed by a photograph taken at the time. Accordingly, the vessel was ordered into quarantine, the case landed to quarantine, with eight local passengers. Crew and passengers not properly vaccinated were re-vaccinated. The vessel proceeded in quarantine to Townsville (16th January) and Brisbane, where, on arrival on 18th January, all were well on board except the chief cook, who had a slight papular rash on the trunk which was diagnosed and later confirmed as not variola. The vessel left Brisbane on 20th January, and arrived at Sydney on 22nd January, where all on board were well. After disinfection, the vessel, with 35 of the crew recently vaccinated, was released. The remaining passengers and crew were all released by 29th January, no further illness having occurred.

In this instance, the history of the case is indefinite, but he must be accepted as a case of variola. As such he had mixed with other passengers from embarkation on 1st January till arrival at Thursday Island on 13th January, with a period in hospital, but apparently not under rigorous isolation. Of the twenty other Malay passengers, none became ill. Most were protected by early vaccination and re-vaccination at the immigration dépôt. The crew are recorded as all having been vaccinated within seven years, 35 “ more recently ” than seven years.

Ho. 15.—“Eastern.'’'’

1913.—This vessel arrived at Darwin on 12th Febraury, 1913, from Moji (25th January), Hong Kong (30th January-lst February). Manila (4th February), Timor (10th February). There were on board a crew of 91 (9 European deck officers, 4 European engineers, and 78 Asiatics, 23 deck, 22 engine-room, and 33 in the purser’s department). Passengers numbered 49 (5 saloon, 10 second class, 9 third class, and 25 steerage).

On 2nd February, a Chinese fireman, ætatis 23, who had joined the vessel at Hong Kong on 30th January, collapsed on coming off watch, was off duty on 3rd February, and resumed duty on 4th February, when he was seen by the port health officer at Manila. On 12th February, prior to arrival at Darwin, the surgeon noted that this man had a vesicular rash on the forehead, with papules on the chest and lower extremities. He was at once isolated in the firemen’s quarters amidships. On arrival at Darwin, the case was diagnosed as small-pox and the vessel ordered into quarantine. The patient was landed to the quarantine station, quarters disinfected, and crew and passengers

vaccinated. Tlie vessel continued the voyage in quarantine, calling at Thursday Island (15th February), Cairns (18th February), Townsville (19th February), Brisbane (22nd February), and Sydney (24th February). Careful inspection at each port showed no further illness. Local passengers were landed at each port into quarantine. The vessel was released after disinfection on 26th February, together with 45 of the crew recently vaccinated. Passengers were released by 3rd March. The vessel left Sydney for Melbourne on 1st March, picking up the remaining crew, and on arrival at Melbourne on 3rd March all were well and were released from quarantine.

1STo. 16.—“ BarralongA

1913.—This vessel arrived at Newcastle on 16th April, 1913, from London (19th January), via Durban (18th-19th February), Delagoa Bay (21st-25th February), Beira (27th February-3rd March), Mauritius (llth-15th March), Albany (30th March to 8th April). There were on board a crew of 64, with the master’s wife. The crew consisted of 13 Europeans and 51 Asiatics (22 deck, 24 engine-room, and 5 stewards).

The master reported a case of illness on board, and on examination a case of variola was found in an Asiatic fireman, Abdool Mozid. He had felt sick on 9th April, but did not report till 14th April, when he had an eruption on the face, scalp, trunk, and extremities. On examination on 17th April the rash was pustular and beginning to scab, temperature 99 degrees. He had four scars of infantile vaccination. The case was isolated in the serang’s cabin under the forecastle head, his bedding was burnt, effects disinfected, crew vaccinated, and the vessel sent in quarantine to Sydney. On 18th April, at Sydney, the case was landed, and all the crew and their effects landed for disinfection and detention. The ship was fumigated and disinfected throughout and released with a scratch crew from the shore on 25tli April. During the course of the quarantine of the crew at Sydney, on 30th April and 1st May, suspicious rashes were observed in five firemen, confirmed as modified variola on 2nd May. The cases were at once isolated. On 13th May, another fireman developed a rash and was isolated. On 14th May, the eighth case amongst the firemen was discovered and isolated. The vessel, with a scratch crew and nine European officers under surveillance, proceeded to Newcastle, Melbourne, and Adelaide, at wdiich latter port the creAv rejoined on 16th May. The patients made a good recovery, and rejoined a vessel which left Adelaide for overseas on 16th June.

The quarantine of this vessel is an interesting study. On arrival at Albany on 30th March (fifteen days after leaving Mauritius), on careful inward inspection, there was no sickness found except a femoral bubo attributable to a skin lesion on the calf in one of the Asiatic crew. The primary case took ill on 9th April (25 clays after leaving Mauritius), and had developed a rash when he reported sick on 14th April (30 days). The source of infection wras, therefore, obscure, but inquiry elicited the fact that a stowaway was discovered on board four days after leaving Mauritius. He had been a hospital attendant at the Infectious Diseases Hospital, St. Louis, where cases of small-pox were under treatment. He was put to work in the same watch as the subsequent primary case, and, as far as can be ascertained, did not change the clothes in which he came on board. All 44 of the native crew occupied berths in the forecastle together.

The five cases which developed eruptions on 2nd May can be traced to infection from the primary case, who had become sick on 9th April and had a rash on 14th April, not being isolated until 17th April. The rash in the secondary cases, therefore, developed fifteen to eighteen days after probable exposure to the eruption in the primary case. The two cases who were diagnosed with a variola rash on 13th and 14th May were evidently infected at the quarantine station from the earlier five cases. Association and contact with previous cases is therefore clear in regard to all the eight cases. It is of importance to find the relationship of these cases and those who were not infected, in regard to sleeping quarters and vaccination status. The sketch plans of the sleeping quarters on board and of the dormitory occupied by the crew at the quarantine station show a scattering of infection, and not a definitely clumped spread in groups of berths such as would supposedly occur if each contact was equally susceptible to infection and otherwise subjected to equal conditions of exposure. The following list indicates the berths occupied by the eight cases on board and at the quarantine station, the berths in both places being head-to-foot and numbered in sequence:—

Case.

Date of discovery of rash.

Berth in

forecastle.

Berth in

station dormitory.

1. Abdool Mozid . .

. . 14 April

2

2. Meer Bux . .

. . 2 May

5

11

3. Troyazalla . .

. . 2 May

19

15

4. Akbroola . .

. . 2 May

7

7

5. Keramatuli . .

. . 2 May

33

. h»

6. Kodomali . .

. . 2 May

25

41

7. Noyau . .

. . 13 May

42

2

8. Kholullalla . .

. . 14 May

14

10

* This case had scabies, and was berthed in the bathroom annexe.

Ho. 17.—“ E. J. Spence.”

1913.—This vessel arrived at Newcastle on 30th April, 1913, from Mauritius (8th March). On arrival there were on board a crew of fifteen, five of whom were convalescent from small-pox, and in addition one patient had died and been buried at sea. Tbe bistory of tbe voyage was as follows:—Tbe vessel arrived at Mauritius on 23rd December, 1912, and remained there until 8th March. A new crew joined tbe vessel on 24th February, but did not sleep on board until 6th March. The vessel sailed from Mauritius on 8th March. On 19th March, Modiste, a Madagascan ordinary seaman, complained of fever, and on 21st March he developed a rash, his face becoming very swollen. He gradually became worse, and died on 2nd April, when he was buried at sea, his bedding, effects, and lining of his hunk being thrown overboard, and the forecastle where he had been isolated fumigated with sulphur. The crew had meanwhile slept in the ’tween decks, and after repainting the forecastle, reoccupied it on 4th April. On 5th April three of the native Mauritian sailors fell sick, developing the rash on 7th April. The mate, a European, fell sick on 7th April, and a rash appeared on 9th April. The Mauritian boatswain was noticed to have a rash on 15th April. On arrival at Newcastle, on 30th April, these five cases had resumed duty, but were still desquamating, and not free from scales. " The vessel was ordered to Sydney in quarantine, and on 3rd May landed the five convalescent cases to quarantine. On 4th May the remainder of the crew were landed for disinfection and detention while thorough disinfection of the vessel was effected throughout. On 10th May a Mauritian able seaman became ill, developed a broncho-pneumonia, and died on 13th May. There was no indication of small-pox. No other cases occurred, and the crew were released on 23rd May to rejoin the vessel. The five patients were discharged on 17th and 20th June.

This outbreak provides an interesting study of a sharp epidemic amongst a small crew. The infection originated at Mauritius, where there was at that time a considerable prevalence of small-pox. The sequence of cases, shown in tabular form, was as follows:—

Name.

Rating.

Onset

symptoms.

Appearance of rash.

Va ccination.

Remarks.

1. M. ..

O.S.

19th March

21st March

9

Died 2nd April

2. J. M...

O.S.

5th April

7th April

Inf.

Assisted at burial and disposal of bodv

3. E. C...

Boy

5th April

7th April

Inf.

Attended (1) and slept in forecastle with him.

4. D. J...

Boy

5th April

7th April

Small-pox 10 years before

Helped at burial and disposal of body

Visited (1) and attended at burial and cleaning up

5. A. W...

Mate

7th April

9th April

Inf.

6. P.B...

Boatswain

?

15th April

Inf.

No definite contact known

Ho. 18.Beunnee.”

1913.—This vessel trading between the Gilbert Islands and Sydney, arrived at Sydney on 5th May, 1913, from Apaiang (11th April), Mariki (12th April), and Dutari Tariti (19th April). There were on board a crew of 28 and one passenger.

On inward inspection on 5th May, a Gilbert Islander sailor, cet. 25, was found to show an eruption on the face, body, and extremities, temperature 103 deg. A diagnosis of small-pox was made and the vessel was ordered into quarantine. The rash had first been noticed in the patient on 29th April, ten days after leaving Dutari Tariti. He was isolated on the bridge deck. The patient and all the crew were landed to quarantine on 8th April. The vessel was disinfected, and handed over to a shore crew on 10th May. The crew were all vaccinated, and all gave successful reactions—100 per cent. Ho further sickness occurred amongst the crew, and all were released on 23rd May. The patient recovered, and wras discharged on 4th July.

Since a 100 per cent, successful vaccination of the members of the crew would presuppose a high susceptibility, the isolation measures adopted must have been effective. It is worthy of note, however, that small-pox was not known to exist in the Gilbert Islands, although the clinical features and the characteristic rash of the patient were accepted as definitely small-pox by quarantine officers who had considerable experience in small-pox of both the classical ” and benign types.

Ho. 19.—“ Malwa."

1913.—This vessel arrived at Fremantle on 2nd December, 1913, from London (31st October), via Gibraltar (4th Hovember), Marseilles (6th-7th Hovember), Port Said (llth-12th Hovember), Aden (16th-17th Hovember), and Colombo (22nd-23rd Hovember). There were on board a crew of 331 with 213 passengers (106 saloon, 107 second class).

On 25th Hovember a second class male passenger from London, cet. 50, fell sick suddenly with headache, was worse on 27th, when small petechice were noted on the abdomen and buttocks, later papular, and quickly becoming haemorrhagic. By the 30th Hovember he was much worse, and died on the morning of 2nd December.

On appearance of the rash on 27th Hovember, he was isolated in the hospital amidships, and the surgeon commenced vaccination of all passengers; the crew, on account of the prevalence of small-pox in Sydney, had all been recently vaccinated and re-vaccinated. On arrival at Fremantle on 2nd December, the vessel was ordered into quarantine. The body was landed to the quarantine station. The only other eruptive sickness on board were three cases of German measles amongst children, one case of chronic eczema of several years’ duration in a

saloon passenger, and one case of phthiriasis amongst the crew. The wife of the patient was landed to the quarantine station, together with two saloon and sixteen second class local passengers. The vessel proceeded to Adelaide (6th December), Melbourne (8th-llth December), and Sydney (12th December) landing local passengers for disinfection, release under surveillance or detention pending completion of vaccination. At Sydney the vessel was released after disinfection with the crew under surveillance, the quarantine expiring on 20th December.

2sTo. 20.—“ OrsovaA

1914.—This vessel arrived at Fremantle on 17th March, 1914, from * London (13tli February) via Gibraltar (17th February), Toulon (19th February), ISTaples (21st February), Taranto (22nd February), Port Said (25th February), Suez (26th February), and Colombo (7th March). There were on board a crew of 330 and 604 passengers (75 saloon, 131 second class, 398 third class).

On arrival a case of sickness was reported in a saloon passenger who joined the vessel at Colombo. He had felt sick on 11th March, and developed a rash on 15th. Successful vaccination was last done when aged sixteen. He had been isolated, but unsatisfactorily, in a block of cabins since 11th March. He was diagnosed as a case of variola, and the vessel ordered into quarantine. The patient, with 74 local passengers, were landed to the Quarantine Station. The vessel, after coaling and lightering cargo under quarantine conditions, left in quarantine, arriving at Adelaide (21st March), Melbourne (23rd-25th March), and Sydney (27th March), local passengers landing at each port to the Quarantine Station. After disinfection at Sydney the vessel with 242 of the crew who were properly vaccinated, released under surveillance, proceeded on 30tli March to the wharf and left for Brisbane, where on arrival on 3rd April all were well, and the quarantine was lifted on 4th April.

Ho. 21.—“ KilchattanT

■ 1914.—This vessel left England on 16th December, 1913, carrying a coloured crew, called at Suez and Port Soudan, and arrived at Calcutta on 1st February, 1914, where the crew was paid off. A new crew was shipped, and the vessel left for Bombay, arriving there on 18th February. At Bombay a new crewT was shipped, and the vessel proceeded to Calcutta, subsequently returning to Bombay, and leaving for Bunbury, Western Australia, on 8th April, 1914. The vessel arrived at Bunbury on 2nd May, 1914; on the 4th May it was discovered that one of the crew was suffering from small-pox. !Ho other member of the crew developed small-pox, but from this original case which was removed to shore hospital six local residents contracted the disease. The point of interest, in connexion with this vessel is that

tlie case (lid not show the first symptoms of illness until 26 days after leaving Bombay. A rigorous examination failed to reveal any evidence whatever that any of the crew had suffered from small-pox at any recent date. A medical examination at the port of Bombay before departure had been made, and it is unlikely that any case of small-pox would have escaped detection. The vessel had left Bunbury before full vaccination histories of the crew could be obtained. The incubation period of 26 days in this case cannot be accepted. It is much more likely that a very light case occurred on board, and was not recognized.

ISTo. 22.—“ Runic/’

1914.—The s.s. Runic left Liverpool on 13th November, 1914, and her ports of call were as follows:—

1914.

Liverpool

Arrived Capetown Left Capetown Arrived Albany Left Albany Arrived Adelaide Left Adelaide Arrived Melbourne


. .    13th    Nov.

. .    5tli    Dec.

. .    7th    Dec.

. .    23rd    Dec.

. .    24th    Dec.

. .    28th    Dec.

*    .    .    29th    Dec.

. . 31st Dec.

1915.    1

Left Melbourne    . .    . .    . .    17th    Jan.

Arrived    Sydney    . .    . .    . .    19th    Jan.

The vessel arrived at Albany with 608 persons on board—

Passengers    . .    . .    . .    . .    446

Crew . .    . .    . .    . .    . .    162

The following persons joined the vessel:—

At Albany    . .    . .    . .    ..    23

Adelaide    . .    . .    . .    . .    6

These made a total of 474 passengers on board the vessel before the discovery of the case.

The following persons landed at the various ports:—



passengers.

V

V


Upon the arrival of the vessel at Melbourne, on 31st December, it was found that the ship’s barber (case B) was suffering from smallpox, with a definite eruption. Upon inquiries being made it was ascertained that another case, one of the passengers (Case A) had passed through and exhibited, at the time of examination, some remaining evidences of a modified attack of variola. Subsequently, one of the female passengers (Case D) developed an eruption and was found to be a definite case of variola. During the location of the passengers who had disembarked at Adelaide, it transpired that one other of the male passengers (Case C) had also had an attack of variola, and was still exhibiting signs of that disease.

A total of four cases, therefore, occurred on this vessel, and the typo of the disease in each was that modified form of variola elsewhere described.

The origin of this limited epidemic was as follows:—

Case A.—Left Buluwayo, South Africa (where the modified form of variola is very prevalent, and where it is known under the local name of Amaas) on 29th November, 1914, and on reaching Capetown stayed at the White House Hotel. There he was ill for one day (4th December) and part of the next. On the evening of 5tli December he felt better, but noticed a rash appearing on his face and forehead. On the following day (6th December) he went on board the Runic. The rash was then becoming very noticeable, and went through the various stages of maturation. The first few days on board he did not like to dine with the passengers, so he had his meals either in his cabin or in the barber’s cabin. During the whole voyage he mixed freely with the passengers on deck. It was ascertained that this boy’s mother had died in Buluwayo just before his departure, and that at the time of her death she had shown a rash identical with his own.

Case B.—The next case was the ship’s barber, who first became ill on 29th December, i.e., 22 days after leaving Capetown. The source of infection is obvious from the fact that Case A frequented B’s cabin, although the length of time elapsing between the time of leaving Capetown and the occurrence of the illness in this case is unusually long. It may have been a late infection or a long period of incubation, the latter is not an uncommon feature of this modified type of small-pox.

Case C.—This case became ill on 21st December, i.e., fourteen days after leaving Capetown. He was frequently in contact with Case A, both being interested in certain matters of the ship’s routine.

Case D.—Became ill on 30th December, i.e., 23 days after leaving Capetown. This person occupied a cabin in the same alleyway as Case A, and was likely to be frequently in close contact with the latter.

Case A, therefore, coming on board at Capetown in an infective condition, infected three other persons on the vessel.

No other definite case occurred amongst the 446 oversea passengers and the crew of 162 aboard the vessel, nor amongst the 29 coastwise passengers.

There were, however, two persons whose cases are worth recording-» They were—

J.D., who occupied the upper berth on the opposite side of the same four-berthed cabin from the berth occupied by Case A. This man had an attack of influenza ” about fourteen days after leaving Capetown. This was severe enough to necessitate his staying in his bunk for one day. He was 46 years of age, and showed three faint vaccination marks on the left arm from a vaccination done in infancy. ITe had never been re-vaccinated. He was vaccinated three times in quarantine with lymph of known activity, but without result.

R.F. occupied the berth below J.D. He had an attack of “malaria” on 24th and 25th December, i.e., seventeen days after leaving Capetown. This attack was sufficiently severe to necessitate his remaining in bed. He was 48 years of age, and bore two good marks of infantile vaccination. He had also been vaccinated twice within the twelve years preceding the occasion now under consideration, but without success. He also was vaccinated in quarantine three times without result.    ■

These two men occupied the same cabin as Case A, and in view of the fact that both failed to react to vaccination although one had not been vaccinated for 45 years, the possibility of these cases being variola sine eruptione cannot be ignored. It cannot, however, be positively accepted, and is placed on record as an interesting occurrence.

Considerable interest attaches to this epidemic. It is well established that the original case (Case A) mixed freely amongst the passengers all the time he was on the vessel, and the members of the crew would, to a certain extent, come into contact with him. The discovery of any reason why four persons (possibly six) only were infected out of a total of 446 passengers and 162 crew must be of distinct value.

The vaccination condition of the six persons may be mentioned here—

Definite Cases.

Case A.—Never vaccinated.

Case B.—States vaccinated 30 years ago, but no scars visible.

Case C.—Vaccinated in infancy, showing three good scars on the left arm. Vaccinated also July, 1913, showing two good marks.

Case D.—Never vaccinated.

Of the four cases, therefore, three had never been vaccinated, and the fourth was well vaccinated in infancy, and had been re-vaccinated.

The vaccination condition of the two cases of indefinite illness showed that one had been vaccinated and re-vaccinated, and the other-had been vaccinated 46 years previously.

It is evident that three of the four definite cases showed absolute lack of vaccination protection, which might at first sight seem to be the reason for their having been attacked.

How did they compare in this respect with the remaining persons on board ?

Firstly, let us compare the four individuals with the other occupants of the cabins in which they were quartered.

Case A.—Occupied cabin 146, with four berths. The three other occupants were:—

(1)    44 years of age. Vaccinated 1903, four good marks

on left arm.

(2)    J. D. As already stated.

(3)    K. F. As already stated.

Case B.—Barber. Occupied his own cabin.

Case C.—Occupied cabin Ho. 3, with ten berths. The eight other occupants were:—

(1)

47 years of age.

Hever vaccinated.

(2)

52 years of age. re-vaccinated.

Vaccinated

in

infancy;

never

(3)

12 years of age. re-vaccinated.

Vaccinated

in

infancy;

never

(4)

68 years of age. re-vaccinated.

Vaccinated

in

infancy;

never

(5)

38 years of age. re-vaccinated.

Vaccinated

in

infancy;

never

(6)

70 years of age. re-vaccinated.

Vaccinated

in

infancy;

never

(7)

60 years of age. re-vaccinated.

Vaccinated

in

infancy;

never

(8)

27 years of age. re-vaccinated.

Vaccinated

in

infancy;

never

Case D.—Occupied two-berth cabin, with her three children—

(1)    6 years of age. Vaccinated in infancy.

(2)    3 years of age. Vaccinated in infancy.

(3)    7 months old. Hot vaccinated previously, but vac

cinated on day of removal of mother.

The children in association with case D may be left out of consideration, as this case D was isolated as soon as it occurred.

Amongst the others, then, in the two cabins concerned, and where the infection was constantly present, there were eleven men, of whom one had never been vaccinated, and ten had all been vaccinated in infancy, butr never re-vaccinated. Hine of these did not show any symptoms, and two showed the inconclusive symptoms already described.

The following table shows the vaccination condition of the remainder of the passengers and of the crew:—

—-

Albany.

Adelaide.

Melbourne.

Sydney.

Crew.

Never vaccinated . .

Vaccination histories

5

31

32

7

not available

Primary Vaccinations—

One year . .

4

17

4

Two years . .

3

2

Three years . .

2

3

Four years . . ..

1

1

1

1

Five years .. ..

2

2

1

Six years . . . .

1

1

Seven years . .

1

4

Eight years . . ..

»

3

1

Nine years . . . .

1

1

Ten to twenty years ..

99

10

10

16

Over twenty years . .

,,

13

97

91

64

Multiple V accinations—

One year . . . .

9

fi

10

40

Two years . . . .

,,

5

1

Three years . . . .

,,

2

1

Four years . . ..

1

2

7

Five years . . . .

2

■ -2

l

Six years . . . .

1

2

1

Seven years . . . .

2

1

2

Eight years .. ..

99

Nine years . . ..

55 *5

2

Ten to twenty years . .

55

10

3

10

Over twenty years . .

’5 '5

l

4

4

Not recorded .. ..

55 ..

2

32

25

3

Variola previously . .

” »

1

3

1

70

25

221

195

161

The position, then, may be summed up by saying that amongst the cabin contacts there were 1 unvaccinated and 1G vaccinated, and amongst the rest of the passengers there were 67 unvaccinated and 391 vaccinated, while amongst the crew there were 7 unvaccinated and 151 vaccinated. This is shown as a table, thus:—

--/

Unvaccinated.

Vaccinated.

Vaccinated

and

Re-vaccinated.

Cabin contacts .. .. ..

1

10

Other passengers .. . . ..

67

391

. 69

Crew .. . . .. ..

7

151

64

After the necessary vaccination and disinfection measures had been carried out at Melbourne, no further case occurred.

Although the 65 passengers who landed at Albany were distributed amongst the community for at least seven days, and the 44 passengers at Adelaide for at least two days, there occurred only one case (case C) amongst these passengers, and only one case amongst the general community. This last case (case Gr) occurred in a suburb of Adelaide, and was directly infected from case C. The two men were in conversation together at the same hotel on the day when case C landed from the vessel, and also on the following day.

Case G was isolated, together with his family, as soon as his condition was known, but no further case occurred, and the epidemic came to an end.

ISTo. 23.—■“ Urlana.^

1915.—This vessel left Calcutta on 28th January, 1915, and on 11th February a case of small-pox occurred in the person of a lascar, by name Saro Obolah.

This lascar was a deck hand, and was living with 41 other lascars in the starboard side of the forecastle. The man was isolated in Nfo. 4 hold as soon as he complained of illness and before any skin eruption had appeared. After isolation, the captain was the only person to have any communication with the men in isolation.

The vessel arrived at Fremantle on 14th February. The patient was removed to the Quarantine Station, where, after a confluent attack of small-pox, he died on 22nd February.

The remainder of the persons on board, consisting of 104 crew and 5 passengers, were all found to be well, and were all vaccinated at Fremantle, with 10 exceptions, who had either been recently vaccinated or had had small-pox, or refused vaccination. The ship was disinfected, and no further cases occurred on the vessel.

It is of interest to analyze the conditions of those on board in respect of vaccination.

The table of conditions on arrival at Fremantle is as follows :—

97 were vaccinated at Fremantle.

3 were recently successfully vaccinated.

2 refused to be vaccinated. .

5 had had small-pox.

2 were patients with small-pox.

109

Of the 97 whom it was found necessary to vaccinate at Fremantle—

80 had been vaccinated previously.

7 had never been vaccinated.

10 showed doubtful marks.

The analysis of the vaccination condition of the persons who occupied the same living quarters, namely, the starboard side of the forecastle, is as follows (there were 33 lascars) :—

Once vaccinated . .

. . 9

Twice vaccinated . .

. . 10

Three times vaccinated . .

. . 5

Four times vaccinated . .

. . 1

Doubtful . . . .

. . 2

Had small-pox . .

. . 3

Hever vaccinated . .

. . 3

The captain, who came most intimately into contact with the patients, was vaccinated in infancy (cet 40) and had had small-pox in 1900—-a mild attack.

No. 24.Umballa."

1915.—This vessel left Bombay on 14th February, 1915, steaming to Fremantle (Western Australia) direct. On arrival at Fremantle on 5th March it was found that there were on board three cases of small-pox amongst the coloured crew.

On arrival at Fremantle, no cases other than the original three had occurred. These three were two lascar deck hands and one coal trimmer.

The total number of crew was 99—11 Europeans, 88 Asiatics. There were no passengers. The whole of the 99 members of the crew, with the exception of four—all white officers, who refused vaccination— were vaccinated at Fremantle, and disinfection was carried out where necessary.

Of the eleven Europeans, all had been once vaccinated, the first vaccinations being from 22 to 39 years old.

Five had not been re-vaccinated, and may therefore be grouped as incompletely protected.

The other six had been re-vaccinated within the following intervals, with a successful result:—

2 cases. 1 case.

1 case.

1 case.

1 case.


2 years 4 years

6    years

7    years 12 years

Amongst the 85 Asiatic crew who did not develop small-pox, 8 had never been vaccinated.

Of the other 77, the vaccination histories may be analyzed as follows :—

Primary Vaccination without Re-vaccination.

Re-vaccination, i.e., Primary Vaccination and a later Re-vaccination. In the case of more than one Re-vaccination the Date of the last success-full one is taken.

1 year . . .. . .

3

2 years .. .. ..

2

3 years .. .. ..

2

4 years .. .. ..

2 '

5 years .. .. ..

3

6 years .. .. ..

5

7 years .. .. ..

* •

2

8 years .. .. ..

4

9 years .. .. ..

..

10 years .. .. ..

4

10-20 years .. .. ..

8

2

20-30 years .. .. ..

24

1

30-40 years .. .. ..

14

40-50 years .. .. ..

50-60 years .. .. ..

1

47

30

^-

77

The three cases which occurred on board were as follows:—

Sazel Mea,

Abdul Kellick,

Ismoola.

The first of these to be discovered was Sazel Mea, wdiose rash appeared on the 23rd February. The other two cases were discovered after the appearance of the rash. In the opinion of the Quarantine Officer at Fremantle the two latter cases had suffered from the disease before boarding the vessel, as on arrival at Fremantle, they were desquamating.

Each of the above cases had been once vaccinated, but owing to the fact that the vessel left Fremantle soon after their disembarkation, and these men could not speak English, no account of the date of the vaccination could be obtained. The scars had the appearance of infantile scars, and the men are well over twenty years of age.

As soon as the cases were discovered they were isolated.

If it be true, as is probable, that Abdul Kellick and Ismoola were infective on joining the ship, then abundant opportunities for infection must have occurred. The vaccination condition of the occupants of the same quarters as the patients is not given.

Sazel Mea was a coal trimmer, and the other two were Lascar deckhands.

It is clear that the vaccination protected the whole of the ship from an outbreak, or that the infectivity was low.

1STo. 25.—“ Gregory Apcar.’’

1915.—This vessel left Calcutta on 13th February, 1915, steaming to Melbourne direct, and arriving at the latter port on 5th March. On arrival at Melbourne it was found that a steward, J.R., was suffering from semi-confluent small-pox.

The patient first complained of feverishness on the 15th February —two days after the departure of the vessel from Calcutta. The patient was the sole occupant of a cabin amidships on the main deck, and he lay in his bunk until the 18th, when the rash was observed. During this time he was waited on by a lascar, G.G. On the 18th both these men were removed to the poop boat deck and placed in a boat where they were kept isolated until the arrival of the vessel, food being brought to the foot of a ladder leading to this deck and taken from there by the attendant, G.G.

The room occupied by the patient was immediately painted with 50 per cent, izal, and then scrubbed down thoroughly with washing soda and water. All the linen and mattrasses were taken by the patient and attendant to the boat. Beyond the Chief Officer and the lascar attendant, nobody came in contact with the patient.

The vessel was quarantined, the patient removed, and vaccination and disinfection measures carried out.

No further case occurred and the vessel was released from quarantine on 24th March.

It will he interesting to analyse the facts connected with this vessel in order to arrive at some idea as to the reason for the failure of the disease to spread.

The vessel carried nine third-class passengers, all Europeans, and the duty of the steward, who developed small-pox, was to wait upon these passengers, and he did so until the first day of his illness.

Of these nine passengers seven had never been vaccinated—two had been vaccinated in infancy (17 and 25 years previously)—with very poor cicatrices.

During the steward’s illness he came into contact with only two persons, the lascar attendant, above mentioned, and the Chief Officer.

The lascar attendant had been well vaccinated in infancy, and also in 1914.

The Chief Officer had been well vaccinated in infancy, and had been re-vaccinated twice within the last three years without result.

It may be accepted, therefore, that each of these persons was probably well protected.

The remainder of the ship’s company may be described as follows:— 12 European officers,

103 Coloured crew,

9 Third-class European passengers.

The Chief Officer, lascar steward, and the passengers have been dealt with—the remainder of the crew were vaccinated as follows:—

Coloured Crew.

White Crew.

Primary.

Re-vaccination.

Primary.

Re-vaccination.

1 year . . ..

2

4

1

2 years . . . .

6

1

3 years .. . .

I

2

4 years . . . .

1

1

1

5 years . . ..

1

1

6 years .. ..

1

7 years .. . .

l

3

1

8 years . . . .

9 years .. . .

3

1

10 years . . . .

10-20 years . .

17

5

20-30 years . .

27

1

4

30-40 years . .

5

40-50 years . .

2

1

50-60 years ..

1

60

24

6

5

Y

84

11

Had previously had small-pox ..    ..    ..    ..    ..    4

Unvaecinated ..    ..    ..    ..    ..    .. '    ..    14

There was then a vessel containing 134 souls.

Of these, 21 had never been vaccinated, and amongst these there were seven who were in intimate contact with the patient, who served them with food until the first day of his illness.

There were 23 who had been vaccinated either for the first time, or re-vaccinated successfully within seven years, and may he accepted as being protected, and with the lascar attendant and the Chief Officer already dealt with, makes a total of 25.

Four had had small-pox and the protection in their cases may he assumed.

The remaining 79 were partially protected, the degree of protection being, of course, unassessable.

The principal fact is that a case of small-pox was located on board for 23 days without any other case occurring. This is explainable in part by the amount of vaccination protection amongst the members, and partly by the completeness of the isolation effected. It is legitimate to draw attention to the fact that only unprotected men were served with food by the patient until the first day of symptoms indicating that this case was probably not infectious until after the onset of symptoms.

iSTo. 26.—■“ Chanda/'

1915.—This steamer arrived at Thursday Island on 7th March, and the Quarantine Officer, on boarding, found one case of small-pox well developed, and one case showing the commencement of the eruption of the same disease.

The vessel left Calcutta on 20th February for Thursday Island direct, and after the discovery of the cases proceeded thence direct to Sydney, where quarantine measures 'were carried out.

The two cases were both lascar sailors, members of the deck crew. They had spent three weeks in a boarding-house in Calcutta before joining the vessel.

The first case, S.A., age 21 years, fell ill with a temperature of 100.6 on 27th February. As it was known that small-pox was unduly prevalent in Calcutta, the master of the vessel at once isolated S.A. in a horse-stall on the port side of the foredeck, together with his brother H.A. The rash appeared on 2nd March, and from that time the disease progressed in a semi-confluent fashion, the patient becoming worse and dying on the 14th March.

The second case, O.A., age 20, was brother to case 1 (S.A.). He first fell ill on 5th March, i.e., six days after case 1, from which, it is evident that both received the infection at Calcutta, case 2 evidently being infected just prior to leaving Calcutta. He was isolated with case 1 on 6th March. The rash appeared on 7th March. He had a moderately severe attack and recovered.

It is noteworthy that there were three brothers concerned in this outbreak—

S.A., Case 1.—Died. Unvaccinated.

O.A., Case 2.—Recovered.    Unvaccinated.

H.A.—Detailed to attend upon above cases. Did not develop small-pox. Vaccinated in infancy with good result. Vaccinated three times by quarantine staff without result.

H.A., although in daily attendance upon his brothers, escaped infection.

The remainder of the ship’s company may be subdivided as follows:—•

Europeans.

Asiatics.

Total.

Officers .. .. .. .. ..

1L

11

Deck Crew .. .. ..

44

44

Engine Crew .. .. .. .. ..

35

35

Stewards .. .. .. . .

16

16

Passengers .. .. .. .. ..

15

15

Pilot .. .. .. .. ..

1

1

•»

27

95

122

Officers:—The whole eleven officers and the pilot had been well vaccinated in infancy, and nine of them had been re-vaccinated as follows:—

19 years previously 13    „    „    '

12    „    „

9    „    ,,

4    „    „

2    „    „

1    „    „

Passengers.—Of the 15 passengers, 14 were well vaccinated in infancy, and 8 had been well vaccinated within seven years. One had never been vaccinated.

Saloon Crew.—Numbered 16, of whom 12 had good vaccination scars, while 5 had scars of small-pox, 4 of these being the four who had no vaccination marks.

Deck Crew.—This section of 41 members of the deck crew is of special interest, inasmuch as the patients came from amongst this group. All except four were vaccinated, and of these four all had had smallpox.

Engine Crew.—This section comprised 35 men, of whom 14 were not vaccinated. Of the 14 unvaccinated men, 11 had had small-pox.

A table may thus be constructed, showing the vaccination condition on the above lines, as follows :—

Total persons on board . . . . . . Suffered from small-pox, both unvaccinated—

122

Died . . . . ..

1

Recovered . . . .

j

1

Contact of patients (vaccinated)

1

Vaccinated . . . . . .

96

H