55

H.—3l

collected and deposited at what would be the base of the pustule. This gave rise to a peculiar mottled appearance to the patient, and has been the cause of many visits to suspected smallpox patients, only to find that they had recovered from the disease weeks previously. One other symptom that was very marked in the earlier cases was the rapidity with which the scabs cleared off the patient, due I think to the fact that the skin was not so deeply invaded as is generally the case in cases of variola. Amongst Europeans attacked no deaths have been recorded, although many of them were unvaccinated. Amongst the Maoris there are estimated to have been 55 deaths, which is a very small number considering that fully 85 per cent, of them were unvaccinated. This certainly is the truest index to the mildness of the outbreak, and up to the present time the cases seem to be decreasing in virulence rather than otherwise. This is not exactly what one would have expected judging by other outbreaks. The absence of the many sequels of smallpox is another factor bearing testimony to the mildness of the epidemic. Distribution of the Rash. —In an epidemic of smallpox in which deviation from the commonly accepted symptoms has been one of the chief features, the distribution of the eruption has perhaps varied least. In every case that I have seen the rash has been present upon the forehead, the spots numbering from one or two to many. On the sides of the nose and around the lips the rash has generally been in evidence. On the wrists, especially on the dorsal surface, one or more spots have always been found. The chest and abdomen have had much less than the back, and in several cases the total number of spots upon the chest has not exceeded half a dozen. The lower extremities have usually shown evidence of the eruption, but not in every case. When affected the palms of the hands and soles of the feet have been the last places in which the rash has appeared. I think lam right in saying that throughout the epidemic the rash has appeared in the order mentioned above, and its regular mode of appearance has been of great assistance in coming to a definite diagnosis in cases where the usual appearances of the eruption, the absence of prodromal symptoms, and the history given by the patient have all been valueless in helping one to arrive at a definite conclusion as to whether or not it was a case of smallpox that was under consideration. The old statement that parts irritated by clothing such as a belt or garter has not been so regularly noticed, probably because the use of these articles of clothing is not so universal as in former days. The District Health Officer, Wellington, reports: — With an outbreak of smallpox of the dimensions of that which occurred in the Auckland Health District it might well have been expected that several cases would have broken out in some portion of the Wellington and Hawke's Bay Health Districts, especially along the tracks of communication between the two districts, and it is a matter for congratulation that only four actually occurred. This result may be attributed to the energetic measures adopted in the matter of wholesale vaccination, the restrictions placed on Maoris travelling, and the quarantining of affected areas. With regard to the action taken in this district, on the first appearance of any eases of a suspicious nature measures were at once taken to quarantine the affected premises until the true nature of the disease from which the suspects were suffering manifested itself, and steps taken to ensure the vaccination of all persons who had come in contact, however slightly, with the cases, if not already previously vaccinated. Consequently no spread of the disease occurred from these four cases, three of which were directly traceable to infected places in the north. It would be difficult to estimate the actual number of suspects investigated through the report of symptoms or circumstances giving rise to suspicion, as owing to stress of work at the time it was only possible to record the more important of these, and of those which were obviously of a negative character on first examination no further note was kept. Apart from the actual cases, only six of the suspects reported were sufficiently so to warrant keeping under observation for a short space of time. The four cases which occurred were as follows :— C.H.H., Wellington, European female. Brought under notice on the 17th July. Employed in domestic service in a family which had just come down from the Hay of Islands district. Last probable exposure to infection 21th June; onset 11th July, the symptoms being shivering, backache, and general malaise. The rash appeared on the 16th July, on the forehead, face, back, and a few spots scattered on the limbs. Reported by medical attendant on the 17th July, and seen by me on the same date, and removed to a special isolation block at the Infectious Diseases Hospital. Result complete recovery, but with slight signs of pitting. R.H., Mormon College, Bridge Pa. near Hastings. Maori male. Reported on the 14th July. He was then in an advanced stage of the disease, and had just arrived from Kaikohe, Auckland. Removed to Quarantine Island, Napier. The College placed in quarantine, all occupants vaccinated, and thorough disinfection of the premises carried out. Recovered. P.J.R., Pahiatua, European male. Reported on the 19th July. He had been on a holiday trip to Auckland and district, returning on the sth. Onset 16th —pyrexia, headache, and " a peculiar feeling down the back"; rash first appeared 18th, on forehead, and later on face. He had been much in contact with the Maoris on his holiday. Had never been vaccinated. Isolated at Pahiatua Hospital. Recovered. F.P., s.s. "Delphic," Wellington, European male. Reported 18th August. Quartermaster on this steamer. Onset 10th August—rigor and malaise. Papular rash appeared on the 13th August (as gathered from patient's description). Vaccinated in Auckland on the 13th, and shipped on board " Delphic," which left Auckland for Well i nut on on that date. Seen by medical man for first time on the 18th August in Wellington, who at once reported the case, and I visited forthwith. Patient then had a copious pustular rash, most marked on face and hands. Removed