- Email: [email protected]
The smallpox outbreak on merseyside, 1946
PUBLIC HEALTH, January, 1947
The Differentiation of Variola and Varleella T h e essential diagnostic criterion in the distinction between variola and varicella lies in the distribution of the rash, centrifugal in smallpox, centripetal in chicken-pox. What is the underlying pathology of this difference ? I am unable to hazard a guess. Extremely valuable as this difference i s - - a n d it is the mainstay of diagnosis--it can to greater or lesser degree be broken down in particular individuals. In the severest confluent cases of smallpox the rash is all but universal. Regions of the body may proportionately be more heavily covered than normal by the rash owing to local causes in both variola and varicella. I have already referred to the case of haemorrhagic chicken-pox with a semi-confluent eruption on the legs ; many years ago I was called to see a St. Helens glassblower with a confluent varicella eruption over his shins where he was exposed to the heat of the furnace. But such localised confluent patches are much commoner in variola than in varicella, and arise at any point of pressure or area of increased blood supply. Examples are from the pressure of a garter, corset or collar stud, an area of sunburn, e.g., on the back of the neck, or due to the occupation of the patient, as for example a ship's steward who had a confluent patch on the palm of his right hand where he held a bread knife, cutting bread having been his principal occupation. A recent case was an officer who, in the tropics, had perspired profusely over the body, and possibly suffered from " prickly heat." He came out with a considerable eruption on the abdomen which upset the normal distribution ; the laboratory, however, confirmed the diagnosis of smallpox. T h e most extraordinary variant of the variola virus is its conversion, per saltum, by animal passage into the vaccinia virus. This has, with the exception of the occasional occurrence of generalised vaccinia, lost its power of dissemination by the blood strear~--though this does not imply necessarily, or indeed probably, that it does not reach the blood stream. An interesting point about this variant is that when it does achieve dissemination the distribution is indifferent, neither centrifugal nor centripetal. This loss of power of dissemination by the blood stream is intimately associated with the loss of power to propagate other than by inoculation, but has not been so completely lost. It is perhaps useless to speculate on the nature of this variation. I expressly refrain in this connection from the use of the word mutation which has reference to genes, seeing that as we have no knowledge of whether the nature of this change is similar to a mutation or not, though it presumably relates to the chemical properties and nature of the virus, a thing, so far as we know, without any visible structure, as indicated by electron microscopy. REFERENCES
HANNA,W. (1913.) " Studies in Vaccination and Smallpox." PETERS, O . H . (1909.) Proc. R. Soc. ivied. (Epidem. Section). ST~LYnR~S, C.O. (1928.) J. State Med., 86, 27.
THE
SMALLPOX
O U T B R E A K ON M E R f l E Y S I D E , 1946" By E. R. PEIRCE, M.R.C.S., L.R.C.P., D.P.H., D.T.M., Senior Assistant Medical Officer, Port of Liverpool Smallpox is endemic in many parts of the world, particularly the eastern hemisphere, and some Indian ports are rarely, if ever, free f r o m cases of the disease: consequently vessels which call at these ports are always a potential source of danger and may be the means of importing smallpox cases into this country. This danger was accentuated in the spring of this year (1946) by the return of large numbers of troops from the East. I propose in this paper to describe the measures taken to guard against the import of cases of smallpox, to give a short description of the signs, symptoms and diagnosis of the disease, and finally an account of the outbreak which occurred on Merseyside during the first half of this year. T h e essential principles in the control of imported smallpox are the early diagnosis and isolation of cases, and the protection of immediate contacts by vaccination. All the measures to be * Paper read to the North-Western Branch, Society of Medical Officers of Health, September, 1946.
79 described are directed to this purpose. All necessary powers are obtained by the Port Sanitary Regulations 1933 and Amending Regulations of 1945. Article I I of these regulations requires the Port Medical Officer to prepare from time to time, and keep up to date, a list of foreign ports and seaboards which are infected or believed to be infected with plague, cholera, yellow fever, typhus fever or smallpox, and this list is compiled from the weekly returns issued by the Ministry of Health to all Port Health Authorities. These weekly returns show the number of cases which have been notified in all ports throughout the world.
Measures for Preventing Imported Infections T h e measures for preventing importation are reasonably uniform for all United Kingdom ports although there may be slight local differences dependent upon the size of the port and the number of staff available, T h e master of any vessel approaching Liverpool, which has called at an ~fected port during the previous six weeks, must send a wireless message to the Port Health Authority not less than four hours or more than twelve hours before arrival, stating the estimated time of arrival and that the Port Medical Officer is required. This message must be sent irrespective of whether or not there are cases of sickness. On arrival in the river the vessel is boarded, before docking, by ja medical officer, who obtains from the master a signed declaration of health concerning all persons on board together with a list of their names and intended destinations. If the vessel carries a surgeon he must also countersign the declaration of health. When the boarding medical officer has satisfied himself that there are no cases of infectious or contagious disease aboard he issues a certificate that the vessel may proceed to dock and pratique may be granted by the customs officer. T h e list of names and destinations of all persons on board is obtained in order that all contacts can be traced should a case occur after disembarkation. If any cases of smallpox are reported or discovered, the vessel is put under detention and ordered to anchor at a specified mooring station; the cases are disembarked by the Port Health Authority's launch and conveyed by ambulance to the Port Health Hospital. All persons aboard are examined and offered vaccination, and the destination of each individual is carefully checked. T h e ship's hospital, the quarters occupied by the patient, and all infected bedding and clothing are put under seal for subsequent disinfection by the staff of the Port Health Authority. T h e vessel is then allowed to dock and disembark passengers and crew. T h e names and addresses of destination of all persons who disembark are sent to the local medical officers of health together with a circular letter giving details of the cases and suggesting the period of surveillance. By this means any secondary cases which might arise can be isolated at the earliest possible moment. Smallpox may vary in severity from the very mild case (who is hardly ill) to the haemorrhagic case which is almost invariably fatal. T h e usual classification is: mild discrete--moderate discrete--severe discrete becoming semi-confluent--confluent --haemorrhagic. T h e incubation period is very consistent and in the great majority of cases is twelve days, although in very mild cases it may be as much as 18 days. A short period of nine days has also been recorded. At the end of the incubation period the temperature rises to 102 ° or 103° and the patient feels ill and apprehensive with severe headache and backache. Many patients have described the headache and backache as almost • unbearable; these symptoms continue until the appearance of the rash on the third day. There may be a prodromal rash simulating scarlet fever or rubella or measles, either in the " bathing-drawer" area or on t h e trunk, but the true rash commences usually about the wrists or ankles or forehead as discrete papules with a shotty feeling to the touch. As soon as the rash appears the temperature drops and the patient feels much better, the headache, backache and apprehension all disappearing. In about three days the rash becomes pustular. T h e change from papule to pustule is so rapid that clear vesicles such as are found in chicken-pox are never seen : moreover
80 t h e rash in each area is all in t h e same stage. T h e h a n d s a n d a r m s m a y be all pustules a n d t h e feet all papules, or vice versa, b u t you n e v e r find a p a p u l e vesicle a n d pustule all close t o g e t h e r in one area as in chicken-pox. T h e rash of smallpox is m o s t profuse on t h e extremities, face a n d scalp, gradually d i m i n i s h i n g towards t h e trunk, a n d e v e n In very severe cases a small area r o u n d t h e u m b i l i c u s will b e f o u n d free f r o m lesions. T h e axillae also escape. Pustules o n the palate are v e r y c o m m o n b u t the t o n g u e is usually free. T h e pustules are u n i f o r m in size, multilocular, a n d b e c o m e u m b i l i c a t e d : they are deeply set in t h e skin as c o m p a r e d w i t h t h e superficial unilocular pustule of chicken-pox. T h e c h i c k e n - p o x lesion also varies m u c h in size, a n d papules, vesicles a n d pustules are f o u n d t o g e t h e r in one area. I n smallpox cases w h i c h recover, t h e p u s t u l e s d r y u p a n d b e c o m e scabs w h i c h d r o p off a n d leave~ a typical b r o w n staining o n the face, limbs a n d t r u n k , a n d dark b r o w n or black seeds deeply set in t h e palms of t h e h a n d s a n d soles of t h e feet. T h e s e b r o w n seeds are diagnostic of smallpox.
Diagnosis T h e first case m a y p r e s e n t some difficulty if n o history of a n y contact is given. I t m u s t b e repeated t h a t this first case m a y b e hardly ill at all. However, the t h r e e days' history of headache, backache a n d pyrexia before the rash appears s h o u l d arouse suspicion, while t h e f o r m a n d d i s t r i b u t i o n o f t h e rash, m o s t m a r k e d o n t h e extremities a n d face, its u n i f o r m size a n d age i n each area, f r e e d o m of t h e umbilical region ancb axillae f r o m lesions, a n d t h e absence of c r o p p i n g s h o u l d confirm the diagnosis. I n c h i c k e n - p o x t h e m a x i m u m intensity of t h e rash is on the t r u n k , gradually d i m i n i s h i n g towards t h e extremities ; lesions v a r y in size a n d age, papules, vesicles a n d pustules b e i n g f o u n d in close p r o x i m i t y to each other. T h e r e are n o b r o w n staining a n d n o b r o w n seeds in t h e palms or soles. I n severe cases of chicken-pox t h e rash m a y spread even to the palms a n d soles, b u t in this event t h e t r u n k will b e f o u n d to b e literally covered w i t h lesions. I n chicken-pox t h e rash appears on the first day of t h e disease a n d t h e i n c u b a t i o n period is f r o m 14 to 21 days. H a e m o r r h a g i c smallpox is invariably f a t a l : the rash is n o t h i n g like the o r d i n a r y smallpox rash, a n d is f r e q u e n t l y diagnosed as h a e m o r r h a g i c measles, h a e m o r r h a g i c scarlet fever or p u r p u r a haemorrhagica. T h e p a t i e n t has the usual s y m p t o m s for t h r e e days a n d t h e n a h a e m o r r h a g i c rash appears, h a v i n g m o r e t h e appearance of measles. T h e face is red a n d bloated, r a t h e r like a lobster, a n d t h e r e is a generalised petechial rash w i t h h a e m o r r h a g e s f r o m t h e m u c o u s m e m b r a n e s . T h e patient b e c o m e s restless a n d delirious a n d d e a t h takes place very rapidly, 24 to 48 h o u r s after t h e appearance of t h e rash. O n e practical p o i n t m u s t n e v e r be forgotten, namely, t h a t w h e n e x a m i n i n g for smallpox the p a t i e n t m u s t always b e stripped.
Treatment T r e a t m e n t is m o s t l y n u r s i n g , a n d in severe cases t h e p a t i e n t m u s t be kept in a d a r k e n e d room. Otherwise t h e t r e a t m e n t is symptomatic :-(a) C o n s t a n t a t t e n t i o n to t h e eyes w i t h (i) use of eye shades ; (ii) use of penicillin eye-drops ; (iii) b a t h i n g w i t h w a r m boracic lotion. (b) C o n s t a n t s w a b b i n g out o f t h e m o u t h w i t h (i) glycerine a n d boracic ; (ii) glycethylamine for gargle. (c) A s o o t h i n g application of calamine lotion for t h e rash. Sulphathiozole 2 x ½ grn. t w o - h o u r l y is of value d u r i n g the p u s t u l a r stage b u t has n o influence earlier in the disease. O n e h u n d r e d a n d twenty-five t h o u s a n d u n i t s of penicillin was given daily to five children, all severe cases, four of w h o m died. D u r i n g t h e period F e b r u a r y 9th, 1946, to J u l y 2nd, 1946, 31 cases of smallpox were a d m i t t e d to t h e P o r t H e a l t h Hospital, N e w Ferry, a n d of these seven were l a n d e d f r o m troopships (two deaths) ; eleven occurred in t h e city of L i v e r p o o l (two deaths) ; t e n in B i r k e n h e a d (five deaths), a n d t h r e e in B e b i n g t o n . I n only one group of two cases in Liverpool could a n y direct c o n n e c t i o n b e t w e e n t h e s h i p b o m e cases a n d the land cases b e found.
PUBLIC HEALTH, January, 1947
Shipborne Cases T h e shipbome cases arose in four different vessels. The source of infection of all shipbome primary cases was Bombay. T h e three secondary cases in Ship II arose from a mild discrete case which occurred on February 11th. Ship I (Patrick M e M . ) - - T h e first case" admitted to the hospital was a member of the crew of a troopship which arrived on February 18th, 1946. T h e case was a very mild discrete smallpox probably contracted in Bombay. This man recovered and was discharged on March 13th. He had three marks of vaccination in infancy and although he stated he had been revaccinated five times in the Merchant Navy there was no evidence of any other take. Ship I I (Norman O., George M., Charles B., Percy R.).---This vessel arrived on March 2nd. The group comprised four cases (one primary and three secondary), three R.A.F. personnel and one Major, R.A.M.C. The first case, an L.A.C. aged 34 years, reported sick on February 11th, just after boarding the troopship at Bombay. There was some doubt about diagnosis owing to the mildness of the case, but some attempt at isolation was apparently made. The three other cases sickened on February 22nd, 24th and 25th, and were admitted to the Por~ Health Flospital on arrival on March 2nd. Of these three cases two were very mild discrete, and the third, who died on March 6th, a very severe confluent case. Atl the mild cases had been vaccinated in infancy with revaccinations in the Services, but there was no evidence of any revaccination takes. The severe confluent case was so ill on admission that it was impossible to obtain any vaccinal history, and, owing to the severity of the rash, it was impossible to discern any marks. Ship l l I (John T . ) . - - T h i s vessel arrived on April 7th. One case (a Chief Petty Officer, R.N.) of mild discrete smallpox was admitted to the Port Health Hospital on April 7th, and subsequently recovered. He was vaccinated in infancy and revaccinated in 1941, 194:4 and 194:6, but again there was no evidence of any revaccination takes. Ship I V (Peter G. B.).--This vessel arrived on April 12th. One case, a Petty Officer, R.N., who was admitted to the Port Health Hospital on April i2th with severe haemorrhagic smallpox, died on April 14:th. Vaccination history was not ascertainable.
Liverpool Cases The Liverpool cases can be divided into four groups.
Group I (Doris L., Florence L.).--This group comprised two cases which occurred at 8, Langrove Street, the first of which, a child aged twelve years, was infected on March 6th and was thought to be suffering from chicken-pox until April 5th, when the illness of her mother led to the true nature of the disease being discovered. T h e mother, a woman of 4:0 years, was admitted to the hospital on April 5th, together with her daughter, and both subsequently recovered. Both had been vaccinated in infancy and showed one mark. T h e daughter's disease was a mild discrete form, whereas the mother developed severe confluent smallpox. T h e source of infection in this group may have been a son who arrived home from Bombay on March 2nd in Ship II, from which four cases were sent to hospital. T h e son, however, gave no history of illness, nor did he show any signs of any recent illness. He disembarked from the vessel, proceeded to a transit camp and ultimately returned home, probably on Marcl~ 4th or 5th. No further case occurred from this focus. Group I I (Ellen J., Graham T., Marie W., Margaret L.).--This group comprised four cases which occurred in Fazakerley Hospital, the first of which (a woman) was probably infected on or about April 13th. She was admitted to Fazakerley Hospital on April 27th with a rash thought to be due to generalised vaccinia as she had been vaccinated successfully on April 17th; a diagnosis which remained unaltered until May 21st, when the true nature of the illness was discovered. She was a case of coincident vaccinia and smalIpox. Three secondary cases arose ; a boy of four years infected on or about May 6th, a girl aged four years infected on or about May 7th, and a girl of five and a half years infected on or about May 16th. T h e primary case in this group was classified as a moderate discrete smallpox with coincident ~vaccinia, and subsequently recovered. All the secondary cases developed severe confluent smallpox, and the boy and the girl aged five and a half years both died, the boy on June 1st and the girl on June 15th. T h e other girl recovered. The girl aged five and a half years was vaccinated successfully for the first time after contracting smallpox---on May 22nd; the other two children were both unvaccinated. T h e source of infection of the primary case is unknown. Group I I I (James W., Alice H., Esther S., and John William S.).-This group comprised four cases in the Everton district of Liverpool. T h e primary case was a man aged 41 years who was thought to be suffering from chicken-pox and had practically recovered before the secondary cases arose. The date of onset was April 30th and the rash appeared on May 2nd. He was admitted to the hospital on May 22nd as a mild discrete smallpox, and ultimately recovered. T h e secondary cases arising from this one were a woman aged 23 years who was admitted on May 21st with mild discrete smallpox;
81
PUBLIC ,HEALTH, January, 1947 a girl of 15 years who was admitted on May 22nd (also a mild discrete smallpox) ; and a man aged 42 years admitted on June 2nd with moderate discrete smallpox. All these cases recovered. All were successfully vaccinated in infancy and the man who was a secondary case stated that he had been revaceinated in 1944 and 1946, no takes. Group I V (Joseph D . ) . - - T h e case was sent to the Port Health Hospital from his home in Mossley Hill on May 21st as a case of suspected smallpox. He was revaccinated unsuccessfully on the same day, before admission to hospital. On examination, in the ambulance, he was found to have a pustular rash on both hands, palms and extensor surfaces which did not extend beyond the wrists, and gave a history of having been in bed for three or four days with headache, severe backache, and a rise in temperature. There were similar pustules on the ankles and soles of the feet. He was not thought to be smallpox and was isolated in a ward by himself, well away from the smallpox patients. He was treated with 125,000 units of penicillin and penicillin cream, and the rash cleared up in six days. He was discharged on May 27th. Two days later, on May 29th, he complained of malaise and headache, and again went to bed. On the 30th the headache and backache were more pronounced and there was some pyrexia. On the 31st the symptoms were still severe and on the afternoon of June 1st there were some discrete macular lesions on the trunk and back. There was no rash on the hands, face or feet. On the morning of June 3rd a typical discrete smallpox rash had developed on the face, hands, feet and back. He was readmitted to the hospital, developed moderate discrete smallpox, and subsequently recovered. He had been vaccinated in infancy. Bebington Cases These comprise two groups. Group I (Mrs. T., Robert T . ) . - - A woman, aged 50 years, was taken ill on March 19th and developed a rash on March °3rd. She was sent into Clatterbridge Hospital for observation on March 25th and transferred to the Port Health Hospital on March 29th, suffering from severe confluent smallpox. She stated that she had been vaccinated in infancy, but there were no marks visible. She subsequently recovered. The source of infection is unknown. This woman's husband, aged 55 years, became ill on April 2nd and developed a rash on April 5th, having been admitted to hospital on the 2nd for observation. He developed moderate discrete smallpox and subsequently recovered. He was vaccinated in infancy and again, successfully, on March 29th. Group II (Mrs. Anne D.).--One case, a woman aged 24 years, was taken ill on June 1st and developed a rash on June 4th, originally thought to be chicken-pox. She was admitted to the Port Health Hospital on June 9th with moderate discrete smallpox. She subsequently recovered and had never been vaccinated. Source unknown. Birkenhead Cases These can be divided into three groups. Group I (Mary B.).--This group comprised a single case, a woman aged 29 years, who was seen on May 13th and found to have a very severe haemorrhagic rash which was stated to have appeared the previous day. She had been ill three days before the appearance of the rash. She died on May 14th. This patient was unvaccinated. The source of infection may have been her husband, who was reported to have had stainings suggestive of a mild attack of smallpox. Group II (Joseph T., Sen., Margaret T., Dorothea May T., Joseph T., Jun., Terence T., Elliott C.).--The primary case was a man of 59 years, vaccinated in infancy and stated to have been revaecinated in 1918--no marks visible, He was taken ill on April 23rd and developed a very mild discrete rash on the 26th. l i e was seen twice by his doctor, once at the surgery and once at home, but the doctor did not suspect the rash to be that of smallpox. On May 9th this man's wife, aged 50 yea~, and daughter aged 15 (both unvaccinated) were taken ill and both developed rashes on May 12th. They were admitted to hospital on the 13th, the wife with severe haemorrhagic smallpox and the daughter severe confluent (becoming haemorrhagic) smallpox. The mother died on the 14th and the daughter on the 24th. On May 13th a son aged 17 years became ill and developed a rash on the 1.gth. He was vaccinated unsuccessfully for the first time on May 14th and ultimately died on the 23rd. On May 16th another son, aged 12 years, became ill and developed a haemorrhagic rash on the 19th. lie was vaccinated . for the first time, and successfully, on May 14th but he died on the 23rd. The last case in this group was the doctor who attended the family, who was taken ill between May 16th and 19th and developed a very mild discrete rash on the 22nd. lie had been vaccinated in infancy and revaccinated on May 13th---successfully. He subsequently recovered. The source of infection of the primary case is unknown. Group I l i (Robert R., Sarah R., Mrs. Sheila L.).--This group comprised three cases. The primary case, a man of 58 years, was taken ill on May 16th and developed a rash on the 18th. He was vaccinated in infancy--four marks--and revaecinated in 1915--two marks, lie developed a mild discrete smallpox and subsequently
recovered. The source of infection is unknown. On May 31st his wife, aged 53 years, was taken ill and developed a rash on June 3rd. She had been vaccinated in infancy and again on May 21st, successfully. She developed moderate discrete smallpox and recovered. A married daughter of this couple, aged 26 years, became ill on June 7th and developed a very mild discrete rash. She was vaccinated in infancy and successfully revaccinated on May 29th ; she was revaccinated, unsuccessfully, on May 19th and June 4th and 5th. This patient was eight months pregnant on admission to hospital on June 9th. She gave birth to still-born twins on June l l t h . There was no sign of any disease on either of the twins. Admb,;atratlve Measures Administrative measures within the hospital i n c l u d e d : - (a) Staff were n o t allowed out while cases w e r e in hospital in the actite stage. (b) D u r i n g the convalescent stage nurses were given leave b u t before leaving the hospital were r e q u i r e d to bathe, w a s h their hair and change all their clothes. (c) All nurses, except the sister-in-charge, were Liverpool nurses and di~l n o t stay in B e b i n g t o n d u r i n g off-duty hours. (d) W a r d floors were s w a b b e d twice daily w i t h disinfectant. (e) W i n d o w s and doors were s c r e e n e d against flies. ( f ) Scabs b u r n e d . (g) N o visiting was allowed, and refuse was disposed o f on the premises. (h) All s t o r e s - - f o o d , milk, e t c . - - w e r e left b y the t r a d e s m e n outside the m a i n gate. Points of Interest 1. Coincidental outbreak ashore w i t h s h i p b o r n e c a s e s - - ? arty connection. 2. M i l d cases can give rise to very severe cases. 3. A moderately severe case n u r s e d i n isolation hospital, in cubicle, gave rise to three cases, two o f w h o m died ; whereas a severe confluent case in a general hospital for five days, w i t h very little a t t e m p t at isolation, gave rise to n o cases there. 4. I n one case, a boy o f twelve, p r i m a r y vaccination was p e r f o r m e d on the n i n t h day and was successful; b u t the boy developed haemorrhagic smallpox and died. 5. A n unvaccinated, w o m a n recovered. 6. T h e table shows dates o f infection. I a m i n d e b t e d to Prof. W . M . Frazer, O.B.E., Medical Officer of Health, City and P o r t o f Liverpool, for permission to p u b l i s h this paper. "I~LS DATES OF I N F E ~ O N (DATI~ OF ADMISSION TO THE PORT HBALTH HOSPITAL IN THE CASE OF SHIPBORNE CASFS) OF ALL SMALLPOX CASES OCCURRING DURING THE OUTBREAK ON MEI~gEySIDE DURING THE FIRST HALF OF 1 9 4 6
Date o f Borough Group admission D s ~ e o f in No. to infeZ'tlon w h i c h case within hospital occurred Borough Feb. 18
~
I
1st
Mar.
2
--
n
II
let
,, ,, .
2 2 2
--~ Mar. 6 ,, 7 ,, 19 ,, 2 1 -A p r . 11 --
,, ,,
I5 II II 5 I 5 I III II IV
--Apr. 7 -,, 1 2 ------
-----
-----
Apr. ,, ,, . ,, ,, May ,, ,, ,, ,, ,, ,, ,, ,, ,, . ,,
Seaborne
Case within Group
12 18 28 28 28 30 1 3 4 4/7 4 6 8 16 17 18 19 20 26
Liverpool BebingtoD Liverpool Bebington Seaborne Birkenhead Seaborne Liverpool Birkenhead. . Liver~l Birkenhead Liverpool Birkenhead ~ Liver~l . ,, ,, Birkenhead Bebington Birkenhead
55 III I II II III II III II II Ill II II 5I III IV III II ISI
2nd 3rd
4th 1st 1st 2rid 2rid ] st 1st 1st 1st 1st 1st 2nd 3rd 2nd 4th 3rd 5th 6th ]st 2nd 3rd 4th 4th let 2nd let 3rd
N a m e o f patient
Patrick McM. "Empress of Australia " Norman O., "Duchess of Richmond" George M. ,, Charles B., . Percy R . , . Doris L. Mrs. T. Florence L. R<~bert T . John T., " Orion " Jc~eph T., Sen. P e t e r G e o r g e B., '" B r i t a n n i c " Ellen J. James W. Mary B. Margaret T. Dorothea May2. Alice H. Joseph T., Jun. Esther S. Terence T. Elliott C. Robert R. Graham T. Marie W. Margaret L. John William S. Jmeph D. Sarah R. Mrs. Anne D. Mrs. Shells L.
The Differentiation of Variola and Varleella T h e essential diagnostic criterion in the distinction between variola and varicella lies in the distribution of the rash, centrifugal in smallpox, centripetal in chicken-pox. What is the underlying pathology of this difference ? I am unable to hazard a guess. Extremely valuable as this difference i s - - a n d it is the mainstay of diagnosis--it can to greater or lesser degree be broken down in particular individuals. In the severest confluent cases of smallpox the rash is all but universal. Regions of the body may proportionately be more heavily covered than normal by the rash owing to local causes in both variola and varicella. I have already referred to the case of haemorrhagic chicken-pox with a semi-confluent eruption on the legs ; many years ago I was called to see a St. Helens glassblower with a confluent varicella eruption over his shins where he was exposed to the heat of the furnace. But such localised confluent patches are much commoner in variola than in varicella, and arise at any point of pressure or area of increased blood supply. Examples are from the pressure of a garter, corset or collar stud, an area of sunburn, e.g., on the back of the neck, or due to the occupation of the patient, as for example a ship's steward who had a confluent patch on the palm of his right hand where he held a bread knife, cutting bread having been his principal occupation. A recent case was an officer who, in the tropics, had perspired profusely over the body, and possibly suffered from " prickly heat." He came out with a considerable eruption on the abdomen which upset the normal distribution ; the laboratory, however, confirmed the diagnosis of smallpox. T h e most extraordinary variant of the variola virus is its conversion, per saltum, by animal passage into the vaccinia virus. This has, with the exception of the occasional occurrence of generalised vaccinia, lost its power of dissemination by the blood strear~--though this does not imply necessarily, or indeed probably, that it does not reach the blood stream. An interesting point about this variant is that when it does achieve dissemination the distribution is indifferent, neither centrifugal nor centripetal. This loss of power of dissemination by the blood stream is intimately associated with the loss of power to propagate other than by inoculation, but has not been so completely lost. It is perhaps useless to speculate on the nature of this variation. I expressly refrain in this connection from the use of the word mutation which has reference to genes, seeing that as we have no knowledge of whether the nature of this change is similar to a mutation or not, though it presumably relates to the chemical properties and nature of the virus, a thing, so far as we know, without any visible structure, as indicated by electron microscopy. REFERENCES
HANNA,W. (1913.) " Studies in Vaccination and Smallpox." PETERS, O . H . (1909.) Proc. R. Soc. ivied. (Epidem. Section). ST~LYnR~S, C.O. (1928.) J. State Med., 86, 27.
THE
SMALLPOX
O U T B R E A K ON M E R f l E Y S I D E , 1946" By E. R. PEIRCE, M.R.C.S., L.R.C.P., D.P.H., D.T.M., Senior Assistant Medical Officer, Port of Liverpool Smallpox is endemic in many parts of the world, particularly the eastern hemisphere, and some Indian ports are rarely, if ever, free f r o m cases of the disease: consequently vessels which call at these ports are always a potential source of danger and may be the means of importing smallpox cases into this country. This danger was accentuated in the spring of this year (1946) by the return of large numbers of troops from the East. I propose in this paper to describe the measures taken to guard against the import of cases of smallpox, to give a short description of the signs, symptoms and diagnosis of the disease, and finally an account of the outbreak which occurred on Merseyside during the first half of this year. T h e essential principles in the control of imported smallpox are the early diagnosis and isolation of cases, and the protection of immediate contacts by vaccination. All the measures to be * Paper read to the North-Western Branch, Society of Medical Officers of Health, September, 1946.
79 described are directed to this purpose. All necessary powers are obtained by the Port Sanitary Regulations 1933 and Amending Regulations of 1945. Article I I of these regulations requires the Port Medical Officer to prepare from time to time, and keep up to date, a list of foreign ports and seaboards which are infected or believed to be infected with plague, cholera, yellow fever, typhus fever or smallpox, and this list is compiled from the weekly returns issued by the Ministry of Health to all Port Health Authorities. These weekly returns show the number of cases which have been notified in all ports throughout the world.
Measures for Preventing Imported Infections T h e measures for preventing importation are reasonably uniform for all United Kingdom ports although there may be slight local differences dependent upon the size of the port and the number of staff available, T h e master of any vessel approaching Liverpool, which has called at an ~fected port during the previous six weeks, must send a wireless message to the Port Health Authority not less than four hours or more than twelve hours before arrival, stating the estimated time of arrival and that the Port Medical Officer is required. This message must be sent irrespective of whether or not there are cases of sickness. On arrival in the river the vessel is boarded, before docking, by ja medical officer, who obtains from the master a signed declaration of health concerning all persons on board together with a list of their names and intended destinations. If the vessel carries a surgeon he must also countersign the declaration of health. When the boarding medical officer has satisfied himself that there are no cases of infectious or contagious disease aboard he issues a certificate that the vessel may proceed to dock and pratique may be granted by the customs officer. T h e list of names and destinations of all persons on board is obtained in order that all contacts can be traced should a case occur after disembarkation. If any cases of smallpox are reported or discovered, the vessel is put under detention and ordered to anchor at a specified mooring station; the cases are disembarked by the Port Health Authority's launch and conveyed by ambulance to the Port Health Hospital. All persons aboard are examined and offered vaccination, and the destination of each individual is carefully checked. T h e ship's hospital, the quarters occupied by the patient, and all infected bedding and clothing are put under seal for subsequent disinfection by the staff of the Port Health Authority. T h e vessel is then allowed to dock and disembark passengers and crew. T h e names and addresses of destination of all persons who disembark are sent to the local medical officers of health together with a circular letter giving details of the cases and suggesting the period of surveillance. By this means any secondary cases which might arise can be isolated at the earliest possible moment. Smallpox may vary in severity from the very mild case (who is hardly ill) to the haemorrhagic case which is almost invariably fatal. T h e usual classification is: mild discrete--moderate discrete--severe discrete becoming semi-confluent--confluent --haemorrhagic. T h e incubation period is very consistent and in the great majority of cases is twelve days, although in very mild cases it may be as much as 18 days. A short period of nine days has also been recorded. At the end of the incubation period the temperature rises to 102 ° or 103° and the patient feels ill and apprehensive with severe headache and backache. Many patients have described the headache and backache as almost • unbearable; these symptoms continue until the appearance of the rash on the third day. There may be a prodromal rash simulating scarlet fever or rubella or measles, either in the " bathing-drawer" area or on t h e trunk, but the true rash commences usually about the wrists or ankles or forehead as discrete papules with a shotty feeling to the touch. As soon as the rash appears the temperature drops and the patient feels much better, the headache, backache and apprehension all disappearing. In about three days the rash becomes pustular. T h e change from papule to pustule is so rapid that clear vesicles such as are found in chicken-pox are never seen : moreover
80 t h e rash in each area is all in t h e same stage. T h e h a n d s a n d a r m s m a y be all pustules a n d t h e feet all papules, or vice versa, b u t you n e v e r find a p a p u l e vesicle a n d pustule all close t o g e t h e r in one area as in chicken-pox. T h e rash of smallpox is m o s t profuse on t h e extremities, face a n d scalp, gradually d i m i n i s h i n g towards t h e trunk, a n d e v e n In very severe cases a small area r o u n d t h e u m b i l i c u s will b e f o u n d free f r o m lesions. T h e axillae also escape. Pustules o n the palate are v e r y c o m m o n b u t the t o n g u e is usually free. T h e pustules are u n i f o r m in size, multilocular, a n d b e c o m e u m b i l i c a t e d : they are deeply set in t h e skin as c o m p a r e d w i t h t h e superficial unilocular pustule of chicken-pox. T h e c h i c k e n - p o x lesion also varies m u c h in size, a n d papules, vesicles a n d pustules are f o u n d t o g e t h e r in one area. I n smallpox cases w h i c h recover, t h e p u s t u l e s d r y u p a n d b e c o m e scabs w h i c h d r o p off a n d leave~ a typical b r o w n staining o n the face, limbs a n d t r u n k , a n d dark b r o w n or black seeds deeply set in t h e palms of t h e h a n d s a n d soles of t h e feet. T h e s e b r o w n seeds are diagnostic of smallpox.
Diagnosis T h e first case m a y p r e s e n t some difficulty if n o history of a n y contact is given. I t m u s t b e repeated t h a t this first case m a y b e hardly ill at all. However, the t h r e e days' history of headache, backache a n d pyrexia before the rash appears s h o u l d arouse suspicion, while t h e f o r m a n d d i s t r i b u t i o n o f t h e rash, m o s t m a r k e d o n t h e extremities a n d face, its u n i f o r m size a n d age i n each area, f r e e d o m of t h e umbilical region ancb axillae f r o m lesions, a n d t h e absence of c r o p p i n g s h o u l d confirm the diagnosis. I n c h i c k e n - p o x t h e m a x i m u m intensity of t h e rash is on the t r u n k , gradually d i m i n i s h i n g towards t h e extremities ; lesions v a r y in size a n d age, papules, vesicles a n d pustules b e i n g f o u n d in close p r o x i m i t y to each other. T h e r e are n o b r o w n staining a n d n o b r o w n seeds in t h e palms or soles. I n severe cases of chicken-pox t h e rash m a y spread even to the palms a n d soles, b u t in this event t h e t r u n k will b e f o u n d to b e literally covered w i t h lesions. I n chicken-pox t h e rash appears on the first day of t h e disease a n d t h e i n c u b a t i o n period is f r o m 14 to 21 days. H a e m o r r h a g i c smallpox is invariably f a t a l : the rash is n o t h i n g like the o r d i n a r y smallpox rash, a n d is f r e q u e n t l y diagnosed as h a e m o r r h a g i c measles, h a e m o r r h a g i c scarlet fever or p u r p u r a haemorrhagica. T h e p a t i e n t has the usual s y m p t o m s for t h r e e days a n d t h e n a h a e m o r r h a g i c rash appears, h a v i n g m o r e t h e appearance of measles. T h e face is red a n d bloated, r a t h e r like a lobster, a n d t h e r e is a generalised petechial rash w i t h h a e m o r r h a g e s f r o m t h e m u c o u s m e m b r a n e s . T h e patient b e c o m e s restless a n d delirious a n d d e a t h takes place very rapidly, 24 to 48 h o u r s after t h e appearance of t h e rash. O n e practical p o i n t m u s t n e v e r be forgotten, namely, t h a t w h e n e x a m i n i n g for smallpox the p a t i e n t m u s t always b e stripped.
Treatment T r e a t m e n t is m o s t l y n u r s i n g , a n d in severe cases t h e p a t i e n t m u s t be kept in a d a r k e n e d room. Otherwise t h e t r e a t m e n t is symptomatic :-(a) C o n s t a n t a t t e n t i o n to t h e eyes w i t h (i) use of eye shades ; (ii) use of penicillin eye-drops ; (iii) b a t h i n g w i t h w a r m boracic lotion. (b) C o n s t a n t s w a b b i n g out o f t h e m o u t h w i t h (i) glycerine a n d boracic ; (ii) glycethylamine for gargle. (c) A s o o t h i n g application of calamine lotion for t h e rash. Sulphathiozole 2 x ½ grn. t w o - h o u r l y is of value d u r i n g the p u s t u l a r stage b u t has n o influence earlier in the disease. O n e h u n d r e d a n d twenty-five t h o u s a n d u n i t s of penicillin was given daily to five children, all severe cases, four of w h o m died. D u r i n g t h e period F e b r u a r y 9th, 1946, to J u l y 2nd, 1946, 31 cases of smallpox were a d m i t t e d to t h e P o r t H e a l t h Hospital, N e w Ferry, a n d of these seven were l a n d e d f r o m troopships (two deaths) ; eleven occurred in t h e city of L i v e r p o o l (two deaths) ; t e n in B i r k e n h e a d (five deaths), a n d t h r e e in B e b i n g t o n . I n only one group of two cases in Liverpool could a n y direct c o n n e c t i o n b e t w e e n t h e s h i p b o m e cases a n d the land cases b e found.
PUBLIC HEALTH, January, 1947
Shipborne Cases T h e shipbome cases arose in four different vessels. The source of infection of all shipbome primary cases was Bombay. T h e three secondary cases in Ship II arose from a mild discrete case which occurred on February 11th. Ship I (Patrick M e M . ) - - T h e first case" admitted to the hospital was a member of the crew of a troopship which arrived on February 18th, 1946. T h e case was a very mild discrete smallpox probably contracted in Bombay. This man recovered and was discharged on March 13th. He had three marks of vaccination in infancy and although he stated he had been revaccinated five times in the Merchant Navy there was no evidence of any other take. Ship I I (Norman O., George M., Charles B., Percy R.).---This vessel arrived on March 2nd. The group comprised four cases (one primary and three secondary), three R.A.F. personnel and one Major, R.A.M.C. The first case, an L.A.C. aged 34 years, reported sick on February 11th, just after boarding the troopship at Bombay. There was some doubt about diagnosis owing to the mildness of the case, but some attempt at isolation was apparently made. The three other cases sickened on February 22nd, 24th and 25th, and were admitted to the Por~ Health Flospital on arrival on March 2nd. Of these three cases two were very mild discrete, and the third, who died on March 6th, a very severe confluent case. Atl the mild cases had been vaccinated in infancy with revaccinations in the Services, but there was no evidence of any revaccination takes. The severe confluent case was so ill on admission that it was impossible to obtain any vaccinal history, and, owing to the severity of the rash, it was impossible to discern any marks. Ship l l I (John T . ) . - - T h i s vessel arrived on April 7th. One case (a Chief Petty Officer, R.N.) of mild discrete smallpox was admitted to the Port Health Hospital on April 7th, and subsequently recovered. He was vaccinated in infancy and revaccinated in 1941, 194:4 and 194:6, but again there was no evidence of any revaccination takes. Ship I V (Peter G. B.).--This vessel arrived on April 12th. One case, a Petty Officer, R.N., who was admitted to the Port Health Hospital on April i2th with severe haemorrhagic smallpox, died on April 14:th. Vaccination history was not ascertainable.
Liverpool Cases The Liverpool cases can be divided into four groups.
Group I (Doris L., Florence L.).--This group comprised two cases which occurred at 8, Langrove Street, the first of which, a child aged twelve years, was infected on March 6th and was thought to be suffering from chicken-pox until April 5th, when the illness of her mother led to the true nature of the disease being discovered. T h e mother, a woman of 4:0 years, was admitted to the hospital on April 5th, together with her daughter, and both subsequently recovered. Both had been vaccinated in infancy and showed one mark. T h e daughter's disease was a mild discrete form, whereas the mother developed severe confluent smallpox. T h e source of infection in this group may have been a son who arrived home from Bombay on March 2nd in Ship II, from which four cases were sent to hospital. T h e son, however, gave no history of illness, nor did he show any signs of any recent illness. He disembarked from the vessel, proceeded to a transit camp and ultimately returned home, probably on Marcl~ 4th or 5th. No further case occurred from this focus. Group I I (Ellen J., Graham T., Marie W., Margaret L.).--This group comprised four cases which occurred in Fazakerley Hospital, the first of which (a woman) was probably infected on or about April 13th. She was admitted to Fazakerley Hospital on April 27th with a rash thought to be due to generalised vaccinia as she had been vaccinated successfully on April 17th; a diagnosis which remained unaltered until May 21st, when the true nature of the illness was discovered. She was a case of coincident vaccinia and smalIpox. Three secondary cases arose ; a boy of four years infected on or about May 6th, a girl aged four years infected on or about May 7th, and a girl of five and a half years infected on or about May 16th. T h e primary case in this group was classified as a moderate discrete smallpox with coincident ~vaccinia, and subsequently recovered. All the secondary cases developed severe confluent smallpox, and the boy and the girl aged five and a half years both died, the boy on June 1st and the girl on June 15th. T h e other girl recovered. The girl aged five and a half years was vaccinated successfully for the first time after contracting smallpox---on May 22nd; the other two children were both unvaccinated. T h e source of infection of the primary case is unknown. Group I I I (James W., Alice H., Esther S., and John William S.).-This group comprised four cases in the Everton district of Liverpool. T h e primary case was a man aged 41 years who was thought to be suffering from chicken-pox and had practically recovered before the secondary cases arose. The date of onset was April 30th and the rash appeared on May 2nd. He was admitted to the hospital on May 22nd as a mild discrete smallpox, and ultimately recovered. T h e secondary cases arising from this one were a woman aged 23 years who was admitted on May 21st with mild discrete smallpox;
81
PUBLIC ,HEALTH, January, 1947 a girl of 15 years who was admitted on May 22nd (also a mild discrete smallpox) ; and a man aged 42 years admitted on June 2nd with moderate discrete smallpox. All these cases recovered. All were successfully vaccinated in infancy and the man who was a secondary case stated that he had been revaceinated in 1944 and 1946, no takes. Group I V (Joseph D . ) . - - T h e case was sent to the Port Health Hospital from his home in Mossley Hill on May 21st as a case of suspected smallpox. He was revaccinated unsuccessfully on the same day, before admission to hospital. On examination, in the ambulance, he was found to have a pustular rash on both hands, palms and extensor surfaces which did not extend beyond the wrists, and gave a history of having been in bed for three or four days with headache, severe backache, and a rise in temperature. There were similar pustules on the ankles and soles of the feet. He was not thought to be smallpox and was isolated in a ward by himself, well away from the smallpox patients. He was treated with 125,000 units of penicillin and penicillin cream, and the rash cleared up in six days. He was discharged on May 27th. Two days later, on May 29th, he complained of malaise and headache, and again went to bed. On the 30th the headache and backache were more pronounced and there was some pyrexia. On the 31st the symptoms were still severe and on the afternoon of June 1st there were some discrete macular lesions on the trunk and back. There was no rash on the hands, face or feet. On the morning of June 3rd a typical discrete smallpox rash had developed on the face, hands, feet and back. He was readmitted to the hospital, developed moderate discrete smallpox, and subsequently recovered. He had been vaccinated in infancy. Bebington Cases These comprise two groups. Group I (Mrs. T., Robert T . ) . - - A woman, aged 50 years, was taken ill on March 19th and developed a rash on March °3rd. She was sent into Clatterbridge Hospital for observation on March 25th and transferred to the Port Health Hospital on March 29th, suffering from severe confluent smallpox. She stated that she had been vaccinated in infancy, but there were no marks visible. She subsequently recovered. The source of infection is unknown. This woman's husband, aged 55 years, became ill on April 2nd and developed a rash on April 5th, having been admitted to hospital on the 2nd for observation. He developed moderate discrete smallpox and subsequently recovered. He was vaccinated in infancy and again, successfully, on March 29th. Group II (Mrs. Anne D.).--One case, a woman aged 24 years, was taken ill on June 1st and developed a rash on June 4th, originally thought to be chicken-pox. She was admitted to the Port Health Hospital on June 9th with moderate discrete smallpox. She subsequently recovered and had never been vaccinated. Source unknown. Birkenhead Cases These can be divided into three groups. Group I (Mary B.).--This group comprised a single case, a woman aged 29 years, who was seen on May 13th and found to have a very severe haemorrhagic rash which was stated to have appeared the previous day. She had been ill three days before the appearance of the rash. She died on May 14th. This patient was unvaccinated. The source of infection may have been her husband, who was reported to have had stainings suggestive of a mild attack of smallpox. Group II (Joseph T., Sen., Margaret T., Dorothea May T., Joseph T., Jun., Terence T., Elliott C.).--The primary case was a man of 59 years, vaccinated in infancy and stated to have been revaecinated in 1918--no marks visible, He was taken ill on April 23rd and developed a very mild discrete rash on the 26th. l i e was seen twice by his doctor, once at the surgery and once at home, but the doctor did not suspect the rash to be that of smallpox. On May 9th this man's wife, aged 50 yea~, and daughter aged 15 (both unvaccinated) were taken ill and both developed rashes on May 12th. They were admitted to hospital on the 13th, the wife with severe haemorrhagic smallpox and the daughter severe confluent (becoming haemorrhagic) smallpox. The mother died on the 14th and the daughter on the 24th. On May 13th a son aged 17 years became ill and developed a rash on the 1.gth. He was vaccinated unsuccessfully for the first time on May 14th and ultimately died on the 23rd. On May 16th another son, aged 12 years, became ill and developed a haemorrhagic rash on the 19th. lie was vaccinated . for the first time, and successfully, on May 14th but he died on the 23rd. The last case in this group was the doctor who attended the family, who was taken ill between May 16th and 19th and developed a very mild discrete rash on the 22nd. lie had been vaccinated in infancy and revaccinated on May 13th---successfully. He subsequently recovered. The source of infection of the primary case is unknown. Group I l i (Robert R., Sarah R., Mrs. Sheila L.).--This group comprised three cases. The primary case, a man of 58 years, was taken ill on May 16th and developed a rash on the 18th. He was vaccinated in infancy--four marks--and revaecinated in 1915--two marks, lie developed a mild discrete smallpox and subsequently
recovered. The source of infection is unknown. On May 31st his wife, aged 53 years, was taken ill and developed a rash on June 3rd. She had been vaccinated in infancy and again on May 21st, successfully. She developed moderate discrete smallpox and recovered. A married daughter of this couple, aged 26 years, became ill on June 7th and developed a very mild discrete rash. She was vaccinated in infancy and successfully revaccinated on May 29th ; she was revaccinated, unsuccessfully, on May 19th and June 4th and 5th. This patient was eight months pregnant on admission to hospital on June 9th. She gave birth to still-born twins on June l l t h . There was no sign of any disease on either of the twins. Admb,;atratlve Measures Administrative measures within the hospital i n c l u d e d : - (a) Staff were n o t allowed out while cases w e r e in hospital in the actite stage. (b) D u r i n g the convalescent stage nurses were given leave b u t before leaving the hospital were r e q u i r e d to bathe, w a s h their hair and change all their clothes. (c) All nurses, except the sister-in-charge, were Liverpool nurses and di~l n o t stay in B e b i n g t o n d u r i n g off-duty hours. (d) W a r d floors were s w a b b e d twice daily w i t h disinfectant. (e) W i n d o w s and doors were s c r e e n e d against flies. ( f ) Scabs b u r n e d . (g) N o visiting was allowed, and refuse was disposed o f on the premises. (h) All s t o r e s - - f o o d , milk, e t c . - - w e r e left b y the t r a d e s m e n outside the m a i n gate. Points of Interest 1. Coincidental outbreak ashore w i t h s h i p b o r n e c a s e s - - ? arty connection. 2. M i l d cases can give rise to very severe cases. 3. A moderately severe case n u r s e d i n isolation hospital, in cubicle, gave rise to three cases, two o f w h o m died ; whereas a severe confluent case in a general hospital for five days, w i t h very little a t t e m p t at isolation, gave rise to n o cases there. 4. I n one case, a boy o f twelve, p r i m a r y vaccination was p e r f o r m e d on the n i n t h day and was successful; b u t the boy developed haemorrhagic smallpox and died. 5. A n unvaccinated, w o m a n recovered. 6. T h e table shows dates o f infection. I a m i n d e b t e d to Prof. W . M . Frazer, O.B.E., Medical Officer of Health, City and P o r t o f Liverpool, for permission to p u b l i s h this paper. "I~LS DATES OF I N F E ~ O N (DATI~ OF ADMISSION TO THE PORT HBALTH HOSPITAL IN THE CASE OF SHIPBORNE CASFS) OF ALL SMALLPOX CASES OCCURRING DURING THE OUTBREAK ON MEI~gEySIDE DURING THE FIRST HALF OF 1 9 4 6
Date o f Borough Group admission D s ~ e o f in No. to infeZ'tlon w h i c h case within hospital occurred Borough Feb. 18
~
I
1st
Mar.
2
--
n
II
let
,, ,, .
2 2 2
--~ Mar. 6 ,, 7 ,, 19 ,, 2 1 -A p r . 11 --
,, ,,
I5 II II 5 I 5 I III II IV
--Apr. 7 -,, 1 2 ------
-----
-----
Apr. ,, ,, . ,, ,, May ,, ,, ,, ,, ,, ,, ,, ,, ,, . ,,
Seaborne
Case within Group
12 18 28 28 28 30 1 3 4 4/7 4 6 8 16 17 18 19 20 26
Liverpool BebingtoD Liverpool Bebington Seaborne Birkenhead Seaborne Liverpool Birkenhead. . Liver~l Birkenhead Liverpool Birkenhead ~ Liver~l . ,, ,, Birkenhead Bebington Birkenhead
55 III I II II III II III II II Ill II II 5I III IV III II ISI
2nd 3rd
4th 1st 1st 2rid 2rid ] st 1st 1st 1st 1st 1st 2nd 3rd 2nd 4th 3rd 5th 6th ]st 2nd 3rd 4th 4th let 2nd let 3rd
N a m e o f patient
Patrick McM. "Empress of Australia " Norman O., "Duchess of Richmond" George M. ,, Charles B., . Percy R . , . Doris L. Mrs. T. Florence L. R<~bert T . John T., " Orion " Jc~eph T., Sen. P e t e r G e o r g e B., '" B r i t a n n i c " Ellen J. James W. Mary B. Margaret T. Dorothea May2. Alice H. Joseph T., Jun. Esther S. Terence T. Elliott C. Robert R. Graham T. Marie W. Margaret L. John William S. Jmeph D. Sarah R. Mrs. Anne D. Mrs. Shells L.