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not extend outside his part of the borough. By inference therefore,
it seemed wellnigh certain that a study of recent and not-sorecent
death certificates would provide a lead to the source of
infection. The complete absence of any reported cases of smallpox
elsewhere in the country suggested that the earlier missed
case (or cases) must either have been modified clinically and have
occurred in a subject who was himself vaccinated and belonged to a
small wel1-vaccinated group or the earlier case must have died
before his disease had reached the infectious stage. The search
was therefore at once narrowed to a retrospective inquiry for
someone who had died in the early stages of haemorrhagic smallpox,
and the presumption was that the cause of death most likely to
have been assigned would be leukaemia. Accordingly, at the
suggestion of one of us (C.G.N.) a scrutiny was made of all death
returns for the past four months, and four deaths which had
occurred during that time seemed worthy of investigation, the
stated cause of death in all cases including the term "leukaemia"'.
Further inquiries readily disposed of any possible suspicion in
the first three cases, late residents of Tottenham, but in the
case of the fourth (Mr. Y.) a licensee lately of the adjoining
metropolitan borough of Islington, an interview with the widow
revealed that she and her late husband had visited his brother
(Mr, X.) in Wembley, who with his daughter (Miss X. aged 8) had
been suffering from "chicken pox" Thirteen days later Mr. Y.
became very ill and was admitted late at night to St Ann's
General Hospital.
This patient had Had an acute febrile illness with haematuria,
massive purpura and an enlarged liver and spleen from which he
died four hours after admission. A white blood count done before
death showed 28,000 cells per ml. 48% of which were primitive
cells of the polymorph series. Haemophilus influenzae and
pneumococci were recovered in large numbers from a blood culture.
As the cause of death was uncertain the coroner was notified and
body removed to the Prince of Wales' s General Hospital for autopsy.
The purpuric condition, with a leukaemoid blood film suggested a
diagnosis of acute leukaemia, but in retrospect he must be regarded
as a case of haemorrhagic smallpox. Post mortem specimens were
sent to the pathological laboratory from where it may be assumed
the cleaner (Mrs. A.) became infected. The brother-in-law (Mr.
X. ) of Wembley, a well vaccinated subject, had returned to this
country by air from Lagos, West Africa, on the 29th March and on
the 11th April had developed a mild illness diagnosed at the time
as chicken pox. The young daughter, vaccinated in infancy, became