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(4) The fourth case in this series occurred in the Metropolitan Asylums Board
Eastern Fever Hospital. The patient, an unvaccinated male child, aged four years,
was admitted to the hospital on the 31st March, 1927, with whooping cough. On
the 17th May he was transferred to the South Wharf Receiving Station on suspicion
of smallpox. The diagnosis was confirmed, and the child was taken to Long Reach
Hospital, where he died on the 23rd May. The infection in this case must have been
contracted in the hospital, probably from some unrecognised case in a visitor, but the
actual origin was never traced.
(5) The fifth London case was imported from the North of England. A male
vagrant, P.R., aged fifty-four years, vaccinated in infancy, tramped from Yorkshire
to London, and was discovered in the Paddington Casual Ward on the 14th June to
be suffering from smallpox. He had had a noticeable rash for seven days when
detected. The case was very mild and typical of those which have been occurring
in the provinces for the past few years.

Note.—During 1927, there were 49 deaths in England and Wales in which smallpox was mentioned
as a primary or contributory cause of death. In 13 of these smallpox is stated to be a contributory or secondary
cause of death. In the remaining 36 cases smallpox is entered on the death certificate as the sole, primary or
immediate cause of death or as a morbid condition giving rise to the immediate cause of death (for further particulars
see the Annual Report of the Chief Medical Officer of the Ministry of Health for 1927 on the "State
of the Public Health" when published).
In last year's annual report it was stated that it was "hardly reasonable to
assume that the Metropolis would remain free indefinitely." The early experience
of 1928 has lent weight to that statement, for in the first three months about fifty
cases of smallpox have occurred in London, mostly among the vagrant or indigent
class, whilst as many have been reported in the surrounding counties. The outbreak
or ginated in a casual ward at East Preston, Sussex, where a tramp was admitted
in December, 1927, in a collapsed condition, having tramped from Lincolnshire.
He was not recognised as suffering from smallpox, but a fortnight later about a dozen
cases were discovered in the casual ward, and it was only then that the nature of
the illness of the earlier admission was detected. In the meantime, large numbers
of tramps had scattered over the countryside and many of them were incubating
smallpox, with the sequel already stated. The outbreak is still in progress at the
time of going to press, and a fuller report will be published in the annual report for
1928. The special danger to London of this mild type o smallpox, apart from the
suffering, disorganisation and expenditure of time and money inherently associated
with an outbreak of this disease, is the recurring risk o the introduction of the severe
form of the malady from the Mediterranean or the Eastern Hemisphere, side by
side with 'he benign form. It is only necessary to compare the mortality in the
"Hendon" outbreak, i.e., thirteen cases with seven deaths (over 50 per cent. mortality),
with that in the provinces (see table above), to realise the anxiety which