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England and Wales ; in the last decade, when sanitary measures outside
London had also improved, the ratios for England and for London fell so as to
approach each other.
Turning to diphtheria, on the other hand. in both England and London the
mortality was less in the second decennium than in the first, but in the last
decennium it was greater than in the second, and in London had increased to
a higher ratio even than in the first. Comparing London to England, in the
first decennium the ratio of mortality was about 5 per cent. lower than in
England, in the second was about equal, and in the third it was about 60 per
cent. higher.
Further, whereas the annual death-rates from all causes, from the seven
principal zymotic diseases, and from enteric fever, have been steadily falling
in England and Wales, in the large towns, and in London; the annual deathrates
from diphtheria have been rising slightly in England and Wales, more
markedly in the large towns, and most markedly in London.

In searching into the cause of this apparently persistent and progressive
increase of the mortality from diphtheria in London, the first point that strikes