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and Western hemispheres—and foreign seaports are among the special breeding grounds of the disease—
it can only be hoped to put off the evil day of the return of smallpox as long as possible; under present
conditions it is not possible indefinitely to escape what is in effect a universal scourge.
The case would be a very different one if general use were made of vaccination. Countries such
as Holland and the Philippine Islands have rid themselves almost entirely of smallpox and any scare of
it by means of vaccination ; but our population is largely unprotected and is yearly becoming more so.
It is always liable to be attacked by the chance importation of a case into a neighbourhood, where infection
will take hold and spread rapidly. This happened towards the end of the year 1919 in a country district
where a mild unrecognised case led in a few weeks to 59 other cases, to the closing of all the elementary
and secondary schools and to the closing of the Sunday schools. Similar happenings have often been
reported. One such occurred in London in 1911, when 70 cases of smallpox followed a single unrecognised
case, infection from which, as it chanced, lit upon a susceptible group of people. Again, in 1901,
a few cases of smallpox were overlooked; with the result that while on 19th August, 1901, there were
only 15 cases in hospital, eight days later there were 73. In that single week of the summer hoi'days
serious damage was done; smallpox went straight ahead after that to the extent of 10,000 cases in
all, and cost the Metropolitan Asylums Board alone £500,000.
It is the special risk of smallpox that it cannot be foreseen, or calculated against beforehand,
either as to time of attack, extent of attack, or as to expense. The late Dr. T. F. Ricketts observed that
"Outbreaks of smallpox are prone to occur without warning and to reach unpleasant proportions with
great rapidity." The story of each successive outbreak emphasises anew the need for being always
prepared to deal with an emergency, so as to check it at the outset; the main item in such preparation
being to use every available means to secure that each case of smallpox is recognised immediately it
occurs.
The deaths from measles in London during 1920 numbered 1,016, as compared with 353 in Measles.
1919. The mortality was 0 22 per 1,000 living, and this is much below the average of the past
20 years. The monthly deaths from measles in London since 1890 are shown in the diagram
facing page 80 in Part II. of this Report. The mortality from measles is greatest in the second year
of life ; the low birth rate of 1917-18 has therefore to be taken into account in contrasting the 1920
figure with that of earlier years.
There were 22,705 cases of scarlet fever in London in 1920 (52 weeks), as against 12,935 in 1919 Scarlet fever.
(53 weeks). The deaths numbered 207 (366 days), giving a death rate of 045, the corresponding
figure for 1919 being .033. The monthly incidence of scarlet fever cases in London since 1890 is
shown in the diagram facing page 80 of this Report, and some notes upon the seasonal fluctuations of
prevalence will also be found there. It will be seen from the diagram referred to that the autumnal
incidence of scarlet fever in London in 1920 was greater than in any year since 1892.
The number of cases of diphtheria notified in 1920 (52 weeks) was 13,780, as compared with 9,459 Diphtheria,
in 1919 (53 weeks). The deaths in the calendar year were 1,023, the corresponding figure for 1919 being
775. The number of cases of diphtheria in London in the year 1920 exceeded that in any calendar
year since the disease became notifiable, although, as will be seen from the diagram facing page 80,
the autumnal incidence in 1893 was slightly higher than that of 1920. The Ministry of Health's annual
returns of the incidence of infectious disease show that the excess in incidence of diphtheria in London
over that in the rest of England and Wales has steadily increased since 1911, the date when the returns'
were first prepared.
Only two cases of typhus fever were notified during 1920, and in both cases the diagnosis was Typhus
revised after admission to an M.A.B. fever hospital. In one of these cases the medical practitioner fever.
called in one of the Council's consulting medical staff to assist in the diagnosis. Dr. J. G. Forbes
examined the patient and advised removal to hospital for observation on suspicion of typhus fever.
The possibility was, however, negatived after a period of supervision of the patient at the South
Eastern M.A.B. Hospital.
No cases of plague or cholera were notified during 1920. It will be of interest, however, to refer Plaaue and
briefly to a case in which suspicion of plague was raised. The patient was a man under treatment at a cholera.
nursing home and was suffering from lumps in the axillae and enlarged glands in the groin. One of
the Council's consulting medical staff (Dr. W. McC. Wanklyn) was called in and he advised that a
specimen of glandular fluid should be taken for bacteriological examination. This course was adopted
and as a result, staphylococcus aureus was isolated from the specimen. It subsequently transpired that
the patient's condition was due to the bite of an Asiatic bug, and that all the members of the family
had suffered in a similar way. The patient and his family had not long previously arrived in this country
from China, and it was ascertained that on board the vessel in which they sailed there was a number
of Chinese coolies travelling en route for Russia.
During 1920, 15 cases of anthrax occurred in London, of which four proved fatal. The origin Anthrax,
of infection was traced in 11 instances to the handling of imported hides, hair or wool, during the course
of the patient's occupation. With regard to the remaining four cases the use of an infected shaving brush
was definitely traced as being the cause of the disease in three cases, and strongly suspected in the fourth;
in the last mentioned case it was ascertained that the patient had used a new shaving brush immediately
before the appearance of the disease, but the brush, which had been bought from an unknown man off
an unknown U.S.A. ship, could not be obtained.
It was pointed out in last year's annual report that certain cases of anthrax had occurred as a
result of using Japanese shaving brushes, and that following upon prompt administrative action an Order
in Council was issued under the Anthrax Prevention Act, 1919, prohibiting the further importation of
these brushes. In spite of this Order, however, it was found that large numbers of Japanese brushes
were still on the market, owing mainly to the difficulty in tracing all the brushes in circulation before
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