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a decline in the mortality from most of the principal causes of infant mortality; diarrhoea is a striking
exception, the mortality from" summer diarrhœa" was considerable owing to the temperature being
above the average throughout the summer. The relationship between summer temperature and infant
diarrhoea is discussed on page 10.
The infant mortality in the four quarters of 1921, was 85, 59, 93, and 78 respectively, and in the
first quarter of 1922, 99. This latter figure is somewhat high owing to the epidemic of influenza.

The deaths from scarlet fever and diphtheria were more numerous in 1921, than in recent years
owing to the exceptionally high prevalence of these diseases. Of other causes of deaths which show
increase in 1921, mention may be made of cancer which caused 6,008 deaths being 418 more than in 1920,
and higher than in any previous years; the diabetes deaths, and still more strikingly those from
appendicitis were also high. The number of suicides was above the average. Deaths from poisons and
poisonous vapours were much above the average and indeed in excess of any year since 1910; a certain
number of these deaths were attributable to coal gas poisoning, there being a number of inquests into
this cause of death in the latter half of the year.
The death rates in each metropolitan borough in 1921 from all causes and certain specified causes
will be found in Table I. appended to this report.
Smallpox.
Infectious diseases.
The number of deaths registered in London has remained quite small since 1901 and 1902, the
epidemic years. In the last seven years the deaths have been 3, 0, 0, 0, 5, 4, 0 respectively. These
figures may be contrasted with the corresponding numbers for British India which have ranged from
60,642 for the year 1916, to 136,077 for the year 1919. In London the numbers of notifications in the
last seven years have been 13, 3, 0, 36, 27, 18, 2.
Only two cases of smallpox occurred in London during 1921, neither of which proved fatal. The
first was a stewardess from a ship on which smallpox had occurred and who was under observation as
a contact. In the second case the patient had just returned to this country from Russia where he had
been engaged on relief work and where there is no doubt the disease was contracted. Dr. Wanklyn was
called in to see the case a few days after the patient's return home and at once diagnosed smallpox.
All the contacts were vaccinated and prompt administrative measures were taken with the result that
no further cases resulted.
Passengers and members of crews of 7 ships on which smallpox had occurred, and of six ships
which arrived from infected ports, were kept under observation. Of these one woman, referred to above,
developed the disease. In order to represent the existing smallpox position with accuracy, a few words
are necessary to draw attention to its main features. On the one hand is a mass of smallpox infection
widely distributed throughout the world,—witness India, for example, the prevalence of smallpox in which
country is of immediate interest to London, since smallpox is apt to be imported from there—and on the
other hand is a population so highly susceptible to the disease that four-fifths of them would be attacked,
if thoroughly exposed; that is to say, that if the population of the County is no better vaccinated than
that of the country generally, as probably is the case, 3,500,000 of the population of the County are liable
to take smallpox. In this exceedingly insecure position, between the positive external pressure of
infection and the predisposing influence exerted by susceptibility, the only effective barrier interposed is
that of the Public Health Services of London, which have the duty of detecting smallpox as soon as a
single case occurs, and of suppressing it as promptly. The penalty of failure in this service is exceedingly
severe, and may result, as has often happened before, in a sudden inrush and spread of smallpox. An
epidemic of this would not only cause the death of some hundreds or thousands of victims, but indirectly
would inflict an additional heavy loss of health and life. This would arise chiefly in three ways, by
producing panic, unemployment, and poverty; by interfering with normal public health activities; and
by incurring an expenditure which almost certainly would run into millions of pounds sterling, the 1902
epidemic having cost the Metropolitan Asylums Board alone £500,000. Such are some of the evils to
which the non-vaccinated condition of the population renders it continuously and closely exposed.
The work of prevention falls mainly under three heads.
1. Arrest of infection at the 'port.—Much depends on this. For instance, in the year 1919, 23
smallpox-infected ships came to the Port of London; 16 of these came from or via India. Most of the
actual cases had been removed before arrival; but 12 cases came to the Port with the rash upon them.
These were all stopped there by the vigilance of the Port Authority. Two cases came through the Port
and actually entered London. Each of these was reported to have passed the Port in the incubation