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of the European death-rate to that of London it will be readily understood that
too much importance may easily be assigned to purely local factors. With regard,
however, to the zymotic diseases, epidemics of cholera and fever led to improvement
of the water supply and methods of sewage disposal. In regard to smallpox, the
more effective enforcement of vaccination by the appointment of public vaccination
officers in 1871 must be associated with the downward trend of smallpox mortality
from about that time. In the early " seventies'' food prices and food supplies became
stabilised, and attention was directed to the housing conditions of the poor, many
clearance schemes being initiated under the Artisans and Labourers'General Dwellings
Act, 1875, and numerous tenement dwellings being provided by private bodies.
In 1870 the Elementary Education Act was passed, and there can be little doubt
that a great deal of the fall in mortality which dates from about the end of the
"eighties," is to be associated with education. Among the factors which have had
much to do with improvement in the diagnosis and certification of deaths, reference
must be made to the greatly increased proportion of deaths occurring in institutions.

Smallpox.
Infectious Diseases.
The attack-rates and death-rates of the principal infectious diseases in London
and the constituent boroughs are shown in the table on page 77.
During 1925, 15 cases of smallpox were notified as occurring within the administrative
county of London, of which five were found not to be suffering from smallpox
on revision of diagnosis. Another case was discovered in London but was referable
to the Port of London authority. Of the 10 confirmed cases in London, 8 occurred
in the metropolitan borough of Bethnal Green, and one of these (a hemorrhagic
case) proved fatal—a female of 57 years who had not been vaccinated since childhood.
The other two cases, which were both non-fatal, occurred in Lambeth
and were apparently unassociated with the outbreak in Bethnal Green, although
they were discovered about the same time. The character of the symptoms in
both these patients indicated the mild type of smallpox which has been prevalent
in the midlands and the north for the past few years. The Port of London case
was that of a sailor who disembarked from his ship in the Port and was later in
the same day diagnosed in a doctor's surgery in Stepney to be suffering from smallpox.
Fuller particulars of the 11 cases to which reference has been made are given
below.
Comment was made in last year's annual report upon the continued prevalence
of smallpox of a mild character in the provinces and upon the remarkable fact
that hitherto London has escaped involvement in this epidemic. Of all the cities
in the United Kingdom, London is probably the most vulnerable to attack, whether
by the mild type of smallpox from the provinces or by the severer kind from the
Mediterranean and the East, firstly because of the large number of visitors it receives
yearly from the country or overseas, and secondly because, as a Port, it is in daily
touch, through sea-borne commercial traffic, with all parts of the world. On
this account it is all the more noteworthy that, apart from local and isolated outbreaks
which occur from time to time, this vast metropolitan area remains, in
spite of its susceptibility and great proportion of unvaccinated inhabitants, comparatively
free from the disease.
The following table which is quoted from the