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25
of shelter during air raids were considered. Fortunately the special opportunities for continuing these
observations no longer occur, but there can be no doubt that among the factors contributing to the
phenomenal spread and fatality of influenza during 1918 in London, congestion and crowding, such as
for example have prevailed in tube railways, have played a part.
Study has been made during the last 8 years of the flea hypothesis of causation of scarlet fever.
The conclusions reached were set out in last year's report. During 1918, however, it has been necessary
to consider further a criticism which has been made. Thus, it has been urged that the incidence of
scarlet fever is in some instances greater upon well-to-do than upon poor populations ; this contention
is undoubtedly justified at certain times and in certain places, but it is not generally true. The
opportunity has been taken to assess, as accurately as may be, the qualifications and limitations to be
put upon such a statement, and incidentally the influences exerted by age incidence, school attendance,
movement of population and the protection afforded by previous attack have been carefully considered.
The results of this enquiry have been illustrated diagrammatically and are set out on pp. 45-48 and in
diagrams A and B. It may be stated broadly that the facts thus summarised strengthen rather than militate
against the flea hypothesis, but it needs to be borne in mind that the children in the slums are
attacked as a rule at an early age, and that when the disease spreads to the surrounding areas the latter
may present the appearance of suffering more heavily from the disease, the poor areas having purchased
comparative immunity at the price of earlier exposure.
The results of medical inspection.
Number of
children
inspected.
The inspection in detail of entrant infants was resumed in the autumn term of 1917, and continued
throughout 1918. Full facilities for inspection were therefore provided for all entrants and leavers,
and, in addition, for the inspection of all elementary school children at the age of eight. 206,938 children
were inspected in the age groups in the elementary schools, 1,579 in the special schools, and, in addition,
47,114 children not in the age groups were officially examined, owing to some indication of ill health
noticed by teachers, school nurses, or care committee workers, or were submitted for examination by
the attendance officers on account of absence from school.
The total number of children inspected during 1918 was therefore, 255,631, as compared with
283,185 in 1917. The detailed results are shown in tables A and B, pp. 53 and 54.
Attendance
of parents at
inspection.
The percentage of parents attending at routine inspections as in tne previous year, was 56. The
greater solicitude felt by the parents for the entrant infants was again manifest, as the percentage o1
parents attending in the case of these was over 70. The least concern was shown for leaving boys
to the examination of whom only 36 per cent. of parents came.
Number of
chi dren
referred for
treatment.
The proportion of children inspected who require medical attention in one form or another remains
very high. At routine inspections advice cards were issued to 91,474 children, or 44 per cent. of those
examined by the doctors. This percentage is higher than in the previous year, but this, to some extent,
is explained by the fact that during the first part of 1917, entrant infants were not all examined in
detail and many defects therefore were not detected.
The comparative figures given in the accompanying tables are worthy of careful study. They
are percentages worked out for each year of the results of the examination of more than 200,000 children
in the age groups. They refer to those index conditions which are most affected by economic changes
in the life of the people, and they tell the story of the war as reflected in the condition of the elementary
school children of London.
The story is one of which London may be proud, for it is one of continuous amelioration throughout
the whole period of the war. Whether judged from the state of the children's clothing, from their
health as expressed by their nutritional well-being or from the conditions found as regards cleanliness,
the result is the same, practically steady improvement in each particular.

* The figures for 1917 are for the third term only, when inspection of entrants in detail was resumed
after its discontinuance in 1916.
50129 D