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(b) When comparison was made, between 20 good elementary schools and 20 poor elementary
schools, the apparently anomalous result was obtained that the former had suffered
more severely than the latter. In order to throw further light upon these school figures the records
of medical examinations of "entrants" and children of the intermediate age (8-9 years) in the two
groups of 20 schools have been analysed. In some 1,700 cases, among "entrants" in the good schools,
3.5 per cent. were stated by the parents to have suffered from scarlet fever, and of 2,030 children of the
age 8-9, 8.4 per cent. had been attacked. For the group containing the poorest schools the corresponding
figures were 4.3 per cent. and 6.5 per cent. respectively. It appears, therefore, that during school life
(8.4—3.5 = 4.9 per cent. of scholars in the good schools, have been attacked, while among the poorest
class (6.5—4.3 = 2.2 per cent.) only suffered. On the other hand, at the age of entering upon school
life, the records among the poorest children show a greater percentage attacked than among those in the
good schools; allowance must, moreover, be made for the fact that the age of commencement of school
attendance among the poorer children is early and bearing this in mind, the figure 4.3 per cent. would
need to be increased and would then stand in still sharper contrast with the 3.5 per cent. obtaining in
the good schools.
The position, therefore, is that on entering upon school life, and for the next two or three years,
the incidence upon children in the good schools is nearly double that upon the poorest children; while
the percentage attacked up to this age is greater among the poorest children. It follows that the attack
rate among these children must be greatly in excess of that among other children in the first few
years of life; and yet when a comparison confined to school age (5-13) is instituted between the
richer and the poorer boroughs the children in the former show excess over the poorer children,
although when comparison is limited to the pre-school age the relation is reversed.

Upon this view of the case the children under school age are exposed to a markedly excessive
extent in the poorest areas to infection by scarlet fever, and then later in virtue of acquirement of
immunity they actually suffer distinctly less at school age than the children of the next higher social
grade, those belonging to the less poor areas; they suffer, indeed, to no appreciably greater extent at
the school age than the children in the still higher grade, those belonging to the least poor areas.
The results are almost as striking if consideration be limited to children attending the
elementary schools (See Diagram E. Annual Report, 1914). In the poorest boroughs elementary school
children constitute the main bulk of children at school age, and they suffer notably less than the children
just under school age (Diagram E(a); in the less poor areas the percentage of children in elementary
schools is still quite considerable, and these children may actually suffer more than the children under
school age; in the least poor-areas the percentage of children of school age is comparatively low and
comparatively speaking few of these children attend public elementary schools; Diagram E (b) shows
that the rates per 1,000 are throughout higher in the good schools than in the poor schools
Questions of
nomenclature
From this analysis it will be obvious that in instituting comparisons between incidence of scarlet
fever in different parts of a town or country, regard must be paid to age and to school attendance as well as
to social conditions. But this is by no means all. As has been shown (Annual Report for 1916), considerable
differences of fashion as regards nomenclature have existed, and to some extent still exist, so that the
cases described as scarlet fever in London have not always precisely corresponded with those so described
say, in Lancashire or Cornwall. The close relation and tendency to confusion between diphtheria and
scarlet fever must particularly be borne in mind in this connection. Again, in some town and country
districts, milk-borne scarlet fever has been more common than in others, and in prevalences of this kind
adults may be even more commonly affected than children. This form of scarlet fever differs in certain
respects from ordinary scarlet fever, notably as regards absence of capacity for spreading from case to
case, and it has even been suggested that milk-borne "scarlet fever" is really altogether distinct from
scarlet fever properly so-called. Yet another point to be recollected is the tendency which both scarlet
fever and diphtheria manifest to attack the suburbs of growing towns, particularly those occupied by
artisans and working people, who have recently migrated there and many of whom have young families
and occupy newly built houses. This subject was carefully considered so far as diphtheria is concerned
by Dr. Dowson in a paper on "Diphtheria in Older and Newer Bristol." Somewhat similar phenomena
have been noted in the case of scarlet fever in London. Still another factor to be reckoned with is that
manifestation of the influence of immunity which is exhibited in the tendency shown by scarlet fever,
and by diphtheria also, gradually to spread from one part of a large town to another a phenomenon
to be more particularly considered almost immediately.
Enough has been said to explain why it has come about that frequent note has been made in the
epidemiological literature of an exceptional predilection often exhibited by both scarlet fever and
diphtheria for attacking well-to-do populations. The writings of Creighton and Hirsch contain many
references of the kind referred to. A striking and particularly interesting allusion was incidentally made
to this question last year by Dr. John Brownlee, who in a report on "Phthisis," to the Medical
Research Committee cited scarlet fever as an example of a disease which may prevail in populations
favourably circumstanced as regards " social condition."