CHAPTER IV

THE EXTENT AND CAUSES OF MALNUTRITION

"Defective nutrition," Sir George Newman points out, "stands in the forefront as the most important of all physical defects from which school children suffer."[456] Malnutrition, 'debility' and other physical defects in childhood "are the ancestry of tuberculosis in the adult. They predispose to disease, and are, in a sense, both its seed and its soil."[457]

Footnote 456:

Report of the Chief Medical Officer of the Board of Education for 1910, p. 26.

Footnote 457:

_Ibid._, p. 1.

It is impossible to give any figures as to the extent of this defect, since nutrition is not a condition which can be measured by any definite standards. The weight of the child is, of course, a most important matter to be noted, but there are other points--"the ratio of stature to weight; the general appearance, carriage and 'substance' of the child; the firmness of the tissues; the presence of subcutaneous fat; the development of the muscular system; the condition of the skin and redness of the mucous membranes; the expression of listlessness or alertness, apathy or keenness; the condition of the various systems of the body; and, speaking generally, the relative balance and co-ordination of the functions and powers of digestion, absorption and assimilation of food."[458] Each observer adopts a different standard of what constitutes good nutrition, and hence the statistics given in the reports of the School Medical Officers cannot be used for comparative purposes. According to the latest figures, as quoted by the President of the Board of Education, 10 per cent. of the elementary school children of England and Wales suffer from defective nutrition.[459] Many of the School Medical Officers, however, have obviously adopted a low standard and Mr. Arthur Greenwood, who has made a careful enquiry into this subject, is of opinion that, "taking the country as a whole, not merely 10 per cent., but probably a number approaching 20 per cent., show perceptible signs of malnutrition."[460]

Footnote 458:

_Ibid._, p. 26.

Footnote 459:

_Hansard_, April 10, 1913, Vol. 51, p. 1381; _The Health and Physique of School Children_, by Arthur Greenwood, 1913, p. 48.

Footnote 460:

_Ibid._, p. 50.

Unfortunately, there is reason to believe that the degeneration is progressive. In an enquiry conducted by Dr. Arkle at Liverpool, 2,111 children from three elementary schools were compared, as to height and weight, with 366 children from secondary schools. The results (see accompanying table) showed that at practically every age the heights and weights of the children varied directly with the class from which they were drawn, and the deficit increased out of proportion to the rate of growth. "These figures," he points out, "are rendered all the more striking when one considers that one is talking of children and not of full-grown men. A difference of a stone in the weight of two men may not be a very great matter, but when the investigation shows such a discrepancy between two groups of boys of eleven, it means that one of the groups is deficient to the extent of one-fifth of the whole body weight, and the decadence is so progressive that the deficiency has by fourteen years of age almost reached a quarter of the whole body weight."[461]

Footnote 461:

"The Medical Examination of School Children," by Dr. A. S. Arkle, a paper read at the North of England Education Conference, January, 1907 (reprinted in _School Government Chronicle_, Supplement, January 12, 1907, pp. 77, 89). As we have already said, the nutrition cannot be determined solely by weight. "In fact," as a School Medical Officer points out, "an ill-nourished child may be above the average weight, or, on the other hand, a healthy child may be much under the average and yet not be ill-nourished." (Report of the School Medical Officer for Leeds for 1910, p. 27.) But when dealing with large numbers of children, the average weight furnishes a reliable index of nutrition.

This malnutrition is to be attributed to many causes besides actual lack of food. Improper food and hurried methods of eating account for much malnutrition. So much has been written on the subject of the wrong feeding of children that it seems unnecessary to labour this point. One can, indeed, hardly open a report of a School Medical Officer without finding this evil deplored. In the poorest homes there are frequently no fixed meal times; the children are given "a piece" when they are hungry, and this is often eaten in the street or on the doorstep. Bread and tea figure largely in the dietary. Supper is frequently the principal meal of the day, with resulting indigestion for the children.

Employment out of school hours and want of sleep are again important factors. Indeed, in the eyes of some School Medical Officers, malnutrition is due more to want of sleep than to lack of food. The children are almost invariably kept up till late at night, it being a rare exception to find a child being sent to bed at anything approaching a reasonable hour.

A still more potent cause, perhaps, is to be found in bad housing conditions. Striking testimony as to the relation between the physique of school children and housing was adduced by Dr. Leslie Mackenzie and Captain Foster, as a result of an enquiry into the condition of 72,857 school children in Glasgow. "If we take all the children of ages from 5 to 18," they report, "we find that the average weight of the one-roomed boy is 52.6 lbs.; of the two-roomed, 56.1 lbs.; of the three-roomed, 60.6 lbs.; of the four-roomed and over, 64.3 lbs. The respective heights are 46.6 inches; 48.1 inches; 50.0 inches and 51.3 inches. For girls the corresponding figures are:--Weights, 51.5 lbs.; 54.8 lbs.; 59.4 lbs.; 65.5 lbs. The heights are 46.3 inches; 47.8 inches; 49.6 inches; 57.6 inches."[462]

Footnote 462:

Report by Dr. Leslie Mackenzie and Captain A. Foster, on the Physical Condition of Children attending the Public Schools of the School Board of Glasgow, 1907, p. v.

At East Ham also the nutrition of the children was found to vary in accordance with the number of rooms:--[463]

Number of Rooms. Number of Percentage with Children Nutritional Examined. Defects.

Children from 2 and 3-roomed 255 17.2 houses

4-roomed houses 486 16.7

5-roomed houses 657 13.2

6-roomed houses 1,486 13.5

Number of Persons per Room. Less than one 877 9.2 One 576 15.4 Between one and two 1,379 15.2 Two and more 181 17.7

Footnote 463:

Report of the School Medical Officer for East Ham for 1911, p. 56.

The interpretation of these tables, as the School Medical Officer points out, must be guarded. But, he continues, "I think it is safe to assume that nutrition ... suffered the more confined the individual."[464]

Footnote 464:

_Ibid._, p. 57.

Actual physical defects, such as decayed teeth,[465] adenoids or enlarged tonsils, or definite diseases, such as phthisis, may account for malnutrition in many cases. Want of cleanliness again may be a cause.[466]

Footnote 465:

The School Medical Officer for Cumberland found that whilst, at the age of 3 to 4, 28.4 per cent. of the boys and 38.7 per cent. of the girls were classified as good, "the percentages diminish gradually till at the age of 7 to 8 they are only 12.8 and 15.9, but from 20.4 and 29.7 at the age of 12 to 13 they gradually rise to 36.0 and 34.6 at the age of 14 to 15. Probably in most cases the condition of the teeth is responsible for this falling off in condition. In the early years of life, before the teeth begin to go bad, the nutrition is good, but gradually gets worse as time goes on and more teeth decay, but nutrition again improves after the eruption of the permanent teeth, which, of course, are in the majority of cases sound for some little time." (Report of the School Medical Officer for Cumberland for 1911, p. 20.)

Footnote 466:

"The cleanliness of the houses and especially of the bedrooms ... has an important bearing on nutrition." (Report of the School Medical Officer for Congleton for 1911, p. 4.) A School Medical Officer in London told us that if a child improved in the point of cleanliness there was a marked improvement also in nutrition.

The precise effect to be attributed to each cause is difficult to estimate. Often, of course, two or more factors will be present, concurrently and interdependently. In an enquiry made in 1910 by Dr. Chate, into the condition of 570 children (307 boys and 263 girls) in a rural or semi-rural district of Middlesex who were suffering from malnutrition, it was found that poverty was the principal cause in 29.5 per cent. of the cases among the boys, and 26.1 per cent. among the girls. Adenoids, worms, rickets, carious teeth and oral sepsis accounted for 32.7 per cent. among the boys, and 33.3 per cent. among the girls. Improper diet was the main cause in 2.3 per cent. of the cases. In 69 cases malnutrition was due to some disease such as tuberculosis, chronic bronchitis, etc., while in 13 cases it was attributed to overcrowding, and in 10 cases to overwork with insufficient sleep.[467] In the following year a similar enquiry was made by Dr. Tate in a suburban residential area of the same county. Out of 167 cases, defective nutrition was found to be due to poverty and neglect in 23.3 per cent.; to rickets, adenoids, worms or digestive disorder in 28.5 per cent.; to lung affection in 5.4 per cent.; in 7.2 per cent. malnutrition "appeared to be associated with some previous or present condition of ill-health, to account for which no organic mischief could be found at the time of inspection"; while in 33 instances no obvious cause could be assigned.[468]

Footnote 467:

Report of the Chief Medical Officer of the Board of Education for 1910, pp. 29-30.

Footnote 468:

_Ibid._, for 1911, p. 30.

At Bootle the School Medical Officer reports that out of 289 cases of sub-normal nutrition, the cause is to be sought in 78 per cent. in some definite disease or physical defect (including disturbances of digestion due to improper feeding); in 17 per cent. there are no definite signs of organic disease; while in 5 per cent. malnutrition is due to neglect.[469]

Footnote 469:

Report of the School Medical Officer for Bootle for 1912, p. 17.

At Wolverhampton Dr. Badger reports that, out of 131 cases, malnutrition is due to the influence or reaction of disease, convalescence from recent disease, or defective heredity in 64; to pampering in 4; to excessive growth in 1; to overwork and insufficient sleep in 11; to ignorance and poverty in 25; while in 26 cases there was strong evidence of neglect, dirt or drink.[470] In his opinion, an opinion based upon a comparison of the clothing and footgear of the malnourished and normal children, "the malnutrition of the scholars examined was not primarily due to poverty."[471] This, as Sir George Newman points out, "may well have been the case, but the fact that the examinations were 'routine' in character, when the children are apt to be specially dressed and boots even borrowed for the occasion, makes this particular item, unless subjected to further analysis, of little or no value as a criterion in forming a judgment as to the relation of poverty to the malnutrition."[472]

Footnote 470:

Report of the School Medical Officer for Wolverhampton for 1911, p. 28.

Footnote 471:

_Ibid._, p. 32.

Footnote 472:

Report of the Chief Medical Officer of the Board of Education for 1911, p. 25.

Other School Medical Officers are of the same opinion as Dr. Badger. At Congleton the School Medical Officer visited the homes of a considerable number of children whose nutrition was defective, with a view to ascertaining the cause of their condition. He found that "actual poverty of the parents and inability to provide food was comparatively rare, that neglect was common, and unsuitable food probably the most frequent cause."[473] At Hornsey in the majority of cases "some definite ailment was apparent to explain, at least partially, the condition. There were very few instances in which it could be certainly stated that insufficiency of food was the sole cause."[474] At Manchester "the vast majority" of children whose nutrition was medium "and many of those who were poorly nourished were not in this condition through want of food.... Each year's work adds to the evidence that poverty is not responsible for more than about 50 per cent. of the cases."[475] On the other hand, the School Medical Officer for Kidderminster reports, "I find that the better condition of trade and employment in the town was reflected in the improved nutrition of the children.... This also tends to show that the majority of cases of defective nutrition arise, not from carelessness and inattention on the part of the parents, but from inability on their part to provide the children with sufficient nourishment owing to want of means."[476]

Footnote 473:

Report of the School Medical Officer for Congleton for 1911, p. 4.

Footnote 474:

Report of the School Medical Officer for Hornsey for 1911, p. 14.

Footnote 475:

Report of the School Medical Officer for 1911, in Report of the Manchester Education Committee, 1910-11, p. 242.

Footnote 476:

Report of the School Medical Officer for Kidderminster for 1911, p. 2.

It is indeed impossible to say how much malnutrition is due to poverty. Though the immediate cause may be disease, overwork, or overcrowding, these evils are themselves largely the result of insufficient means.

The relation between the malnutrition of the children and the amount of the family income is strikingly illustrated by the results of an enquiry recently made into the diet of the labouring classes in Glasgow. A careful study was made of the family diet of certain selected families during a week, or in some cases a fortnight, and the energy value of each diet expressed in terms of the requirements of a man per day, a woman or a boy of 14 to 16 being reckoned as equivalent to .8 of a man, a girl of 14 to 16 as .7, and children of 10 to 13, 6 to 9, 2 to 5, and under 2 respectively as .6, .5, .4, .3. "If a family diet expressed in this way gives a yield of energy of less than 3,500 calories per man per day, it is insufficient for active work, and if less than 3,000 calories, it is quite inadequate for the proper maintenance of growth and of normal activity."[477]

Footnote 477:

Report upon a Study of the Diet of the Labouring Classes in the City of Glasgow carried out during 1911-12, by Dorothy E. Lindsay, B.Sc., 1913, pp. 5-6.

"Taking the average intake of energy and of protein in the various groups [comprising 52 families], the results are as follows:--

Energy. Protein.

Group A. [Income regular, average 39s.] 3,184 113.8 (excluding LIX. abnormal)

Group B. [Income regular, lodgers kept, 3,316 111.7 average 43s.]

Group C. [Income regular, between 27s. & 3,467 118 31s.]

Group D. [ " " " 20s. & 3,456 117.7 25s.]

Group E. [ " " under 20s.] 2,690 97.8

Group F. [Income irregular, over 20s.] 2,994 108

(excluding XLIV. abnormal) 2,784 101.4

Group G. [Income irregular, under 20s.] 2,797 96.6

Group H. [ " " father 3,155 103.9 drinks]

or, excluding XXVII. abnormal 2,921 95.6

"These figures show conclusively that, while the labouring classes with a regular income of over 20s. a week generally manage to secure a diet approaching the proper standard for active life, _those with a smaller income and those with an irregular income entirely fail to get a supply of food sufficient for the proper development and growth of the body or for the maintenance of a capacity for active work_."[478] "An interesting point in connection with these studies is the influence of the diet on the physical condition of the children." The weights of a number of children which were obtained "show very markedly the relationship between the physique and the food. _When the weight is much below the average for that age, almost without exception the diet is inadequate._"[479]

Footnote 478:

_Ibid._, p. 27. The numbers in each group are so small that the average does not furnish a reliable index, but that the conclusion drawn from the figures is warranted is shown by the fact that of the 27 families in the first four groups (excluding one case where the circumstances are abnormal), 8 have a dietary yielding over 3,500 calories of energy and only 6 fall below the minimum of 3,000, while of the 22 families in the remaining groups (excluding two abnormal cases), only one has a dietary yielding over 3,500 calories, while no less than 16 fall below the minimum. (_Ibid._, pp. 12-23.) Here, of course, again we have the question of wrong feeding. In many cases the income could have been laid out to better advantage. "Where one family gets nearly their minimum adequate diet on an expenditure of 5.1 pence per man per diem ... others on an expenditure of nearly 9d. fail to secure it." (_Ibid._, p. 29.)

Footnote 479:

_Ibid._, p. 30.

Dr. Larkins, late assistant School Medical Officer for Surrey, also came to the conclusion "that a steady wage of 20s. a week is required to produce and properly maintain average strong well-nourished children; that below this figure, the danger zone is reached." This conclusion was based on an enquiry he made into the wages of the parents of all children aged 13 that he examined during a considerable period.[480] The results are seen in the following table:--

Footnote 480:

The actual number of children examined is not stated.

Average Average Weight General Condition of Average number of Weekly in lbs. of the children children in family. Wages. children aged (Percent Very Good / (Total, Under 14, between 13 and Average / Poor) Over 14) 14.

Over 25s. 99.6 50 / 46 / 4 5.5 3.4 2.1

20s. to 84.1 15 / 73 / 11 5.7 2.8 2.9 25s.

18s. to 77.0 / 56 / 44 6.3 3.8 2.5 20s.

16s. to 72.6 / 42.5 / 57.5 6.6 4.2 2.4 18s.

14s. to 74.3 / 22 / 78 7.6 2.9 4.7 16s.

12s. to 70.8 / 20 / 80 3.6 2.2 1.4 14s.

The wages are the total weekly income out of which everything has to be paid, including rent, which varies from 4s. to 7s. 6d. ("The Influence of Wages on the Child's Nutrition," by F. E. Larkins, M.D. Edin., D.P.H., late Assistant School Medical Officer for Surrey, in _The Medical Officer_, December 17, 1910, p. 347.)

The effect of education is, as was recognised thirty years ago, to intensify the evil of malnutrition. "To educate underfed children," says Dr. Leslie Mackenzie, "is to promote deterioration of physique by exhausting the nervous system. Education of the underfed is a positive evil."[481] "Defective nutrition," says the School Medical Officer for Blackburn, "to a far greater extent than any other single cause, and probably more than all other causes combined, renders children incapable of education. In a growing child the demands of muscle and bone must be satisfied before those of nervous tissue, and consequently when there is deficiency, or what comes to the same thing, unsuitability of food or inability to assimilate it, the nervous system is the first to suffer, the brain is starved and anaemic, and the extra strain involved in school work can have only a harmful, and in some cases a disastrous result."[482] "There is probably no disease of children," says another School Medical Officer, "which needs combating more than bad nutrition.... It is quite impossible for any child thus affected to compete mentally with normal children of similar age; in fact, mental defect is frequently found in association with malnutrition."[483]

Footnote 481:

_The Medical Inspection of School Children_, by Dr. W. Leslie Mackenzie, assisted by Dr. E. Matthew, 1904, p. 196.

Footnote 482:

Report of the School Medical Officer for Blackburn for 1911, p. 190.

Footnote 483:

Report of the School Medical Officer for Leeds for 1912, p. 30.

This relation of mental capacity to nutrition was exemplified in the figures quoted by Dr. Ralph Crowley at the Education Conference in 1907. He examined 1,840 children in elementary schools at Bradford, and classified them according to their nutrition and intelligence.

Of the children of exceptional intelligence, 62.7 per cent. were of good nutrition, 35.6 per cent. were below normal, and 1.7 per cent. were of poor or very poor nutrition. Of the children who were exceptionally dull, only 24.9 per cent. were of good nutrition, 39.5 were below normal, and no less than 35.6 poor or very poor.[484]

Footnote 484:

"The Physical Conditions of School Children," by Dr. Ralph H. Crowley, North of England Education Conference, January, 1907 (reprinted in the _School Government Chronicle_, Supplement, January 12, 1907, pp. 80-81).

In an enquiry made at Manchester by the School Medical Officer a few years ago, it was found on examining 146 poorly nourished and 163 markedly badly nourished children, that 56.1 per cent. of the former were below par in mental capacity, and 4.8 per cent. were classed as bad; of the latter 63.2 per cent. were below normal, and 12.9 per cent. bad.

But the most remarkable results are recorded by Dr. Arkle, of Liverpool, in the enquiry to which we have already referred. He asked the teachers to give evidence as to the intelligence of the 2,111 elementary school children whom he examined. "The teachers in 'A' and 'B' both return about 60 per cent. of the children as normal in intelligence, but whereas the former returns 25 per cent. as above and 15 per cent. below normal, the latter only returns 5 per cent. above and 35 per cent. as below the normal. But it is in the return from the poorest school that we get the most curious result. In 'C' the master only feels justified in calling 22 per cent. of the boys normal, while he puts 33 per cent. above and 45 per cent. below normal." These figures, "it seems to me," writes Dr. Arkle, "can only be explained on one hypothesis. I believe, and my personal notes tend to confirm this view, that almost all the abnormal intelligences in the poorest school are due to the one factor--starvation.... Over and over again I noted such cases of children without an ounce of superfluous flesh upon them, with skins harsh and rough, a rapid pulse and nerves ever on the strain, and yet with the expression of the most lively intelligence. But it is the eager intelligence of the hunting animal.... I fear it is from this class that the ranks of pilferers and sneak thieves come, and their cleverness is not of any real intellectual value. On the other hand, with children of a more lymphatic temperament, starvation seems to produce creatures more like automata.... If I told one of these children to open its mouth, it would take no notice till the request became a command, which had to be accompanied by a slight shake to draw the child's attention. Then the mouth would be slowly opened widely, but no effort would be made to close it again until the child was told to do so.... I believe both these types of children are suffering from what I would call starvation of the nervous system, in one case causing irritation and in the other torpor. And, further, these cases are always associated with the clearest signs of bodily starvation, stunted growth, emaciation, rough and cold skin and the mouth full of viscid saliva due to hunger."[485]

Footnote 485:

"The Medical Examination of School Children," by Dr. A. S. Arkle, in _School Government Chronicle_, Supplement, January 12, 1907, p. 78.

Somewhat similar results were observed by Dr. Badger, the School Medical Officer for Wolverhampton. In comparing 1,299 normal children of thirteen years of age with 100 mal-nourished children, he found that, while of the normal scholars 16.6 per cent. were of good intelligence, 68 per cent. of average intelligence and 15.5 per cent. dull, among the mal-nourished children the percentages were respectively 16, 59 and 25.[486] This "record in respect of intelligence," points out Sir George Newman, "shows, what has been noted by other observers, that though the proportion of children considered as 'dull' by the teachers is considerably larger among mal-nourished children than among children generally, nevertheless there are children who suffer serious defects in nutrition whose mental powers are well above the average. It is naturally quick and keen children such as these who require care in order that their physical health may not be further injured by excessive mental application."[487]

Footnote 486:

Report of the School Medical Officer for Wolverhampton for 1911, p. 24. (Quoted in Report of Chief Medical Officer of the Board of Education for 1911, p. 24.)

Footnote 487:

Report of Chief Medical Officer of the Board of Education for 1911, p. 24.