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]]
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 Children Examined. | Percentage with Nutritional Defects. |
|---|---|---|
| Children from 2 and 3-roomed houses | 255 | 17·2 |
| 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 |
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]]
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]]
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]]
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]]
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]]