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]]
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]]
"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.] (excluding LIX. abnormal) | 3,184 | 113·8 |
| Group B. [Income regular, lodgers kept, average 43s.] | 3,316 | 111·7 |
| Group C. [Income regular, between 27s. & 31s.] | 3,467 | 118 |
| Group D. [ " " " 20s. & 25s.] | 3,456 | 117·7 |
| 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 drinks] | 3,155 | 103·9 |
| 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]]
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:—
| Average Weekly Wages. | Average Weight in lbs. of children aged between 13 and 14. | General Condition of the children (Percent Very Good / Average / Poor) | Average number of children in family. (Total, Under 14, Over 14) |
|---|---|---|---|
| Over 25s. | 99·6 | 50 / 46 / 4 | 5·5 3·4 2·1 |
| 20s. to 25s. | 84·1 | 15 / 73 / 11 | 5·7 2·8 2·9 |
| 18s. to 20s. | 77·0 | / 56 / 44 | 6·3 3·8 2·5 |
| 16s. to 18s. | 72·6 | / 42·5 / 57·5 | 6·6 4·2 2·4 |
| 14s. to 16s. | 74·3 | / 22 / 78 | 7·6 2·9 4·7 |
| 12s. to 14s. | 70·8 | / 20 / 80 | 3·6 2·2 1·4 |
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 anæmic, 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]]