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About seven per cent. (164 out of 2,251) of these children were in a condition suggesting the
advisability of surgical operation. The figures themselves give little of the impression conveyed by
reading the individual notes, of the mass of educational inefficiency which they represent. Inattentiveness,
dullness, backwardness, spurious mental defect, varying deafness, coughs, bronchial irritability,
recurring colds, these are the regular accompaniments of most of the cases of obstructed nasal
breathing, and are so frequently mistaken for signs of early phthisis that one lady medical inspector in
another part of the country has recently attempted to show that some 14 or 15 per cent, of the elementary
school children in that district are consumptive.
UNDERFED CHILDREN.
The question of underfed children is one of great interest and importance, and one with which
the medical inspector is immediately concerned. The aspect of the question which is of the greatest
importance from his point of view is the detection of the cases, for it will often happen that he will
be called upon to give an opinion as to whether a particular child is uuderfed or not.
The detection of an underfed child is by no means so easy and straightforward a matter as at
first sight might appear. In point of fact there is no certain criterion of these cases. Underfed children
are usually undersized, they are always pale and anæmic, they take no interest in their surroundings,
they look hopeless and forlorn. But so do many children whose fathers are in regular work, whose
mothers are not drunkards, who perhaps are well clothed and have sound boots—the most certain stamp
of the relatively well-to-do, and who when asked what they have had for dinner will describe meals of
Gargantuan proportions. The explanation of these cases is probably not insufficiency, but unsuitability
of food.
What is ill-nutrition.—An attempt was made to standardise the criteria of nutrition in some
way, but it was found impossible.
Physical measurements.—The body weight in relation to height appears to be a quantitative
measure which, however, was found not to furnish any very definite proportion below which it would
be possible to say a child was ill-nourished. Variation of stature may be a racial quality, or the
results of old troubles as rickets, so that it cannot be taken as an expression of existing conditions
in the individual.
Anæmia.—The presence and amount of anæmia is sometimes most difficult to assess, the fair
complexioned children often appearing much more anæmic than they really are. In the open-air schools
Tallquist's colorimetric method was used, but not in this enquiry. The condition may be due to so
many other causes that it cannot be taken as an index of nutrition, although when well established
it is no doubt also a cause of malnutrition.
General appearance.—The general appearance to a practised eye sums up many slight signs,
the looseness and smoothness of the skin, the firmness of the flesh, the amount of subcutaneous fat,
the indications of lowered nutrition in eruptions, slight inflammation of eyelids, roughness of the hair
and so on. This may lead to incorrect estimation, for instance, the anxious expression and temporary
pallor of a neurotic child may lead to a much lower estimate of nutrition than is correct. Such estimates,
too, appear often at fault when checked by physical measurements. Without any indication of actual
disease one child in a family may appear miserably nourished whilst another is in most excellent and
robust condition. The alteration in facial expression is perhaps the most marked effect of the improved
nutrition effected by open-air schools. The animal spirits and vitality of ordinary children are not only
lacking, there is often listlessness in the poorly nourished, but this is not usually capable of being inspected
and recorded by the doctor. The personal equation of the examiner will always have considerable
influence so that too close comparisons of the work of different doctors should be avoided.
How children are fed.—The children of the poor, and not necessarily the very poor, never have
fresh vegetables, rarely have fresh milk and never in adequate quantity; good eggs are unknown to
them, in fact they appear to live largely upon bread, tea, and either beef or mutton broth with an
occasional meal of bacon or frozen meat. It is partly the result of carelessness, partly of ignorance,
and largely owing to the fact that the mothers often have far more to do than they can manage. Two
or three small children to look after and often, in addition, washing or other work to do, leave but little
time or opportunity for the preparation of food of suitable nature. From careful school enquiries
the usual breakfast of most children seems to consist of tea with bread and butter. Such cheap and
wholesome foods as porridge, dripping, milk, etc., appear to be almost entirely neglected.
A further point of considerable importance in regard to the feeding of children where a meal
is only given four or five times a week, is the nature of the dietary. If poverty is the cause of want
of feeding, then the child is probably supplied quite sufficiently with the cheaper starchy foods, and
the costlier fats and proteids are what is required. No diets for helping underfed children are likely