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13
The nutritional state of the body depends upon the smooth flow of chemical
processes involved in growth and repair. Malnutrition results from interference
with this rhythm. The amount of food taken can vary widely without interfering
with nutrition.
The character of the food can also vary considerably but not so widely as the
amount. The ratio of the kinds of food is fairly fixed; in a good dietary the
amount of protein must be between one-fifth and one-sixth of the whole. The fats
and carbohydrates cannot take the place of protein, but can replace one another.
The recently acquired knowledge of vitamins and other accessory factors
emphasises that we cannot do without freshness in the food consumed: fresh
vegetables and raw fruit are essential.
The child can accommodate himself to a wide variation in amount, and it is not
easy to overfeed an active child on a properly balanced diet. Overfeeding on an
incorrectly balanced diet is, however, invariably attended with interference with
nutrition and growth.
Malnutrition is also related to poor home hygiene, lack of ventilation, lack of
sleep and overcrowding.
It is also produced by undue expenditure of energy. There is nothing like a
fever to reduce the body rapidly. Illness is a frequent cause, but over-work and
over-activity also have similar effects. There is a kind of over-work almost
impossible to control which is found in certain school children. These are the nervous
worrying type, who are never still. There are also children who are the subjects of
congenital asthenia not infrequently encountered in the schools. They are the
"lean kine" whom it is impossible to fatten.
In the estimation of the state of nutrition of the child, height and weight are
most useful, but the normal variations are so great that the results in each case
must be carefully checked by a physician's examination. Most ill-nourished
children are under weight, but many under weight children are not ill-nourished.
Of many boys much under weight the mother says with truth "He is thin but wiry,
just like his father before him and he nevers ails anything." The physical estimate
of the physician is based upon colour, weight, subcutaneous fat, condition of muscles
—flabby or firm, defective posture and other fatigue signs.
The Board of Education syllabus provides for every child to be marked during
routine inspection as "1," "2," "3" or "4"; 1 being exceedingly good nutrition,
2 normal, 3 subnormal, and 4 definite pathological malnutrition. Complete surveys
by the school doctors exist for about a quarter of a million children examined each
year since 1912. In that year the number returned in classes 3 and 4 taken together
formed 12.8 per cent. of the total examined. This proportion was gradually reduced
until in 1930 the proportion was 4.8 per cent., and in 1931 this proportion remained
unchanged. In 1932 there was a very slight set back to 4.9 per cent., the result
mainly of an increase in ill-nourishment in the entrants who had just been through
a very severe epidemic of measles.
In 1933 the proportion of poorly nourished children is returned at 4.7 per cent.
which is the lowest figure ever attained in London.

The number of children found in category 4, i.e., definitely malnourished, again
was insignificant, viz., 29, being exactly the same as that in the previous year.
B