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The children who come have been recommended by school doctors, and have been chosen
chiefly because the reason for their "not getting on" or departing from accepted standards was
obscure. The problems raised are individual and clinical rather than collective and economic.
Perhaps the most significant feature of the children as a group is their diversity. Except
that they are London children, they have almost no quality in common. Most, though not all,
are thinner than the child whose image is carried in the mind as a standard of health ; most, but
not all, depart in some direction from the recorded average in stature or weight, or both ; most
show some degree of pallor or do not look in really good health, but some have none of these
qualities and few have all.
It is not difficult to come to a conclusion supported by evidence as to the main factors responsible
for each child's condition or appearance, but these factors are numerous in the aggregate
and almost always multiple in any one case.
The question of anaemia, a condition with which a large number of the children were credited
before being sent to the clinic, has also been further investigated. The estimation of haemoglobin
has been considered to be part of the routine examination of the children sent. The blood is
obtained by needle puncture from the lobe of the ear, and the haemoglobin estimated by the Sahli
method.

The single case with hæmoblobin below 70 per cent. was a boy with hypochromic anaemia
of obscure origin. The groups with haemoglobin between 70 and 100 per cent. do not seem to
call for special comment, except to say that there was nothing distinctive in the colour or appearance
of the 71.80 group, and that, in some cases at least, the administration of iron made no
difference to the haemoglobin level.
The group 101.120 per cent. have perhaps more in common and seem to merit further study.
Of these 21 children, I placed 9 in nutritional category "3" and 2 in "4" and the group contained
some of the palest children sent up. These pale children with high hæmoglobin have much in
common. They are, typically, thin, lacking in signs of vitality, the very reverse of "sanguine"
in appearance. A dark, "thick.looking" drop of blood flows sluggishly from the ear when
pricked, and the high hæmoglobin can be confidently guessed before it is measured.
That the condition is not one of good health is, I think, beyond dispute; what are its concomitants
and significance, if there is in fact a general hyperhæmoglobinaemia, I cannot ascertain
in the course of the ordinary work of the clinic. I can at present record my belief only that a
small group of similar children exists who characteristically show this phenomenon; and, so far
as I know, it has not been clinically recognised.
Dr. Elman's report on the Poplar centre and the two sub.centres at Kingsland
(Hackney) and Wapping is summarised below:—
The total number of attendances was 705, made by 128 old and 93 new cases. Progress
was very satisfactory in 72 old and in 30 new cases. Out of 221 children, 14 are recorded as
having made no progress. These were, however, chiefly in those seen in the latter part of the
year. Thirty.three children were discharged.
Economic conditions played a considerable part in the causation of malnutrition. Among
the new cases the amounts available for food per head per week were obtained in 81. They were
as follows:—Less than 4s., 15; 4s..6s., 36; 6s..8s., 19; 8s..10s., 7; over 10s., 4.
Housing conditions were classified in the 93 new cases as:—Very bad, 16; bad, 29; moderate,
36; good, 12.
Among the "very bad" cases there were two families sleeping five in a bed, and one family
sleeping seven in a room; and among the "bad" there were three families sleeping six in a room.
One family of five is said to have slept in one room with six cats.
In 28 children the main cause was considered to be other than economic. In 18 children,
physical causes alone (e.g., infectious and other illnesses) were assigned, and in ten there were
psychological causes; this was also probably a contributory cause in others.
The methods of treatment available included advice as to house management and diets,
extra nourishment, milk and school dinners, convalescence, admission to open.air school, and
prescription of iron, malt and oil.
The question of sleep is intricately bound up with that of housing, and it must be obvious
that in overcrowded dwellings the entry of older children and adults into the bedroom of the
younger children must cause great disturbance of sleep.
The general progress of the children appears satisfactory, although the economic status
and the unwholesome surroundings of many make improvement a slow process.