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never started, or, if started, not completed, and the child was left with his disability
or only partially restored to health or fitness. Early in the 1920's the special clinics
began to make their appearance in areas all over the country. By 1925 there were 70
orthopaedic clinics, rising to 382 in 1938. Along with these went the appointment of
physiotherapists and, in many areas, ultra-violet ray clinics were combined with
the orthopaedic clinic.
With the improvement of the mortality figures in children of school age from other
diseases, the returns noting rheumatic fever and heart disease as a cause of death in
children of school age began to loom more prominently than in the earlier years of the
School Medical Service and many education authorities started " rheumatism " clinics
and an increasing number of hospital schools were provided in the late 1920's and
early 1930's. About this time, too, Child Guidance Clinics made their appearance
and many Local Education Authorities agreed to support cases attending them even if
they did not actually run one themselves.
In the 20 years, then, from 1918 to 1938, the foundations of the School Health
Service were laid. If every Local Education Authority had implemented the 1921 Act
as fully as the more progressive authorities had done, and if there had been no panic
economy measures cutting down the services in the days of the "depression", the
bills we are having to pay to-day for the National Health Service and the needed
extensions to the School Health Service would not have been so high.
Changes in Nutritional States.
It was in these 20 years, too, that an effort was made to study nutritional needs and
standards. As you all know, the necessity to feed adequately the children in our poorer
schools was the first recommendation made by the Royal Commission on Physical
Training in Scotland (1903) and the Interdepartmental Committee on Physical
Deterioration in England (1904), but the niggardly Poor Law spirit with which school
feeding was administered right from the start is rather a shameful story. Even up to
the 1930's that spirit peristed. You will remember we were not supposed to order free
meals or milk unless the children showed signs of malnutrition. It is true that this
was subsequently amended, after protests, to "however slight", but it was not really
until the Second World War that this mean spirit was finally exorcised.
It is not only that that attitude has changed, however. Twenty years ago we were
all preoccupied by questions of basic needs for health, optimum standards, and
"measurements of nutrition", fallible and infallible. I can remember a packed
meeting (Public Health, 1935) of specialists and consultants at the Society's old
headquarters telling the medical officers of health and assistant medical officers of
health there, including the late Dr. McGonigle, that we could give them no scientific
evidence that the economic depression was affecting our school children adversely,
and so we set about the search for standards, and many measurements were made and
many " sums " were done, as the late Prof. Major Greenwood would have said, all in
an effort to find a foolproof yardstick for " nutrition " that does not exist. I even
joined in the research myself but, looking back on it all to-day, I doubt if it was
necessary.
If a child has no demonstrable disease or emotional feeding difficulties the question
of whether or not it is suffering from underfeeding depends mainly on economics.
We know what constitutes a balanced diet and how much of certain foods are needed
to keep a child fit and well. If we know how much of the weekly wage is left to spend
on food per head in a family after all other commitments are met then we know which
children require watching on the question of good or bad nutrition.
I think the following extract from Public Health of July, 1953, illustrates this
point. Prof. Fraser Brockington, in reviewing a report on " Domestic Food Consumption
in 1950 " by the National Food Survey Committee, said, " In terms of the
B.M.A. recommendations, the diet of families with over three children was 'marginal'.
Both protein and calcium were below standard at all seasons of the year ; vitamin C
fell below in April and May ; after the lowering of the extraction rate of flour, iron
and riboflavine fell below the standard in October and November". He goes on,
"We are, therefore, left with little doubt that the average diet of working class families
with more than three children in 1950 was only on the borderline of sufficiency".
And it should be realised that food prices have risen considerably since 1950.
That the deficiency is much less than it was in pre-war days I am well aware,
but it does mean that there is still a necessity for the School Medical Officer to report
to the education authority quickly on cost of living changes, remembering that it is the
children in our larger families who are the first to suffer from a rise in prices of food.