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Disturbances of School Arrangements.
No one supposes that the ordinary school curriculum is not disorganised to some extent by
the needs of medical inspection especially where all the available accommodation is required for
educational purposes. The Head Teachers of the district, however, are to be congratulated upon
the arrangements they make under such difficult conditions, and I should like to place on record
once again my appreciation of the fact that the inspecting Medical Officer is always made as
comfortable as circumstances permit.
5.—FINDINGS OF MEDICAL INSPECTIONS.
(a). Malnutrition.
Our figures are probably as near the truth as any other figures sent in to the Board of
Education, but are really not a reliable index of what is malnutrition.
As I have said before, again and again, mathematical formulae as evidence of the amount
of nutrition are in most cases not worth the paper they are written on, in that many of the cases
of carbo-hydrate surfeit, particularly those who are large and bulky, slip through the wide mesh of
the mathematical net. Again in these mathematical formulas no account is taken of the genetic
conditions, as exampled from a report of a racing centre where the children of the jockeys of
small build were largely put down as suffering from malnutrition, a report about on a par with one
which came from the Midlands some time ago where, owing to the exuberance of one of the
Medical Officers, the percentage of children reported to be suffering from demonstrable
Tuberculosis astounded the whole country.
The trouble is that the early training of the medical student, as far as malnutrition is concerned,
is entirely wrong. His experience is largely spent in the normal from the merely nutritional
point of view, and the hinterland between normal and disease with its graduations from one to the
other is to him an uncharted sea.
I withdraw nothing I have said in the past with regard to malnutrition and its existence,
and this is summed up in the following letter which appeared in the Lancet on the 16th March,
1935, over my signature, which, although strictly not arising in the year under discussion, sets
forth my opinions.
To the Editor of The Lancet.
What is Malnutrition ?
Sir,—Your leading article of Feb. 16th with this title is timely indeed. It is such a relief
to find that mathematical indices and formulae have no place therein. There has been so much
uninformed writing in the past which has only obscured the issue, and those who have followed
these mathematical standards have missed many of the most marked cases of malnutrition. Much
of malnutrition, as you so rightly point out, is not due to shortage of food but to wrong feeding.
How often one has seen the active wiry youngster, particularly about 10 years of age, put down as
malnourished because, measured by the standard laid down by one writer, its ribs were obvious.
Active, glossy, elastic skinned, glossy haired, with mucous membranes of good colour, true, with
every bit of fat run off in its activities, but in perfect health, this child is as far removed from
malnutrition as the poles asunder. On the other hand, the big bloated, carbohydrate, surfeited
child with its ribs invisible, but dull, lack-lustre skin and hair, and pallid mucous membranes, often
with a lack of appetite which deludes the ignorant into the idea that the child cannot want food,
is suffering from severe malnutrition. Malnutrition is a syndrome which those who know rarely
mistake. It is true that in the pre-war days there was an added item which helped in the case of
girls—viz., the character of the hair. This, owing to the habit of bobbing, and the greater care
necessitated thereby, has definitely diminished the character of this contribution to the syndrome.
In dealing with children in school there are two opinions which often do not coincide : that
of the medical officer and that of the teacher. Just after the war, when attached to the headquarter
staff of the L.C.C., I got a far-seeing head teacher in a boys' school in a poor area to help
me in an investigation. I got him to go right through the school and put down all the boys he
thought were suffering from malnutrition. Afterwards I went right through the school and put
down those I considered were suffering from malnutrition. We had a central block where we
agreed. The head teacher had a block at one end that he thought were malnourished, and I did
not. I had a block at the other end that I considered malnourished, and he did not. The ones he
considered malnourished and I did not, appeared to be cases where the head teacher, knowing the
family circumstances, thought that they ought to be.
There is another mistake that is frequently made in some of these cases in mistaking pallor
for anaemia. There is a certain type of child whose face is habitually pale, but its mucous membranes
are good. There is another that gets a temporary pallor when confronted with an
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