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The high incidence of physical defects in five- to six-year-old school children
1937
PUBLIC
HEALTH
The High Incidence of Physical Defects in F i v e - t o Six-Year-Old School Children" By E. H. WILKINS, M.B., D.P.H.
Assistant School Medical O~cer, City of Birmingham. This investigation was prompted by problems in the assessment of nutrition.- For instance, it was felt to be incongruous to record as normal children who presented well-marked abnormalities of an anatomical kind. By " normality," I mean true biological normality; the normal in this relation has nothing to do with existing averages, which include the pathologically abnormal. The series reported on includes a total of 1,083 children from 5 to 6 years of age, and the data have been collected during the ordinary course of medical inspection. In addition to recording defects and ailments calling for treatment, I have taken notes of the incidence and degree of certain deformities which previous observation had lead me to believe were extremely common. These deformities are: bossing of the skull, depressions and irregularities of the chest wall, knock-knee and deformities of the feet. Faulty posture was recorded only when the defect was very noticeable, attention in this respect being directed primarily to the condition of the chest wall. A count was also made of the n u m b e r of temporary teeth in each child's mouth which were grossly hypoplastic, carious or which had been extracted or otherwise treated for caries. Dental probe and mirror were not used, and no exhaustive search for hidden spots of caries was made. At this age, none of the temporary teeth has been shed naturally. The average number of defective teeth was found by this method to be almost 6.82 per head or, in the aggregate, 34 per cent. of the total number of teeth. The number of complete, naturally sound sets of temporary teeth was 6-1 per cent. In other words, almost 94 per cent. of the children had suffered some decay or had some gross defect of the enamel of their temporary teeth. It should be emphasised that a complete survey of the child was not attempted; dental irregularity and narrowness of the palate, for instance, were not recorded. Bossing of the skull is an accepted sign of rickets. Bossing of the parietal bone has been assessed in the manner described by Dr. G. C. M. M'Gonigle in the Report published in 1931 by the Board of Education Committee on the Association of Rickets and Dental Disease with Adenoids *Paper read to a joint meeting of the Maternity and Child Welfare and School Medical Groups, May 21st, 1937,
and Enlarged Tonsils. The frontal boss, being less frequent, and, in its minor degrees, more difficult to assess with certainty, has not been systematically recorded in this series. In any case, where there has been the slightest doubt in my mind about the existence of bossing of the parietal bone, the child has been recorded as not presenting this sign. I quite agree with M'Gonigle that the even convexity of the parietal bone in some skulls is very different from that of the bossed skull. Whether all those skulls which I have recorded as " bossed " are pathological, is a matter which may call for further investigation. Authorities do not seem to be agreed about the persistence of rachitic bossing in children of school age. For instance, Park and Eliot of Baltimore say, " The heads of many normal infants show large frontal and parietal eminences and protruding foreheads." By this, I take it, they do not regard these signs as indicating what they call tickets. But that is not to say that what the Board of Education Committee recorded as bossing, and what I have recorded as bossing, is not pathological. That it /s pathological is supported by the lower percentages of the various degrees of bossing found in the more prosperous as compared with those in the less prosperous group of schools. In this respect the figures for bossing are roughly parallel with those for chest deformity and knock-knee, though they do not necessarily correspond in the same individuals. At any rate, those children whom I have classified as having a pronounced degree . of bossing have prominent knobs which are almost visible through the hair and in some cases feel like rudimentary horns. I cannot believe that these can be mere anatomical variations. According to M'Gonigte, bossing never begins after the first few weeks of life, and would, therefore, seem to be due to prenatal malnutrition, that is, malnutrition of the mother. If this is so, it is of value as a record of malnutrition occurring at a very early stage of life. Following the directions of the Board of Education Report, I found that bossing occurred in 74-2 per cent. of the children examined. M y experience of examining the skulls of these children leads me to suspect that there is a great prevalence of bossing of a minor degree which I have not recorded. That is to say, that the standard used in assessing bossing of the skull has been less exacting than that used for the other abnormalities. 29I
PUBLIC HEALTH Deformities of the chest wall are extremely common in the elementary school children of all social classes in my district. In a previous investigation, published in the Birmingham School Medical Officer's Report for 1927, I found 77-0 per cent. of 5 to 6 year-old children presenting a clearly noticeable degree of chest deformity, that is, omitting the very slight degrees. The standard of normality adopted in the present investigation is slightly more exacting. It is impossible in the space available to describe these deformities in detail. A description is given in the Board of Education Report already referred to. The deformities consist of irregularities, depressions and projections, which are departures from the even convexity of the well-built chest wall. Many of these irregularities are obvious from a cursory glance at the unclothed chest. Very slight degrees may be noticeable only on viewing the chest from certain angles. The chest has two. convex curvatures: one passing vertically from the collar bone downwards to merge with the contour of the abdomen, the other, a transverse convexity, passing horizontally from the back to the middle line of the front of the chest, where there is normally a slight dip over the sternum. I should emphasise that slight but indisputable degrees of deformity may be easily overlooked. A type which most easily escapes notice is a disproportionate bulging of the third, fourth and fifth ribs, at the front of the chest, often associated with a slight relative or actual, depression of the lower ribs or Harrison's sulcus. This bulging of the fibs, when well marked, merges with the type of deformity known as pigeon chest. The view which I expressed in 1927, that there are no distinct types of chest deformity, is confirmed by my present observations. There is no definite line of demarcation, for instance, between pigeon chest and Harrison's sulcus; the various types can be shown to merge into each other. Chest deformity commonly consists of a combination of two or more out of six or seven kinds of abnormality of contour of the chest wall. The composite deformity which a chest assumes doubtless depends on the degree of softness of the bones in relation to the combination of normal and abnormal strains and stresses to which they are subjected by breathing, coughing, abdominal distension, and so on. The deformities, be it noted, occur in the front of the chest where the movement of, and .probably for that reason the strain on, the ribs Is greatest. Chest deformity occurred in 89.4 per cent. of the children. Its very high prevalance suggests that this kind of deformity is a sensitive index of some morbid influence during the early years of the child's life. I would expect that these defects of the chest wall do not occur, or at least ~92
.JUNE not to the same extent, in the well-nourished, wellprovided for classes of the community. So far as I am aware, they do not occur in very young infants. Respiratory catarrhs, nasal obstruction and cough, undoubtedly aggravate the tendency to deformity, but it is necessary to postulate a much more widespread cause or set of causes for deformities occurring in so large a proportion of the children examined. Of deformities of the legs, knock-knee is very much more prevalent at the age of 5 years than is bow-leg. Bow-legs at this age are rare and of slight degree, whereas at earlier ages, say 2 years, there is, I believe, more bow-leg deformity. My impression is also that, in boys at least, knockknee becomes progressively less as one passes from the 5 year to the 12 year group, that there is a progressive change over from knock-knee to the bow-legged tendency by the age of puberty. I intend to make this the subject of further enquiry. ! have recorded these leg deformities roughly by measurement. I suggest that my method is an advance on that described by M'Gonigle in the Education Board Report mentioned above. In my inspection, the child is made to stand bare-footed with the feet parallel, the knees straight, and the internal condyles of the knees in contact; the contact of the knees should be fairly firm but they should not be squeezed together. These conditions are necessary in order to avoid overestimating or overlooking an existing knock-knee. The gap, if any, between the ankles is then noted. In this investigation a gap of less than a good half inch has been ignored, and such a pair of legs recorded as straight. Knock-knee is often associated with genu-recurvatum which, when well marked, considerably accentuates the appearance of knock-knee when the feet are turned outwards. Knock-knee was recorded in three degrees : (i) less than 1 inch, (ii) from 1 to 2 inches inclusive, and (iii) over 2 inches. The maximum gap in this series was 4~ inches. It is tempting t o try to assess knockknee by the quicker method of making the child sit on a low chair facing the observer, who then takes the ankles in his hands, the knees being straight. This method is faulty, as knock-knee in many cases is decidedly greater when the legs bear the weight of the body ; in some, an increase of an inch is caused by making the child stand. For bow-legs, the child stands with the feet together and the knees straight, when the gap between the condyles of the knees is noted. Knockknee was found in 76.7 per cent. and bow-leg in less than 1.0 per cent. of the children examined. I found no bow-leg of more than an inch. The deformities of the feet at this age consist of deflection of the big toe, and various degrees of flattening of the arch or dropping inwards of the
1937
PUBLIC
HEALTH
ankles; the latter two conditions are associated probably has much to do with general liability with each other and also with knock-knee. to ill-health and disease. This investigation may Decision as to the presence and degree of sagging be described as an attempt to trace the beginnings of the arch is not always easy. It is essential to of that poorness of physique which is so prevalent make the child stand, turn round, and change its and in some ways so much more obvious in the position several times, the feet being viewed adult population. It is significant that out of the especially from behind and from the side, for total of 1,083 children examined, not one normal projection of the cuboid and internal cuneiform child was found. Even if dental decay be set aside, bones. There seems to be every reason to regard as perhaps to a certain extent a separate problem, even the slightest foot deformity in children as of we find that almost every child examined presented serious significance, in view of the enormous at least two well-defined defects other than amount of suffering due to defective feet in adult dental. Compared with some of the other areas of the life. Observation of the general public makes it clear that foot deformities in the adult are for the city, my district may contain an unusually large most part the same as those noticed in 5-year-old number of the very poor, but when the data children; 28.0 per cent. of the children were are tabulated for the schools attended by the more recorded as showing one or more of the foot prosperous as compared with the less prosperous the differences noted are not very great. The deformities mentioned. It is hardly necessary to say that the anatomically more prosperous group contained 44.2 per cent. normal leg is straight; when the knees are in of the children reported on, and included the contact the ankles should also be in contact. families of many skilled workers earning what are The foot and ankle should not sag inwards, and regarded as good wages. The two groups are on the there should be an adequate arch. The straightness whole probably not very widely separated in their The differences in of the leg has its significance in the biological average economic status. fact that any departure from it places the leg and expenditure per head on food, of the two groups, foot at a mechanical disadvantage. In knock- we should expect to be less than the apparent knee the normally horizontal axes of the knee and difference in economic status. It must be borne ankle joints are not parallel and the weight-bearing in mind also that the apparently more prosperous schools include a number of the very poor. function of the limb is impaired. It will be noticed that the defects here tabulated Nevertheless, such differences as exist in the are of a very definite kind. Neither their existence proportion of defects found are all in favour of the nor their degree can be a matter of opinion once a more prosperous group. On the whole, I have no set of standards has been decided on. The assess- reason to think that the school population I have ment is purely objective. With the exception of examined differs very much from that of any bossing, about which there seems to be difference other urban district in the country. It is interesting to compare my figures with of opinion, there can be no doubt as to whether these deformities are defects ; they are pathological those obtained in two similar investigations elseM'Gonigle some 10 years ago reports departures from normality and contribute to where. defective physique in the adult. It is not claimed 83 per cent. of Durham school children (of all that all these deformities are of serious consequence ages) as showing one or more of these signs which The Board of Education as deformities; they are, I suggest, significant I have described. as indices of widespread defect of physique, which Report already quoted gives lower figures for bony Percentages of Children showing Evidence of Attending Schools in
Number Examined.
t 37"5
Poorer District Better District Aggregate Figures
Bossing of Parietal Bone. s. m. I P" 2 - ~ - ' 5 I' ~ . 7
Deformity of Chest Walt.
s.
j m. ~ p .
1,083
4"0
22"0
36.0
Knock Knee.
s.
~ m. i p .
Bow Leg.
1
j,12 1 97 j 212 011T 0.7 t - ~ - ' - - ~ 17o. - - " ( ' ~1 - - " - ~
92"8 479
I I
8.2 52.7 12 .2 ---@--I
17.8
Average Defective Teeth Foot t Perfect Deformity. Dentition. per Head.
30"0
5.9
6.9
0-62
26-0
6.2
6.6
0.7
28'0
6-1
6.8
1
19.3 i 49.6 [ 4.6
~-~i 73-----~
74.2
Degrees of defectiveness : s = slight ; m = m e d i u m ; p = plus.
293
PUBLIC H E A L T H deformities in L.C.C. children, but when the findings of their medical officers are considered separately, we find that the highest figure for parietal bossing is practically the same as m i n e - 73 per cent. as compared with my 74 per cent. Their highest figure for knock-knee is higher than mine--82.5 per cent. compared with my 76.7 per cent. Their highest for deformity of the chest wall is 43-6 per cent., and if beading of the ribs is included, it is 55 per cent. against my 89.4 per cent. This difference I think must be due to the L.C.C. medical officers having adopted a much lower standard and passed many minor degrees of deformity as normal. Estimates of the prevalence of rickets by other workers are interesting in comparison. To quote from Parsons and Barling, Schmorl in Dresden, 1901-5, in 386 children dying from all causes, found by autopsy a maximum of 98 per cent. with rickets between the ages of 4 and 18 months, and this figure did not include cases of completely healed rickets. An investigation in Baltimore, 1926-30, showed up to 60 p e r cent. with rickets between 7 months and 2 years. More recently, Eliot and Souther, U.S.A., examined 1,186 children from 1 to 5 years, by physicalexamination and by X-rays, and found a total of 61 per cent. rachitic. The peak of more severe rickets (24 per cent.) occurred at about 17 months; the peak of the slighter degrees (37 per cent.) occurred at about 4 months. Eliot and Souther emphasise that these slighter degrees of rickets, between the third and tenth months, usually pass unnoticed. They say : " This association between mild rickets and rapid growth has raised the question whether mild rickets should not be regarded as physiological, but the question is of an academic interest only since the occurrence of rickets of this mild degree is of little practical importance." My comment on this is that, whatever the clinician may do, the M.O. of Health should not countenance the acceptance of any degree of disease as physiological; and I suggest that what is recognisable as clinical disease may fall considerably short of the full extent of pathological defect in the community. May it not be, for instance, that there is a prevalence of slight rickets, not clinically recognisable as such, which produces these minor bony deformities and a good deal of impairment of physique ? Whether the figures I have quoted for rickets relate to the same sort of thing that 1 have been recording is not what I am immediately concerned with. My point is that other investigators have found a high prevalence of something which militates against normality of physique. Apart from the findings of M'Gonigle and the Board o f Education Committee already referred to, my figures are, therefore, not entirely unsupported.
294
JUNE To what is this very high incidence of defects due ? What cause or set of causes can act so generally as to affect practically the whole of the child population examined ? There is one cause more than any other to which these defects of physique are fundamentally attributable, namely, faulty nutrition. The work of Sir Robert McCarrison, among others, can leave little doubt on this point. Experiments in animal nutrition have demonstrated conclusively that food outweighs all other factors put together, in deciding the standard of growth and physique. We need not attribute all these malformations to rickets, for the common dietary deficiencies are multiple. Faulty nutrition is most likely to occur, or at least, is most serious in its effects, in the prenatal period and in the first few years of postnatal life. It is in this early period that these defects originate. Are Maternity and Child Welfare Medical Officers aware of the poor standard of physique in the child they pass on to the School Medical Officer at 5 years of age ? Can they throw any light on the causation of these defects ? What are the precise periods of origin of bossing, chest deformity and knock-knee ? I should like to ask other school medical officers to make investigations similar to mine. In doing so, I would urge them to adopt a strict standard of anatomical normality. No other standard is of the slightest scientific value. With the increasing attention being devoted to improving the physique of the people, the responsibility for accounting for these things will fall more and more on the shoulders of the Health and School Medical Services of this country. REFERENCES. Board of Education : Committee on Adenoids and Enlarged Tonsils (1931). The Association of Rickets and Dental Disease with Adenoids and Enlarged Tonsils. Park, E.A., and Eliot, Martha M., contribution in Parsons' and Barling's Diseases of Infancy and Childhood, Vol., I, p. 282. -p. 228 and 229. Wilkins, E. H. Report of the School Medical Officer, Birmingham, 1927. DISCUSSION.
Dr. Agnes Nlc011 (President, M. & C.W. Group), said that we all agreed that there was a large degree of minor deformities or variations from the normal in children under five years of age, and she asked what was the real significance of these variations and suggested that they might be comparable with the variations between one human face and another. She suggested that bony deformities might be due to inequalities of growth so that it could not be assumed a priori that they were rachitic in origin. Regarding chest deformities, she thought that tight clothing of infants had a large influence in preventing normal development. In general, her impression was that the physical and general
1937 condition of children had improved greatly in the last ten years. Replying to Dr. Nicolls' points, Dr. Wilkins said that one had only to compare the poor with more prosperous and well-nourished children to see that such deformities were abnormal. Dr. Murlel Radford asked whether inquiries had been made about the ante-natal health of the mothers, their attendance at M. & C.W. centres, and whether there was any X-ray evidence, and Dr. Marjorie Bank inquired as to the passing on of records from the M. & C.W. to the School Medical Service. Dr. Wilkins replied that there was an arrangement for the passing on of records at Birmingham but thought it had not been of much value as one medical officer's records were often not intelligible to another. This reply led to an appeal from Dr. Puddicolnbe that such records must be made intelligible as between one department and another, and also as between medical officers, Dr. C. E. St. Clair Stockwell (S.M.O., Leeds), said that the School Medical Service was hidebound to Board of Education standards. Regarding nutrition estimates, he said that in Leeds these varied from 5 to 40 per cent. in the records of eight medical officers. Regarding knock-knees, he thought that the normal difference between the sexes had not been taken into account and he went on to stress the importance of early X-rays to make sure that the children were not rachitic. X-rays in infancy could show definite changes in the growing ends of bones. He thought bad breathing largely responsible for chest deformities. Dr. V. Freeman (Dep. M.O.H., Islington Met. B.) wondered whether bad early feeding of infants, e.g., with condensed milk, had an influence on the chest deformities and suggested also that respiratory catarrhs had a decalcifying effect. School records gave a static analysis only, and he felt that the school system might be altered to allow of intensive and continuous investigations of small numbers, with X-rays, controls, etc. Dr. Wilkins said that an investigation on proper feeding had been in progress in Birmingham for some three months and had already shown astonishing results. It consisted of the giving of extra rations to 30 children who were in poor nutritional condition. The ration consisted of 1½ pints per child of a chocolate and dried milk preparation, which contained a special addition of vitamins A, C and D, and of calcium glutinate. Iron was present in the chocolate part of the preparation. The vitamin B was given in the form of one-eighth of a grain of dried brewers' yeast supplied fresh daily and put into a wholemeal sandwich. Dr. E. H. R. Smithard (M.O.H., Southall-Norwood) thought that the symptoms described by Dr. Wilkins were not correlated with any known pathological condition, and Dr. E. V. Saunders Jaeobs (A.M.O., Woolwich) said that the records of the toddlers' clinics at Woolwich showed anatomical abnormalities in so many children that it was dif~cult to know whether they were pathological. Proposing a vote of thanks, Dr. Jean Mackintosh (A.M.O., Stockport C.B.) said that the discussion had been most useful in drawing attention to the difficulty of variations between one medical officer's assessment of nutrition and another's.
PUBLIC H E A L T H T H E B O U R N E M O U T H , POOLE A N D CHRISTCHURCH TYPHOID EPIDEMIC * By H. GORDON SMITH, M.D., D.P.H., Medical Officer of Health, Bournemouth C.B. This afternoon I shall endeavour to give you an account of the epidemic of typhoid which began in the latter weeks of August in Bournemouth and the neighbouring boroughs of Poole and Christchurch. As Bournemouth is a County Borough and provided the largest number of cases, the outbreak has, unfortunately, been referred to by many as the Bournemouth epidemic. The populations of the three districts concerned are--as given by the Registrar-General for 1935 :-Bournemouth, 118,200; Poole, 65,600; and Christchurch, 12,820. It will be apparent, however, that in the holiday season the total population will be increased by some 60,000 visitors to at least a quarter of a million and, of course, there are in addition many people who pass through the town and partake of meals without becoming temporary residents. In Bournemouth the epidemic commenced in a somewhat insidious manner. In July there had been one or two household cases of what appeared to be food poisoning, though laboratory reports did not confirm this diagnosis. Also it was reported that outside Bournemouth numerous people were suffering from a mild illness characterised by sickness, diarrhoea and slight pyrexia. It seemed probable therefore that Bournemouth would be similarly affected. Consequently, when Dr. C. F. Pedley, Deputy M.O.H., communicated with me on August 20th informing me that he had been called in to see patients whose symptoms suggested food-poisoning, I was not at all surprised. Dr. Pedley, who was acting for me while I was away on holiday, told me that on August 13th a general practitioner had asked him to see in an hotel certain individuals who had recently been taken ill. The prominent symptoms were headache and other pains associated with pyrexia. Dr. Pedley advised that blood cultures should be made but these did not give definite results. On August 20th other practitioners drew attention to similar cases and enteric was seriously considered. On August 21st, Dr. Maule Home, of Poole, communicated with Dr. Pedley, as he had found various patients in his area who were possibly suffering from enteric. Dr. Pedley and Dr. Maule Home decided to inform the Ministry immediately. In consequence, Dr. Vernon Shaw, one of the Ministry's M.O.s, whose recent death was so much regretted, came down on August 22nd. A conference was held in Poole. There were present: Dr. Shaw, Dr. Pedley, certain practitioners who were in attendance on the patients and the manager of a dairy whom we will describe as Mr. X. Dr. Pedley had already made enquiries as to the food supplied to the patients, and had discovered that most of them, if not all, had consumed milk from a dairy of which Mr. X. was the manager. At this conference, in the morning of August 22nd, it was decided that there was in the area an outbreak of enteric, probably paratyphoid, and * Paper read to the Southern Branch, May 10th, 1937.
295
PUBLIC
HEALTH
The High Incidence of Physical Defects in F i v e - t o Six-Year-Old School Children" By E. H. WILKINS, M.B., D.P.H.
Assistant School Medical O~cer, City of Birmingham. This investigation was prompted by problems in the assessment of nutrition.- For instance, it was felt to be incongruous to record as normal children who presented well-marked abnormalities of an anatomical kind. By " normality," I mean true biological normality; the normal in this relation has nothing to do with existing averages, which include the pathologically abnormal. The series reported on includes a total of 1,083 children from 5 to 6 years of age, and the data have been collected during the ordinary course of medical inspection. In addition to recording defects and ailments calling for treatment, I have taken notes of the incidence and degree of certain deformities which previous observation had lead me to believe were extremely common. These deformities are: bossing of the skull, depressions and irregularities of the chest wall, knock-knee and deformities of the feet. Faulty posture was recorded only when the defect was very noticeable, attention in this respect being directed primarily to the condition of the chest wall. A count was also made of the n u m b e r of temporary teeth in each child's mouth which were grossly hypoplastic, carious or which had been extracted or otherwise treated for caries. Dental probe and mirror were not used, and no exhaustive search for hidden spots of caries was made. At this age, none of the temporary teeth has been shed naturally. The average number of defective teeth was found by this method to be almost 6.82 per head or, in the aggregate, 34 per cent. of the total number of teeth. The number of complete, naturally sound sets of temporary teeth was 6-1 per cent. In other words, almost 94 per cent. of the children had suffered some decay or had some gross defect of the enamel of their temporary teeth. It should be emphasised that a complete survey of the child was not attempted; dental irregularity and narrowness of the palate, for instance, were not recorded. Bossing of the skull is an accepted sign of rickets. Bossing of the parietal bone has been assessed in the manner described by Dr. G. C. M. M'Gonigle in the Report published in 1931 by the Board of Education Committee on the Association of Rickets and Dental Disease with Adenoids *Paper read to a joint meeting of the Maternity and Child Welfare and School Medical Groups, May 21st, 1937,
and Enlarged Tonsils. The frontal boss, being less frequent, and, in its minor degrees, more difficult to assess with certainty, has not been systematically recorded in this series. In any case, where there has been the slightest doubt in my mind about the existence of bossing of the parietal bone, the child has been recorded as not presenting this sign. I quite agree with M'Gonigle that the even convexity of the parietal bone in some skulls is very different from that of the bossed skull. Whether all those skulls which I have recorded as " bossed " are pathological, is a matter which may call for further investigation. Authorities do not seem to be agreed about the persistence of rachitic bossing in children of school age. For instance, Park and Eliot of Baltimore say, " The heads of many normal infants show large frontal and parietal eminences and protruding foreheads." By this, I take it, they do not regard these signs as indicating what they call tickets. But that is not to say that what the Board of Education Committee recorded as bossing, and what I have recorded as bossing, is not pathological. That it /s pathological is supported by the lower percentages of the various degrees of bossing found in the more prosperous as compared with those in the less prosperous group of schools. In this respect the figures for bossing are roughly parallel with those for chest deformity and knock-knee, though they do not necessarily correspond in the same individuals. At any rate, those children whom I have classified as having a pronounced degree . of bossing have prominent knobs which are almost visible through the hair and in some cases feel like rudimentary horns. I cannot believe that these can be mere anatomical variations. According to M'Gonigte, bossing never begins after the first few weeks of life, and would, therefore, seem to be due to prenatal malnutrition, that is, malnutrition of the mother. If this is so, it is of value as a record of malnutrition occurring at a very early stage of life. Following the directions of the Board of Education Report, I found that bossing occurred in 74-2 per cent. of the children examined. M y experience of examining the skulls of these children leads me to suspect that there is a great prevalence of bossing of a minor degree which I have not recorded. That is to say, that the standard used in assessing bossing of the skull has been less exacting than that used for the other abnormalities. 29I
PUBLIC HEALTH Deformities of the chest wall are extremely common in the elementary school children of all social classes in my district. In a previous investigation, published in the Birmingham School Medical Officer's Report for 1927, I found 77-0 per cent. of 5 to 6 year-old children presenting a clearly noticeable degree of chest deformity, that is, omitting the very slight degrees. The standard of normality adopted in the present investigation is slightly more exacting. It is impossible in the space available to describe these deformities in detail. A description is given in the Board of Education Report already referred to. The deformities consist of irregularities, depressions and projections, which are departures from the even convexity of the well-built chest wall. Many of these irregularities are obvious from a cursory glance at the unclothed chest. Very slight degrees may be noticeable only on viewing the chest from certain angles. The chest has two. convex curvatures: one passing vertically from the collar bone downwards to merge with the contour of the abdomen, the other, a transverse convexity, passing horizontally from the back to the middle line of the front of the chest, where there is normally a slight dip over the sternum. I should emphasise that slight but indisputable degrees of deformity may be easily overlooked. A type which most easily escapes notice is a disproportionate bulging of the third, fourth and fifth ribs, at the front of the chest, often associated with a slight relative or actual, depression of the lower ribs or Harrison's sulcus. This bulging of the fibs, when well marked, merges with the type of deformity known as pigeon chest. The view which I expressed in 1927, that there are no distinct types of chest deformity, is confirmed by my present observations. There is no definite line of demarcation, for instance, between pigeon chest and Harrison's sulcus; the various types can be shown to merge into each other. Chest deformity commonly consists of a combination of two or more out of six or seven kinds of abnormality of contour of the chest wall. The composite deformity which a chest assumes doubtless depends on the degree of softness of the bones in relation to the combination of normal and abnormal strains and stresses to which they are subjected by breathing, coughing, abdominal distension, and so on. The deformities, be it noted, occur in the front of the chest where the movement of, and .probably for that reason the strain on, the ribs Is greatest. Chest deformity occurred in 89.4 per cent. of the children. Its very high prevalance suggests that this kind of deformity is a sensitive index of some morbid influence during the early years of the child's life. I would expect that these defects of the chest wall do not occur, or at least ~92
.JUNE not to the same extent, in the well-nourished, wellprovided for classes of the community. So far as I am aware, they do not occur in very young infants. Respiratory catarrhs, nasal obstruction and cough, undoubtedly aggravate the tendency to deformity, but it is necessary to postulate a much more widespread cause or set of causes for deformities occurring in so large a proportion of the children examined. Of deformities of the legs, knock-knee is very much more prevalent at the age of 5 years than is bow-leg. Bow-legs at this age are rare and of slight degree, whereas at earlier ages, say 2 years, there is, I believe, more bow-leg deformity. My impression is also that, in boys at least, knockknee becomes progressively less as one passes from the 5 year to the 12 year group, that there is a progressive change over from knock-knee to the bow-legged tendency by the age of puberty. I intend to make this the subject of further enquiry. ! have recorded these leg deformities roughly by measurement. I suggest that my method is an advance on that described by M'Gonigle in the Education Board Report mentioned above. In my inspection, the child is made to stand bare-footed with the feet parallel, the knees straight, and the internal condyles of the knees in contact; the contact of the knees should be fairly firm but they should not be squeezed together. These conditions are necessary in order to avoid overestimating or overlooking an existing knock-knee. The gap, if any, between the ankles is then noted. In this investigation a gap of less than a good half inch has been ignored, and such a pair of legs recorded as straight. Knock-knee is often associated with genu-recurvatum which, when well marked, considerably accentuates the appearance of knock-knee when the feet are turned outwards. Knock-knee was recorded in three degrees : (i) less than 1 inch, (ii) from 1 to 2 inches inclusive, and (iii) over 2 inches. The maximum gap in this series was 4~ inches. It is tempting t o try to assess knockknee by the quicker method of making the child sit on a low chair facing the observer, who then takes the ankles in his hands, the knees being straight. This method is faulty, as knock-knee in many cases is decidedly greater when the legs bear the weight of the body ; in some, an increase of an inch is caused by making the child stand. For bow-legs, the child stands with the feet together and the knees straight, when the gap between the condyles of the knees is noted. Knockknee was found in 76.7 per cent. and bow-leg in less than 1.0 per cent. of the children examined. I found no bow-leg of more than an inch. The deformities of the feet at this age consist of deflection of the big toe, and various degrees of flattening of the arch or dropping inwards of the
1937
PUBLIC
HEALTH
ankles; the latter two conditions are associated probably has much to do with general liability with each other and also with knock-knee. to ill-health and disease. This investigation may Decision as to the presence and degree of sagging be described as an attempt to trace the beginnings of the arch is not always easy. It is essential to of that poorness of physique which is so prevalent make the child stand, turn round, and change its and in some ways so much more obvious in the position several times, the feet being viewed adult population. It is significant that out of the especially from behind and from the side, for total of 1,083 children examined, not one normal projection of the cuboid and internal cuneiform child was found. Even if dental decay be set aside, bones. There seems to be every reason to regard as perhaps to a certain extent a separate problem, even the slightest foot deformity in children as of we find that almost every child examined presented serious significance, in view of the enormous at least two well-defined defects other than amount of suffering due to defective feet in adult dental. Compared with some of the other areas of the life. Observation of the general public makes it clear that foot deformities in the adult are for the city, my district may contain an unusually large most part the same as those noticed in 5-year-old number of the very poor, but when the data children; 28.0 per cent. of the children were are tabulated for the schools attended by the more recorded as showing one or more of the foot prosperous as compared with the less prosperous the differences noted are not very great. The deformities mentioned. It is hardly necessary to say that the anatomically more prosperous group contained 44.2 per cent. normal leg is straight; when the knees are in of the children reported on, and included the contact the ankles should also be in contact. families of many skilled workers earning what are The foot and ankle should not sag inwards, and regarded as good wages. The two groups are on the there should be an adequate arch. The straightness whole probably not very widely separated in their The differences in of the leg has its significance in the biological average economic status. fact that any departure from it places the leg and expenditure per head on food, of the two groups, foot at a mechanical disadvantage. In knock- we should expect to be less than the apparent knee the normally horizontal axes of the knee and difference in economic status. It must be borne ankle joints are not parallel and the weight-bearing in mind also that the apparently more prosperous schools include a number of the very poor. function of the limb is impaired. It will be noticed that the defects here tabulated Nevertheless, such differences as exist in the are of a very definite kind. Neither their existence proportion of defects found are all in favour of the nor their degree can be a matter of opinion once a more prosperous group. On the whole, I have no set of standards has been decided on. The assess- reason to think that the school population I have ment is purely objective. With the exception of examined differs very much from that of any bossing, about which there seems to be difference other urban district in the country. It is interesting to compare my figures with of opinion, there can be no doubt as to whether these deformities are defects ; they are pathological those obtained in two similar investigations elseM'Gonigle some 10 years ago reports departures from normality and contribute to where. defective physique in the adult. It is not claimed 83 per cent. of Durham school children (of all that all these deformities are of serious consequence ages) as showing one or more of these signs which The Board of Education as deformities; they are, I suggest, significant I have described. as indices of widespread defect of physique, which Report already quoted gives lower figures for bony Percentages of Children showing Evidence of Attending Schools in
Number Examined.
t 37"5
Poorer District Better District Aggregate Figures
Bossing of Parietal Bone. s. m. I P" 2 - ~ - ' 5 I' ~ . 7
Deformity of Chest Walt.
s.
j m. ~ p .
1,083
4"0
22"0
36.0
Knock Knee.
s.
~ m. i p .
Bow Leg.
1
j,12 1 97 j 212 011T 0.7 t - ~ - ' - - ~ 17o. - - " ( ' ~1 - - " - ~
92"8 479
I I
8.2 52.7 12 .2 ---@--I
17.8
Average Defective Teeth Foot t Perfect Deformity. Dentition. per Head.
30"0
5.9
6.9
0-62
26-0
6.2
6.6
0.7
28'0
6-1
6.8
1
19.3 i 49.6 [ 4.6
~-~i 73-----~
74.2
Degrees of defectiveness : s = slight ; m = m e d i u m ; p = plus.
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PUBLIC H E A L T H deformities in L.C.C. children, but when the findings of their medical officers are considered separately, we find that the highest figure for parietal bossing is practically the same as m i n e - 73 per cent. as compared with my 74 per cent. Their highest figure for knock-knee is higher than mine--82.5 per cent. compared with my 76.7 per cent. Their highest for deformity of the chest wall is 43-6 per cent., and if beading of the ribs is included, it is 55 per cent. against my 89.4 per cent. This difference I think must be due to the L.C.C. medical officers having adopted a much lower standard and passed many minor degrees of deformity as normal. Estimates of the prevalence of rickets by other workers are interesting in comparison. To quote from Parsons and Barling, Schmorl in Dresden, 1901-5, in 386 children dying from all causes, found by autopsy a maximum of 98 per cent. with rickets between the ages of 4 and 18 months, and this figure did not include cases of completely healed rickets. An investigation in Baltimore, 1926-30, showed up to 60 p e r cent. with rickets between 7 months and 2 years. More recently, Eliot and Souther, U.S.A., examined 1,186 children from 1 to 5 years, by physicalexamination and by X-rays, and found a total of 61 per cent. rachitic. The peak of more severe rickets (24 per cent.) occurred at about 17 months; the peak of the slighter degrees (37 per cent.) occurred at about 4 months. Eliot and Souther emphasise that these slighter degrees of rickets, between the third and tenth months, usually pass unnoticed. They say : " This association between mild rickets and rapid growth has raised the question whether mild rickets should not be regarded as physiological, but the question is of an academic interest only since the occurrence of rickets of this mild degree is of little practical importance." My comment on this is that, whatever the clinician may do, the M.O. of Health should not countenance the acceptance of any degree of disease as physiological; and I suggest that what is recognisable as clinical disease may fall considerably short of the full extent of pathological defect in the community. May it not be, for instance, that there is a prevalence of slight rickets, not clinically recognisable as such, which produces these minor bony deformities and a good deal of impairment of physique ? Whether the figures I have quoted for rickets relate to the same sort of thing that 1 have been recording is not what I am immediately concerned with. My point is that other investigators have found a high prevalence of something which militates against normality of physique. Apart from the findings of M'Gonigle and the Board o f Education Committee already referred to, my figures are, therefore, not entirely unsupported.
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JUNE To what is this very high incidence of defects due ? What cause or set of causes can act so generally as to affect practically the whole of the child population examined ? There is one cause more than any other to which these defects of physique are fundamentally attributable, namely, faulty nutrition. The work of Sir Robert McCarrison, among others, can leave little doubt on this point. Experiments in animal nutrition have demonstrated conclusively that food outweighs all other factors put together, in deciding the standard of growth and physique. We need not attribute all these malformations to rickets, for the common dietary deficiencies are multiple. Faulty nutrition is most likely to occur, or at least, is most serious in its effects, in the prenatal period and in the first few years of postnatal life. It is in this early period that these defects originate. Are Maternity and Child Welfare Medical Officers aware of the poor standard of physique in the child they pass on to the School Medical Officer at 5 years of age ? Can they throw any light on the causation of these defects ? What are the precise periods of origin of bossing, chest deformity and knock-knee ? I should like to ask other school medical officers to make investigations similar to mine. In doing so, I would urge them to adopt a strict standard of anatomical normality. No other standard is of the slightest scientific value. With the increasing attention being devoted to improving the physique of the people, the responsibility for accounting for these things will fall more and more on the shoulders of the Health and School Medical Services of this country. REFERENCES. Board of Education : Committee on Adenoids and Enlarged Tonsils (1931). The Association of Rickets and Dental Disease with Adenoids and Enlarged Tonsils. Park, E.A., and Eliot, Martha M., contribution in Parsons' and Barling's Diseases of Infancy and Childhood, Vol., I, p. 282. -p. 228 and 229. Wilkins, E. H. Report of the School Medical Officer, Birmingham, 1927. DISCUSSION.
Dr. Agnes Nlc011 (President, M. & C.W. Group), said that we all agreed that there was a large degree of minor deformities or variations from the normal in children under five years of age, and she asked what was the real significance of these variations and suggested that they might be comparable with the variations between one human face and another. She suggested that bony deformities might be due to inequalities of growth so that it could not be assumed a priori that they were rachitic in origin. Regarding chest deformities, she thought that tight clothing of infants had a large influence in preventing normal development. In general, her impression was that the physical and general
1937 condition of children had improved greatly in the last ten years. Replying to Dr. Nicolls' points, Dr. Wilkins said that one had only to compare the poor with more prosperous and well-nourished children to see that such deformities were abnormal. Dr. Murlel Radford asked whether inquiries had been made about the ante-natal health of the mothers, their attendance at M. & C.W. centres, and whether there was any X-ray evidence, and Dr. Marjorie Bank inquired as to the passing on of records from the M. & C.W. to the School Medical Service. Dr. Wilkins replied that there was an arrangement for the passing on of records at Birmingham but thought it had not been of much value as one medical officer's records were often not intelligible to another. This reply led to an appeal from Dr. Puddicolnbe that such records must be made intelligible as between one department and another, and also as between medical officers, Dr. C. E. St. Clair Stockwell (S.M.O., Leeds), said that the School Medical Service was hidebound to Board of Education standards. Regarding nutrition estimates, he said that in Leeds these varied from 5 to 40 per cent. in the records of eight medical officers. Regarding knock-knees, he thought that the normal difference between the sexes had not been taken into account and he went on to stress the importance of early X-rays to make sure that the children were not rachitic. X-rays in infancy could show definite changes in the growing ends of bones. He thought bad breathing largely responsible for chest deformities. Dr. V. Freeman (Dep. M.O.H., Islington Met. B.) wondered whether bad early feeding of infants, e.g., with condensed milk, had an influence on the chest deformities and suggested also that respiratory catarrhs had a decalcifying effect. School records gave a static analysis only, and he felt that the school system might be altered to allow of intensive and continuous investigations of small numbers, with X-rays, controls, etc. Dr. Wilkins said that an investigation on proper feeding had been in progress in Birmingham for some three months and had already shown astonishing results. It consisted of the giving of extra rations to 30 children who were in poor nutritional condition. The ration consisted of 1½ pints per child of a chocolate and dried milk preparation, which contained a special addition of vitamins A, C and D, and of calcium glutinate. Iron was present in the chocolate part of the preparation. The vitamin B was given in the form of one-eighth of a grain of dried brewers' yeast supplied fresh daily and put into a wholemeal sandwich. Dr. E. H. R. Smithard (M.O.H., Southall-Norwood) thought that the symptoms described by Dr. Wilkins were not correlated with any known pathological condition, and Dr. E. V. Saunders Jaeobs (A.M.O., Woolwich) said that the records of the toddlers' clinics at Woolwich showed anatomical abnormalities in so many children that it was dif~cult to know whether they were pathological. Proposing a vote of thanks, Dr. Jean Mackintosh (A.M.O., Stockport C.B.) said that the discussion had been most useful in drawing attention to the difficulty of variations between one medical officer's assessment of nutrition and another's.
PUBLIC H E A L T H T H E B O U R N E M O U T H , POOLE A N D CHRISTCHURCH TYPHOID EPIDEMIC * By H. GORDON SMITH, M.D., D.P.H., Medical Officer of Health, Bournemouth C.B. This afternoon I shall endeavour to give you an account of the epidemic of typhoid which began in the latter weeks of August in Bournemouth and the neighbouring boroughs of Poole and Christchurch. As Bournemouth is a County Borough and provided the largest number of cases, the outbreak has, unfortunately, been referred to by many as the Bournemouth epidemic. The populations of the three districts concerned are--as given by the Registrar-General for 1935 :-Bournemouth, 118,200; Poole, 65,600; and Christchurch, 12,820. It will be apparent, however, that in the holiday season the total population will be increased by some 60,000 visitors to at least a quarter of a million and, of course, there are in addition many people who pass through the town and partake of meals without becoming temporary residents. In Bournemouth the epidemic commenced in a somewhat insidious manner. In July there had been one or two household cases of what appeared to be food poisoning, though laboratory reports did not confirm this diagnosis. Also it was reported that outside Bournemouth numerous people were suffering from a mild illness characterised by sickness, diarrhoea and slight pyrexia. It seemed probable therefore that Bournemouth would be similarly affected. Consequently, when Dr. C. F. Pedley, Deputy M.O.H., communicated with me on August 20th informing me that he had been called in to see patients whose symptoms suggested food-poisoning, I was not at all surprised. Dr. Pedley, who was acting for me while I was away on holiday, told me that on August 13th a general practitioner had asked him to see in an hotel certain individuals who had recently been taken ill. The prominent symptoms were headache and other pains associated with pyrexia. Dr. Pedley advised that blood cultures should be made but these did not give definite results. On August 20th other practitioners drew attention to similar cases and enteric was seriously considered. On August 21st, Dr. Maule Home, of Poole, communicated with Dr. Pedley, as he had found various patients in his area who were possibly suffering from enteric. Dr. Pedley and Dr. Maule Home decided to inform the Ministry immediately. In consequence, Dr. Vernon Shaw, one of the Ministry's M.O.s, whose recent death was so much regretted, came down on August 22nd. A conference was held in Poole. There were present: Dr. Shaw, Dr. Pedley, certain practitioners who were in attendance on the patients and the manager of a dairy whom we will describe as Mr. X. Dr. Pedley had already made enquiries as to the food supplied to the patients, and had discovered that most of them, if not all, had consumed milk from a dairy of which Mr. X. was the manager. At this conference, in the morning of August 22nd, it was decided that there was in the area an outbreak of enteric, probably paratyphoid, and * Paper read to the Southern Branch, May 10th, 1937.
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