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(Continued from preceding page)prevention rather than attenuation, especially childrenunder 3 years of age. ,

According to Kohn and Koiransky, radiologicalevidence supports the belief that peribronchialinfiltration occurs in every case of measles, mild orsevere. The frequency with which measles lightsup a latent focus of tuberculosis is disputed, but thereis no doubt that it occasionally does so and thatrapid dissemination may result. Far more important,but as yet not accurately assessed, is the extent towhich measles complicated by broncho-pneumoniais the starting point of fibroid lung and bronchiectasis.

E. H. R. HARRIES, M.D., D.P.H.,Medical Superintendent, North-Eastern

Hospital (L.C.C.).

SPECIAL ARTICLES

FOOD, HEALTH AND INCOME

A NATIONAL SURVEY OF NUTRITION

FoR the first time the food position of the countryhas been surveyed on a large scale to show the relation-ship of income, food, and health. The investigation,which relies largely upon statistical methods, has beenundertaken by the staff of the Rowett Institute incooperation with the staff of the Market SupplyCommittee. It is described by Sir John Orr, M.D.,F.R.S., director of the institute. 1

Instead of discussing minimum requirements, aboutwhich there has been so much controversy, the reportconsiders optimum requirements. These are basedon the physiological ideal, defined as " a state ofhealth such that no improvement can be effected bya change in the diet," and the standard of adequacyof diet adopted is one which will maintain thisstandard of perfect nutrition.The survey attempts to find out the proportion of

the population attaining this standard ; and thestate of health of the country is reviewed to determinehow far inadequacy of diet is reflected in poorphysique and impaired health. The tentative con-clusion is found that a diet completely adequate forhealth according to modern standards is reached atan income level above that of half the population.The important aspect of the survey is the inadequacyof the diets of the lower income-groups and the muchlower standard of health of the people (especially ofthe children) in these groups compared with thosewho have more money.

HISTORICAL COMPARISONS

In 1835 the prices of bread and flour were muchthe same as they are to-day, but the average con-sumption per head was 80 per cent. greater. The

consumption of sugar was 20 lb. per head, whereasnow it is 100. This increase has, of course, beenrendered possible by the great fall in price ; sugar,which was about 6d. a lb. in 1835, now costs less thanhalf as much.A committee of the British Association appointed

in 1881 gave the first estimates of food consumption.Comparing the figures of 1934 with those estimates,the most striking changes are : consumption per

1 Food, Health, and Income. Report on a Survey of Adequacy of Diet in relation to Income. By John Boyd Orr. London : Macmillan and Co., Ltd. 1936. Pp. 72. 2s. 6d.

head of bread and potatoes is 30 per cent. less ; ofmeat 45 per cent. more ; of sugar 40 per cent. more ;of tea and butter the consumption is double. Thesame trend of changes is shown by comparison of thefigures of 1934 with those of 1909-13 and 1924-28.

METHODS OF INVESTIGATION

To get an idea of the diet in different sections ofthe community, the whole population was classified,according to the income per head, into six groups ;those at the top and bottom consisting of 10 percent., and the four intermediate groups of 20 percent. of the population. The composition of thesegroups was obtained by statistical analysis of a largenumber of figures, taken from income-tax statistics,wage statistics, and data relating to unemployment,old-age pensions, and other forms of social income.These figures were correlated with a sample takenfrom the 1931 Population Census and designed toyield information on the sizes of the families and theratio of earners to dependants in different occupationgroups.The six groups had average incomes per head per

week of 10s. and less (group 1.), 10-15s., 15-20s.,20-30s., 30-45s., and 45s. and over (group VI.).The corresponding estimated average expenditureson food were 4s. (group 1.), rising by 2s. incrementsto 14s. per head weekly (group VI.). The averageincome per head was 30s. and the average expenditureon food 9s.

Since the income per head is the income of thefamily divided by the number of persons supported,an average per head income of (say) 30s. per weekmay be reached in many ways-for instance, by askilled worker at E3 per week with only a wife tosupport, by a worker and his wife both in employ-ment with earnings of 38s. and 22s. per week, or bya man earning 550 per year with a wife, four children,and a maid. This means that any one group willcontain a heterogeneous collection of occupations,wage-earners, and non-earners. The poorest 10 percent. of the population (group I.) consist in the mainof families having a disproportionate number ofchildren or other dependants per earner. It isestimated that half the persons in this group arechildren under 14 and that it contains between20 and 25 per cent. of the children in the country.The total food-supply of the country having been

estimated, its distribution among the differentincome groups was estimated from 1152 familybudgets. These ranged from very poor familiesspending less than 2s. per head weekly on food,up to families with an income of E2000 per annum

spending 15s. or more per head weekly on food.The composition of the average diet of each groupwas then examined.

CONSUMPTION OF PARTICULAR FOODS AT DIFFERENT

INCOME LEVELS

The consumption of flour (see Fig. 1) and of

potatoes is remarkably uniform in all groups exceptI. and VI. In group VI. there is evidence thatmore expensive foods are substituted for potatoesand bread. In the lowest group there is no indicationof any substitution, nor indeed is there any cheaperfood which could be substituted for potatoes andbread. It looks as if the purchasing power of thisgroup is sd low that the consumption of even thecheapest foodstuffs is limited; or, what is moreprobable, the appetite in the lowest income-group is

680

below the average-one of the first

signs of sub-optimal nutrition beingdiminished appetite.

Graphs published in the report showthat as income rises the consumptionof margarine falls and of butter rises ;but if butter, margarine, lard, suet,and dripping are grouped together thetotal fat consumption rises steadilywith income. The consumption of meat,fish, milk, eggs, sugar, vegetables, andfruit increases with income. The figuresfor milk, fish, and fruit are shown inFig. 1.

COMPARISONS OF DIET AND STANDARD

REQUIREMENT

The next step is the comparison q,:

of the quantities of the constitu- (

ents in the average diets of each

group with the amounts requiredfor health. The standards of require-ments adopted are those compiled

,

by Stiebeling, of the United States GovernmentBureau of Home Economics. The vitamin require-ment for health is taken as twice that which will

prevent the occurrence of obvious deficiency disease.An ample supply is necessary since it is known thatthere are minor degrees of ill-health caused bydeficiencies of vitamins not great enough to showobvious symptoms. For mineral elements thestandards are based on the minimum requirementsfor the maintenance of a positive balance plus anallowance of 50 per cent. for additional requirementsof maintenance of health.

Assuming the validity of the standards, the averagediet of group I. is found to be inadequate for perfecthealth in all the constituents considered. Group II.is adequate only in total proteins and total fat ;group III. is adequate in energy value, protein, andfat, but is below standard in minerals and vitamins ;group IV. is adequate in iron, phosphorus, andvitamins, but probably below standard in calcium ;group V. has ample margin of safety in everythingwith the possible exception of calcium ; in group VI.all standard requirements are exceeded. Theseresults are shown in Fig. 2. The quality of the proteinis ̂ ;important, especially for children ; and the per-centages of protein and fat of animal origin, whichare of higher biological value than those of plantorigin, increase from group to group. Ifence theintake of the several constituents increases in qualityand in quantity with expenditure.

It should be kept in view that the standards withwhich the above comparisons are made are for themaintenance of perfect health, which is a standard

FIG. 2-Average intake of vitamins and minerals by income-groups.(Modified from the Report.)

very different from the average health of the com-munity. That average diets of the lower income-groups are inadequate according to these standardsdoes not mean that these people are starving or evensuffering from such ill-health as is recognised in theterm disease. These diets may suffice to maintainlife and a certain degree of activity, yet may beinadequate for the maintenance of the fullest degreeof health.

EVIDENCE OF IMPERFECT NUTRITION

Owing to differences in their diet, a comparison ofthe health of children of the lower income-groupswith that of childI8n of the higher should showa slower rate of growth and a greater incidence ofdeficiency diseases in the former. Stature is largelydetermined by heredity but the extent to which achild will attain the limit set by heredity is affected

by diet. Because of these hereditary factors, datawhich are numerically few are of little value. Ampledata on height and weight of the same race do,however, give an indication of the relative adequacyof diets. A conspicuous difference in the heights ofboys drawn from different classes is shown by alarge number of observations of council schoolboysand employed males (belonging mainly to groupsI. to IV.), and those attending Christ’s HospitalSchool (groups III. to VI.). Thus at 13 years of

age the boys of Christ’s Hospital School are on theaverage 2-4 inches taller than those of the councilschools. At 17 they are 3-8 inches taller than

" employed males " of the same age. Figures takenfrom observations of public schoolboys (belonging

FIG. 1. Consumption per head of certain foodstuffs by income-groups. The income in Group I. is less than 10s. a week;in Group VI. it is 45s. or over. (Modified from the Report.)

681

almost entirely to group VL) show further increaseon those for Christ’s Hospital.Three characteristic signs of malnutrition in

children-rickets, bad teeth, and aneemia-are fairlywidespread in the lower income-groups, the onlygroups in which extensive observations have beenmade. There is evidence to show that the same

dietary deficiencies which cause these conditions alsoaffect resistance to some infectious diseases, such aspulmonary and intestinal disorders of children.Such imperfect nutrition in childhood should be

traceable as poor physique in adult life and has beenfound, for instance, in army recruits. Furthermore,susceptibility to some infections, more especially totuberculosis, is influenced by nutrition and the reportstates that the most effective line of attack ontuberculosis is probably by improvement of diet.Figures are insufficient to show the incidence of

anaemia in the higher income-groups, but some degreeof anaemia is known to be common in women in thelower income groups. This is at least in part preven-table and diet is an important factor in its prevention.The correctness of the general picture presented

here has been confirmed by various experiments, insome of which (e.g., Corry Mann) a supplement ofmilk increased the rate of growth among children.In another, groups of rats kept on diets similar tothose of various Indian tribes showed to a remarkabledegree the physique and incidence of diseases corre-sponding to those of the respective tribes (McCarrison).In similar experiments in Scotland, reported in theJournal of Hygiene (1935, xxxv., 476), two groups ofrats have been given a diet resembling that of income-group 1., one group of rats having in addition anabundance of milk and green food. Not only werethe rates of growth markedly divergent but thedeath-rates of the two groups differed conspicuously.The mortality to 140 days of age on the supple-mented diet was 11-6 per cent., while for those onthe experimental diet the rate was 54-3 per cent.This heavy death-rate was mainly due to epidemicinfections to which both groups were equally exposed.

SUMMARY AND CONCLUSION

We reproduce substantially Sir John Orr’s con-

cluding statements :-The food position of the country has been investi-

gated to show the average consumption of the mainfoodstuffs at different income levels. The standardof food requirements and the standard of health

adopted are not the present average but theoptimum-i.e., the physiological standard, which,’though ideal, is attainable in practice with a nationalfood-supply sufficient to provide a diet adequate forhealth for any member of the community. Themain findings are as follows :i.-Of an estimated national income of 3750

millions, about n075 millions are spent on food.This is equivalent to 9s. per head per week.

11.—The consumption of bread and potatoes is

practically uniform throughout the different incomelevel groups. Consumption of milk, eggs, fruit,vegetables, meat, and fish rises with income. Thus,in the poorest group the average consumption ofmilk, including tinned milk, is equivalent to 1-8 pintsper head per week ; in the wealthiest group 5-5 pints.The poorest group consume 1-5 eggs per head perweek ; the wealthiest 4-5. The poorest spend 2-4d.on fruit; the wealthiest Is. 8d.Ill.-An examination of the composition of the

diets of the different groups shows that the degreeof adequacy for health increases as income rises.The average diet of the poorest group, comprising

4 million people, is, by the standard adopted,deficient in every constituent examined. The second

group, comprising 9 million people, is adequate inprotein, fat, and carbohydrates, but deficient in allthe vitamins and minerals considered. The third

group, comprising another 9 million, is deficient inseveral of the important vitamins and minerals.

Complete adequacy is almost reached in group IV.and in the still wealthier groups the diet has a surplusof all constituents considered.

’

iv.-A review of the state of health of the peopleof the different groups suggests that, as incomeincreases, disease and death-rate decrease, childrengrow more quickly, adult stature is greater, andgeneral health and physique improve.v.-The results of tests on children show that

improvement of the diet in the lower groups is

accompanied by improvement in health and increasedrate of growth, which approximates to that ofchildren in the higher income-groups.vi.-To make the diet of the poorer groups the

same as that of the first group whose diet is adequatefor full health (i.e., group IV.) would involve increasesin consumption of a number of the more expensivefoodstuffs-viz., milk, eggs, butter, fruit, vegetables,and meat-varying from 12 to 25 per cent.

If these findings be accepted as sufficiently accurateto form a working hypothesis, they raise importanteconomic and political problems. Consideration ofthese is outside the scope of the investigation. It

may be pointed out here, however, that one of themain difficulties in dealing with these problems isthat they are not within the sphere of any singleDepartment of State. This new knowledge of £nutrition, which shows that there can be an enormousimprovement in the health and physique of thenation, coming at the same time as the greatlyincreased powers of producing food, has created anentirely new situation which demands economic

statesmanship.

MEDICINE AND THE LAW

The Ruxton Murder Trial

IN his summing-up to the jury at the trial of Dr.Buck Ruxton for murder, Mr. Justice Singleton paida compliment to the medical witnesses who had beencalled by the Crown. "Never," he said, "have Iseen expert witnesses more careful or more eagernot to strain a point against an accused person :there was no evidence to contradict them except byRuxton himself." Their evidence indeed was vital.Dr. Ruxton’s wife and Mary Rogerson, the nurse tohis children, were last seen at his house in Lancasteron Sept. 14th ; on the 29th dismembered parts ofhuman bodies were found in a ravine at Moffat,Dumfriesshire; there were two heads, and theremains were referred to during the proceedings asbody No. 1 and body No. 2, these being alleged tobe the remains of Mary Rogerson and Mrs. Ruxtonrespectively. Dealing with body No. 1 Prof. Glaister,Regius professor of forensic medicine at GlasgowUniversity, described the extent to which tissue andskin had been cut from the face ; both eyes had beenremoved. Asked by the judge if he could see anyother reason than the prevention of identification,he observed that the removed parts of the bodyincluded those which might have borne signs ofasphyxia. ’The dismemberment had been done bycutting through the joints. There had been bruisingbefore death ; blood had been drained away before