•^"^'^Jt. '"■•«F^'''""^.rwfri(xmT- ■.,>:Lv.^:eh.i^ ^ tihr) CJ> --i t^ 2 CO CO -rj< t- « 2 ■^ ?^ o t^ CO 8 00 —1 -«• 01 ■re cs c 'rf Jco'.. ^ s <: o 2; 00 n 00 o> (M 2 ■^ to o> ^ •re ■* 00 CO ^ c, t^ Tf CO TJ* z « Q 5 a> •<)< o ^ o « CO (M ^ CO 05 TK ^ to 00 <^4 N S 22 oo « o o -<** CO CO 12 CO CO ;:; m M 2 r>^ to "* s ^ - " Oi CO - « — . »re CO ^ ■* Jj 22 •* t^ CO 03 W m «5 n •re TJH '" s •*J^ •^ " to 00 c^ Tf* CO = IM ■«< o PS a ■c 1 3 a 3 o ■3 a CO 3 3 a .2 '3 3 cU a a fco 3 d c. 3 3 C3 3 3 K 3 3 2 02 ca 2 3 3 60 a 3 3 ca 3 3 3 ja 3 1 C 2 < The Health of the Children 23 Table 16 gives the number of children now living at vari- ous ages, by provinces. The total for each year is represented in Figure 7. MASCULINITY The number of children dealt with is not large enough to make division of statistics into male and female of value. It is of interest, however, to note the relation of total male and female births and deaths. In Table 17 the births and deaths are divided into groups of provinces. Group 3 com- prises the provinces having the highest child mortality and Group 1 those with the lowest. In those where the death rate is highest the number of boys born is lowest. Of the total births there are 1,032 boys to 1,000 girls, about the usual pro- portion. For every 1,000 girls who have died, 1,267 boys have died. This means that the living boys and girls are equal in number — 1,310 of the former to 1,312 of the latter. Table 17 RELATION OF MALE TO FEMALE BIRTHS. BY GROUPS OF PROVINCES Total living births Number male births to 1,000 female Total deaths Number male GROUP Male Female Sex not stated Male Female Sex not stated deaths to 1,000 female 3 2 1 561 572 414 573 557 369 50 61 46 979 1.027 1,122 no 87 40 95 63 29 14 6 1 1,158 1,381 1,379 Total 1,547 1,499 157 1,032 237 187 21 1,267 Twins are reported nineteen times (.6% of the total). In six cases there were twin sons, in seven cases twin daughters, in five cases half and half, and in one case sex was not stated. CONDITIONS AFFECTING CHILDREN There is a variety of conditions which react adversely on foreign children in China. These are, briefly: (1) Low moral atmosphere — of non-Christian Chinese servants, etc., and, in port cities, of non-Christian foreigners. (2) Conditions which may affect the nervous poise of the child: isolation, occasionally fright from Chinese mobs, and almost constantly, unnatural tension over food and drink. '*My father is dead," said one child. Quickly her play- mate asked, "What did he eat?" 24 The Health of Missionary Families in China "My," said another little girl, on reaching a Vancouver hotel en route from China, "isn't it grand to take a bath in drinking water?" (3) Lack of proper educational and social advantages. (4) Diflficulty in maintaining physical health because: {a) of climate, sun, lack of space for play; {h) because of diffi- culty in obtaining good fresh milk and other elements of a balanced diet or sufficient vitamins from fruit which is pared and vegetables which are cooked, and (c) because of the prev- alence of infectious diseases. All these phases of child life are important. This study is concerned chiefly with the question of physical health. COMPARATIVE MORTALITY MISSIONARIES AND CHINESE Table 18 MORTALITY OF CHILDREN OF MISSIONARIES AND OF LOWER CLASS CHINESE Total Births Number of Deaths Number of Deaths Per 1,000 Births CHILDREN OF Total 0-5 Years 0-1 Year Total 0-5 Years 0-1 Year 3,254 8,468 451 2,751 366 2,203 196 1,321* 139 325 121 272 60 156* ♦Number infant deaths unreliable because of Chinese method of counting ages. Figure 1. Mortality of Children of Mission- aries and of lower class Chinese. (Illus- trating Table 18.) How does the death rate among mis- sionary children compare with that of the Chinese among whom they live? In order to answer this question, the writer* had inquiry made of 4,000 male patients who attend the dispensary of the Union Medical College in Peking. Compara- tive mortality is shown in Table 18 and Figure 1. How do the rates for children of mis- sionaries and children of non-missionary foreigners compare? The writer knows of no data for children. Statistics for a small number of persons in Africa^ showed the following number of deaths per 1,000 persons: European officials, 8.10; non-officials, 8.49; missionaries, 31.7. The Health of the Children 25 MISSIONARIES IN CHINA AND JAPAN Table 19 MORTALITY OF MISSIONARY CHILDREN IN CHINA AND IN JAPAN Number of Living Births Number of Deaths Number of Deaths Per 1,000 Living Births COUNTRY Total 0-5 Year3 0-1 Years Total 0-5 Years 0-1 Years China 3,254 377 451 36 366 28 196 20 139 95 112 74 60 Japan 53 How does the death rate among chil- dren in China compare with that in other mission fields? The writer has sent a questionnaire to all missionary families in Japan. The answers so far received, as shown in Table 19 and Figure 2, reveal a much lower rate in Japan than in China, the largest dif- ference occurring in children over 1 and under 5 years. Mission doctors in Seoul are making a similar study for missionaries in Korea. How does the rate among mission- ary children in China compare with rates in the home lands? It is hardly fair to compare the mis- sionary group with the general popu- lation, for the following reasons : Missionaries are far above the average in education and intelligence; they have passed physical examinations ; they are free from the diseases which lie behind such a large proportion of the deaths of children, viz., the venereal diseases and alcoholism. Another difficulty is that general mortality statistics are based on the number of persons dead to the number living, in any geographical or age group for a certain year, whereas in this study births and deaths extend over many years and the number living in any one year is not known. In order to secure figures for accurate comparison, the writer is at present sending questionnaires similar to those used in China and Japan, to ministers and educated church members in America. A comparison of health conditions in these three groups will be presented in a later paper. Figure 2. Mortality of missionary children in China and Japan. (Illus- trating Table 19.) 26 The Health of Missionary Families in China In the meantime, there is some value in comparing results obtained with available government statistics. The mission- aries participating in this study have been married an average of 11.4 years. Wherever possible, statistics corresponding to this time period, rather than the latest returns, are used. INFANT MORTALITY First : in regard to infant mortality. This term means in government statistics the number of infants under one year old who have died in a certain year per 1,000 babies born alive dur- ing that same year. In this study it means the number of infants who have died per 1,000 born. Instead of one year, it covers a number of years. There are two sources of error. First, there are 177 infants not yet a year old. Probably five of these will die before reaching a year. This would raise the infant mortality from 60.2 to 61.7, a small difference. The second possible source of error is larger. The parents of 15 babies made the report "Died at birth." It is assumed that these babies were dead when born, and they are therefore classed among the still births. If, however, they were alive when born, they should be classed as infant deaths, and this would raise the infant mortality rate from 60.2 to 64.7. This indefiniteness concerning infants dying at birth is a source of error in most mortality statistics. Table 20 PERCENTAGE OF INFANT DEATHS OCCURRING BY MONTHS FOR UNITED STATES' AND VARIOUS CLASSES OF ENGLISH SOCIETYs, AND FOR MISSIONARY CHILDREN Infant Mortality Infant Deaths Occurring in Specified Months Under 1 Mo. 1-2 3-5 6-11 171 151 90 76 69 42 60 Percentage 27 24 50 39 44 50 34 Percentage IS 21 17 19 21 14 6 Percentage 21 19 15 17 20 14 21 Percentage 34 35 United States children of native born mothers IS 24 15 Professional and business group in England- . 22 39 Table 20, Column 1 gives infant mortality rates for vari- ous groups of English and American society. In this comparison, missionary infants show up very well (60 against 42 for the children of English professional and business men). There is a striking difference, however, in the distribution of deaths during the first year, as shown in Table 21 and Figure 3. The Health of the Children 27 Table 21 INFANT MORTALITY OCCURRING BY MONTHS FOR TWO CLASSES OF ENGLISH SOCIETYio AND FOR MISSIONARY CHILDREN Number of Births Number of Deaths Per 1,000 Births 0-1 Year 0-1 Month 2-3 Months 4-6 Months 7-12 Months Factory laborers in England Professional and business groups in England Missionaries in China.. _ 80,919 8,658 3,20t 171 42 60 46.3 21 20.9 31.7 6.2 3.4 36.4 6.2 12.8 56.8 8.1 23.4 Figure 3. Infant Mortality by Months for two classes of English Society and for missionary children. (Illus- trating Table 21.) In communities where in- fant death rates are low, a larger proportion of the in- fant deaths occur in the first months of life than in communities where rates are higJi." (This because of the unpreventable accidents and defects at birth.) Among missionary chil- dren, however, 39% of the deaths occur in the last half of the year, giving a curve which follows that of Eng- lish factory laborers. The cause of this upward turn is shown in Table 50. 31 of the 67 deaths during these six months were due to intestinal infection, viz., dysentery, infec- tious diarrhoea, cholera, and typhoid. Were it not for these infections, the infant rate would nearly equal that of the fav- ored English class, which it actually surpasses for the first six months. Breast-fed babies have no right to these infec- tions. Many mothers complained that they were able to nurse their babies but a few months, which fact, with the consequent artificially prepared food, accounts in large measure for the rising death curve after the first six months. It has been shown that the mortality among bottle-fed infants in New York is 12 times what it is among the breast-fed.^- The ratio in China, where clean, fresh milk is hard to get, and dysentery is rife, is probably not less. The extent and cause of this inability to nurse needs special investigation. If it is found that too much mission work is responsible, the price paid for that work is a high one. 28 The Health of Missionary Families in China MORTALITY IN EARLY CHILDHOOD The hope aroused by this comparatively low infant mor- tality of finding a low death rate among children is quickly dashed. In comparing various city rates with the English "Healthy District Life Table," English health officers have shown that children are most affected by an unhealthy envi- ronment during the third year of life/^ From this high point the curve sinks gradually to the tenth year, when unhealthy cities show little more mortality than the ** Healthy Districts." This finding is verified in these statistics. Table 22 MORTALITY FOR THE FIRST TEN YEARS AMONG MISSIONARY CHILDREN AND AMONG CHILDREN IN AMERICA AND ENGLAND Number of Deaths Per 1,000 Living Number of ) Missionary Children 1 Children of General Year Alive at Begin- Deaths During Children of Native White Population of Age ning of Year That Year Missionaries Parents, U. S. A. 1900 England and Wales 1904-1908 0-1 3,212 194 60 133 117 1 2,841 87 31 32 35 2 2,587 48 18 14 14 3 2,332 17 7 9 9 4 2,147 19 9 7 7 5 1,967 12 6 6 6 1,820 15 8 5 7 1,673 5 3 4 8 1,534 10 6 '. 3 9 1,399 4 3 1 , ---- Figure 4. Mortality for the first ^^|"^^ ^- Mortality of the first fivP vears imone rnism-nnarv rhil ^^® ^^^^^ among missionary chil- JLr, oi^r.h^U. Tf ^i?-^! Lf dren and children in England and dren and children of white native- Wales (Illustratin- Table 2"? ^ born Americans. (Illustrating ^^^^^- UHustratm^ iable 16.) Table 22.) Infant deaths, as shown in Table 22 and Figures 4 and 5, for the general population of England^'' and the native white population of the United States,^ are more than double the missionary rate, but after the first year deaths are about the same. The Health of the Children 29 Table 23 CHILD AND INFANT MORTALITY IN CITY AND COUNTRY DISTRICTS OF ENGLAND (1914; COMPARED WITH THAT OF MISSIONARY CHILDREN NUMBER OF DEATHS PER 1,000 LIVING 0-1 Year j 1 Year 2-3-4 Years 130 66 60 55.7 11.7 30.6 13.5 3.8 11.2 If, as in Table 23, we compare our rates with the cities of North England,^" we find the same condition, a relatively- high rate for missionary children for the ages 2, 3 and 4. If we compare with the rural districts of South Eng- land, where infant death rates are near- ly as low as missionary, we find that during the second year missionary rates are more than double, and during the third, fourth and fifth years are three times the rates of the country districts of England. This is illustrated in Figure 6. Differences in the methods of arriving at results make comparison of the two curves of more value than com- parison of any two points on the two curves. These comparisons show clearly an excessive mortal- ity for the second, third and fourth years of life. These years, rather than the first year, are, compared with the homeland, the dangerous ones for missionary children. These compari- sons are made with English and American statistics rather than with European, because only about one-tenth of the chil- dren are from European societies. Except for Germany, which has a high rate, infant mortality rates in Northern European countries are lower than those in England and America. For the five-year period from 1906 to 1910, the following was the infant mortality rate in various countries ■}* United States, 124; England and Wales, 117; Netherlands, 114; Scot- land, 112 ; Denmark, 108 ; Sweden, 78. Figure 6. Mortality in first five years among Missionary Children and children in rural districts of England. (Illustrating Table 23.) 30 The Health of Missionary Families in China Table 24 PERCENTAGE OF CHILDREN DYING AND PERCENTAGE NOW LIVING, AT VARIOUS AGES AGE Percentage Dying At Specified Age Percentage Now Living At Specified Age 0-1 _.. ..._ 43.6 19.6 10.8 3.8 4.2 2.7 3.4 1.1 2.2 .9 4.2 3.8 6.6 1 .. _ 6.6 2 7.7 3 ... 6.1 4 6.1 5 . . 6.2 6.... 5. 7 5. 8 4.7 9 4.2 10-19 _ 26. 14.4 Total-- 100.3 99.1 D EA D - PERCEN TAQE OP TOTAL NUMBER. DEAD LIVINQ- PERCENTAGE OF TOTAL NUMBER. UIVINQ U3. IIM Q Sfl 13 ^ ^ 1 M « -29 70 80 and oyer Years not stated 56 67 If we divide the children into two groups, the first group comprising those whose parents have been married less than 20 years, the second group those whose parents have been married more than 20 years, and if we count the deaths for the first group by adding the number of children at present living, but who will die before completing the first or the fifth year, we get the following figures : Infant mortality, first group 58, second group 66. Mortality under 5 years, first group 120, second group 145. This means a reduction of mor- tality between the two groups {i.e., in the 10-15 years which separates the two) of 12% in infant mortality and 18% in mortality under five years. Because of the round-about method of arriving at the above figures, comparison with government statistics must be far from accurate. The Health of the Children 49 Between the years 1900 and 1911 infant mortality in the United States" was reduced 22%, and mortality under five years 27%. In England,^^ during the 40-year period ending; 1911-15, mortality was reduced as follows : for the first year of life, about 30% ; for the second year, a little over 40% ; for the third, fourth, and fifth years, about 50%. Table 38 MORTALITY AMONG FIRST AND SECOND BORN CHILDREN BY NUMBER OF YEASS PARENTS HAVE BEEN MARRIED Number Number of Living Births Number of Deaths Number of Deaths Per 1,000 Living Births of Years Married Total 0-5 Years 0-1 Year Total 0-5 Years 0-1 Year 0-9 815 679 313 106 79 94 70 27 77 76 45 13 38 47 21 10 97 138 227 225 94 112 144 169 47 10-19 69 20-29 67 30 or more 94 In Table 38, as illustrated in Figure 19, only first and second births in each marriage period are counted. In this way the births are more sharply con- fined within the various periods. The difference in mortality for the 0-1 and 0-5 age periods of these first and sec- ond-born children is greater than when all children are counted. The difference is due largely to the very low mortality of third and later bom children among those married more than 30 years. These 143 children show an infant mortality of only 21. Is this a case of survival of the fittest or of acquired immunity? In Table 38 mortality of children of the first group (parents married less than 20 years) show, for infants, 25%, and for children under five, 32% improvement over the second group (parents married more than 20 years). These figures would be slightly less if corrected for the first and second bom living children under five and one who will die before reaching those ages. Figure 19. Mortality of first and second born children by number of years parents have been married. (Illus- trating Table 38.) 50 The Health of Missionary Families in China The study of this phase shows that there has been a reduc- tion of child mortality among missionary children in recent years. It is doubtful, however, if this is greater than the reduction which has taken place among the general population of civilized countries during the same period. Probably the reduction would be greater if we had figures for children of the entire previous generation of missionaries. The families now on the field have demonstrated their abilitv to survive. Table 39 ORDER OF BIRTH MORTALITY OF CHILDREN BY ORDER OF BIRTH Ordw Total Number of Livina Births Number of Deaths Number of Deaths Per 1,000 Living Births of Birth Total 0-5 Yean 0-1 Year Tctal 0-5 Years 0-1 Year lat bom and " 3rd " 4th " 5th " 6th and more. - 1,122 854 569 340 17S 152 158 117 72 42 22 30 130 90 62 32 19 27 70 49 30 20 10 12 141 137 127 124 123 197 115 105 108 94 100 177 62 57 53 58 56 79 Total 3,215 441 360 191 137 112 59 In Table 39 and Figure 20 is sho\sTi the mortality of children by the order of birth. There is a slight do^vnward tendency of all age groups until after the fifth child, when all rates leap upward. This rise is due entirely to increase in deaths among children under 5 years. The cause for this, in part at least, is shown in Figure 28, second column. figure 20. Mortality of children by order of birth. (Illustrating Ta- ble 39.) The Health of the Children 51 NUMBER OF CHILDREN IN FAMILY Table 40 MORTALITY OF CHILDREN BY NUMBER OF CHILDREN IN FAMILY Number of Children Total Number of Living Births Number of Deaths Number of Deaths Per 1,000 Living Births in Family Total 0-5 Years 0-1 Year Total 0-5 Years 0-1 Year 1 264 380 689 625 490 252 74 72 63 62 20 50 96 99 66 51 21 11 18 18 19 40 80 81 48 45 16 8 15 18 19 41 42 27 23 10 4 6 75 132 139 158 135 202 284 153 286 290 70 105 116 130 98 179 216 111 233 226 60 2 8 50 60 4.. 67 5 . 55 6 93 7 135 8.. . . 56 9 95 10.11.12 14 6 97 Total 3,229 450 66 194 139 113 60 Figure 21. Mortality of children by num- ber of children in the family. (Illus- trating Table 40.) Table 40 and Figure 21 show mortality ac- cording to the size of the family. Infant mor- tality remains fairly constant until families having more than five children are reached. Mortality of other chil- dren, however, increases progressively, as the family increases in size. A curious fact is the relatively low mortality in families where there are five children. The increase of rate for large families is due in part to the fact that the children are older. 52 The Health of Missionary Families in China Table 41 BIRTHPLACE OF CHILDREN MORTALITY OF CHILDREN BY BIRTHPLACE Number of Living Births Number of Deaths Number of Deaths Per 1,000 Livinj; Births BIRTHPLACE Total 0-5 Years 0-1 Year Total 0-5 Years 0-1 Year Outside of China 385 49 40 20 128 104 52 In China 2,819* 399 325 174 141 115 62 ^Includes a few children whose place of birth was not stated. Figure 22. Mortality of children by birthplace. (Illustrating Table 41.) Among missionaries one often hears discussions concerning the relative health of children born in China and those born at home. Table 41 shows that there is no great difference of mortality in the two groups. The advantage for those bom outside China is 14% for the first year and 10% for the rest of life. Children born outside China have spent 58% of their life in China, while all chil- dren have spent 67%. The following is the list of birthplaces of chil- dren born outside of China: United States, 191; England and Wales, 53; Canada, 28; Scotland, 15; Sweden, 12; Australia and New Zealand, 11; Ger- many, 10; Norway and Finland, 6; Ireland, ;'. ; miscellaneous, 56; total, 385. Percentage of chil- dren born in China, 87.5; percentage of married life spent in China, 81.0. OTHER FACTORS OF CHILD MORTALITY It was realized that the more questions asked in the ques- tionnaire, the fewer would be the answers. Therefore, sev- eral important factors not included in the statistical study should be mentioned. Salaries — As a rule, curves of child mortality closely par- allel the curves representing family income, i.e., the lower the wages, the higher the number of deaths. It is likely that where missionary salaries are insufficient to provide summer vacations, the best milk available, medical overhauling on fur- lough, etc., deaths will result. Though exact information has not been obtained, the writer thinks that the average salary paid by societies in the lower half of Table 26 is less than that The Health of the Children 53 paid by societies in the upper half. One parent in the former group writes, '^How can I bring up and educate my children on a salary of (the equivalent of) G $400 a year?" However, such a cry was found in the letters but rarely. Information as to whether there is waste of life and efficiency because of sub-living salaries would be hard to secure from the mission- aries directly. Amahs. ''The environment of the infant," says Sir George Newman,^^ "is its mother." "The problem of infant mor- tality is not one of sanitation alone, of housing, or indeed of poverty as such, but is mainly a question of motherhood."^* Another says, "The most important factors in infant mortal- ity are the strength, the health, the character and the intelli- gence of the mother. "-° An extremely pertinent question is, "What is the effect on child mortality in China of the substi- tution of hired nursehood for motherhood, of the substitution of the 'health, the character and the intelligence' of a Chi- nese servant woman for the 'health, the character and the intelligence' of the missionary mother? If children are deliv- ered entirely into the keeping of servant Chinese, we cannot expect a mortality a great deal lower than that for the Chinese children, as shown in Figure 1. There is naturally a wide difference of opinion as to how much the personal care of children should be subordinated to the prosecution of mission work. One mother takes her small children with her on country trips purely as a bait for attract- ing crowds. Though these statistics do not permit analysis of the part care and feeding of the children by amahs plays in child mortality, a number of the correspondents deal with the point and make it clear that they consider it an important fac- tor in mortality of missionary children in China. Kitchens — A third of all deaths of these children were due to intestinal infections ; dysentery, diarrhoea, cholera, and tjrphoid fever. This points to the enormous importance of the kitchen in the life, or death, of missionary children. Many kitchens in North China are dark, dirty, and fly-infested, used by all the servants, the government an absolute monarchy with the native cook on the throne ; in short, a favorable port of embarkation for all germs bound intestineward. The importance of breast-feeding and medical care have been mentioned. Other factors which can be only named are : milk and water supply, location in the city or country, method of sewage disposal, summer vacations, location of schools, etc. 54 The Health of Missionary Families in China THE CAUSE OF DEATH, BY GROUPS OF DISEASES Besides knowing the proportion of children dying, it is important from the side of prevention that we know the causes of death. For purposes of comparison, all causes of deaths are divided into ten groups. By this means we diminish the error from using small numbers and from inexact diagnoses. The groups used are as follows: (1) dysentery ("with blood and mucus" specified on question blank), both acute and chronic. (2) Intestinal infections aside from dysentery and typhoid fever, Including diarrhcea, colitis, cholera infantum, Asiatic cholera, enteritis. (3) Respiratory infections — bronchitis, pneumonia, and whooping cough. (4) Smallpox. (5) Six major infections, viz., diphtheria, scarlet fever, typhoid fever, tuberculosis, malaria and meningitis. (6) Birth defect and injury, difficult labor, eclampsia, malformation, etc. (7) Prematurity. (8) Malnutrition, difficult feeding. (9) All other causes, and (10) cause unknown, not stated or unin- telligibly stated. Table 42 GEOGRAPHICAL LOCATION MORTALITY FROM VARIOUS DISEASES BY SECTIONS OF CHINA Total Number of Deaths Per 1,000 Living Births From Specified Causes a □ u, Z 1 5 SECTION OF CHINA Number o ° ■3 Li\'ing Births t J3 g S g S „ 8 £ 3 o 03 O 3 fc & O o :S"c a ^ o a h Q ^ a CO ■& H (X, S < 6 North 95S 1,740 506 32 21 9 19 17 1 22 14 1 9 6 38 25 19 8 7 5 7 5 3 5 4 7 29 19 16 11 Central 10 South 7 Figure 23. Mortality of children from various causes by sections of China. (Illustrating Table 42.) Tables 42-49 give the number of deaths for all ages per 1,000 children born. Table 42 and Figure 23 show why death rates decrease from North China to South China. Every disease group with the single exception of ''malnutrition" The Health of the Children 55 shows this downward curve. The sharpness of the descent is most marked for the intestinal, respiratory and smallpox groups, and less marked for the major infectious group. The figures show strikingly the disproportionate impor- tance of infections over constitutional causes of death in North China. If we add the first five groups embracing the infec- tious (bacterial) diseases, and take the ratio for North China as the index, Central China shows 39% and South China only 14% of the deaths which North China records. Now if we combine the next three groups — which gives the deaths for nutritional, developmental and birth causes — we find that Central China has 80% and South China 75% of the rate for North China. In other words, as a cause of death these non-infectious conditions are, in relation to North China as a standard, two times more important in Central China and five times more important in South China than the infectious diseases. MISSIONARY SOCIETIES Some of the external factors which influence mortality rates in societies (i. e., age of children, number in family, per- centage of time in China, geographical distribution of work- ers, proportion of doctors) have been considered. Other even more important factors are internal to the societies, having to do with the policy of the boards towards the selection of workers and subsequent care of them. There is no attempt in this paper to relate mortality rates of individual societies to these internal factors. This can be done best by members of the various societies. It is important, however, that this study help show soci- eties from what quarters death has come in the past. This is attempted in Table 43. Division of the statistics into so many groups diminishes the reliability of results, soi that only marked differences from the average should attract attention. 56 The Health of Missionary Families in China Table 43 MORTALITY OF CHILDREN FROM VARIOUS CAUSES, BY SOCIETIES Total Number of Living Births Number of Deaths Per 1,000 Living Births From Specified Causes SOCIETY 1 "o t 3 1 1 a 1 J o h pa 1 1 "3 1 o & ■S o < 1 S CO o 1 o Am. Bapt., North_ 99 10 10 20 20 10 78 26 13 13 13 13 Am. Meth., North 197 20 5 15 5 10 10 15 82 12 12 60 Y. M. C. A. 120 17 17 8 8 8 17 25 437 16 9 18 7 25 2 7 2 16 9 1,013 16 10 14 4 18 3 7 4 16 5 Canadian Meth 134 30 7 15 7 7 7 7 15 15 94 11 21 32 11 32 11 Am. Presb., North 314 22 6 9 6 18 6 9 6 26 6 137 21 7 7 21 14 14 42 13S 43 7 7 36 7 36 7 98 20 20 20 20 20 20 20 20 915 24 8 12 5 20 6 6 4 24 15 Other Eng. Sec 291 34 7 10 7 31 7 7 34 China Inland Mis 449 22 9 22 4 40 4 4 7 29 22 Am. Presb., South. 106 56 19 56 28 9 9 9 Other European Soo 171 40 18 29 18 23 6 6 40 12 Am. Baptist, South 119 25 33 8 75 17 17 42 17 European C. I. M _ 139 43 72 14 22 43 29 7 1 Total — 3rd group 1,275 28 26 18 6 40 5 4 4 31 12 All Societies - 3,203 23 15 15 6 28 5 6 4 24 11 1 The Health of the Children 57 Figure 24. Mortality of children from various causes by societies. The societies are in the order of total mortality, as in Figures 11 and 12. (Illustrating Table 43.) Table 43 gives the deaths from various causes by soci- eties. Figure 24 shows the relative number of deaths from four of the groups of diseases. Here, as in Table 42, the striking difference is between the infectious and constitutional causes. Societies which are near the bottom of the list are there because of the six major and the intestinal infectious diseases. There is little difference between the first and third groups of societies in respiratory infections, and practically no difference in the deaths connected with birth and nutrition. Three of the society groups show relatively twice as many deaths from smallpox as all other societies combined. 58 The Health of Missionary Families in China NATIONALITY OF SOCIETIES Table 44 MORTALITY OF CHILDREN FROM VARIOUS CAUSES BY NATIONALITY OF MISSIONARY SOCIETIES Total Number of Deaths Per 1,000 Births From Specified Causes C3 3 -o SOCIETIES WITH Number o 3 a •HEAD OFFICES IN of Living o >> ■g o o o CQ - Births >> S g M a ?^b s 'S l~> o fc A o 5'a a a o Q ■q fS a CO s m £ S ^ 1,662 776 21 21 14 9 13 11 5 2 27 20 6 8 5 1 5 1 19 28 1 Great Britain and Canada. 6 (China Inland) 449 310 22 42 9 42 22 22 4 19 40 32 4 4 3 7 3 29 35 22 10 Figure 25. Mortality of children from various causes by nationality of missionary societies. (Illustrating part of Table 44.) Table 44 and Figure 25 show the causes of deaths by nationality of societies. American and English (including colonial) societies show no significant differences in causes of death. The China Inland group (which is mostly English and American) shows an increase in respiratory and major infections. The European societies (which include those asso- ciated with the C. I. M.) show greatest increase in the intes- tinal infections, in smallpox, and in miscellaneous causes. The Health of the Children 59 BIRTHPLACE OF PARENTS Table 45 MORTALITY OF CHILDREN FROM VARIOUS CAUSES BY BIRTHPLACE OF PARENTS Total Number of Deaths Per 1,000 Births From Specified Causes a ^ ^ TJ BIRTHPLACE OF PARENTS Number of Living -a O >. a S 3 OS O 5 Births 5 "S g _o Q& 3 •E te o .t! 3 g s a. ^ 2 "5 a a s o 3 >> Q i3 1 CO CP £ 2 < One or both born in China . . 176 28 5 11 39 11 5 17 Both born in Europe 218 50 22 36 32 36 4 4 36 18 All others where both stated 1,503 18 18 15 5 28 8 • 6 4 15 6 Total al' societies 3,203 23 15 15 6 28 5 6 4 24 11 Table 45 is deficient because for more than one-half of the children the birthplace of parents was not recorded. Un- fortunately for the accuracy of the computation, the number of children with a parent bom in China is small. These chil- dren have no deaths from smallpox or malnutrition, and rela- tively few from diarrhoea. Of all the children whose parents were bom in Europe 5% have died of dysentery and more than 3% of smallpox. Of the children who have died, 15% have died of smallpox. MEDICAL TRAINING OF PARENTS Table 4ft MORTALITY OF CHILDREN FROM VARIOUS CAUSES BY MEDICAL TRAINING OF PARENTS Total Number of Living Births Number Deaths Per 1,000 Living Births From Specified Causes MEDICAL TRAINING OF PARENTS 1 3 Q a "o O i 5 >> 1 o. "a a a o a "3.2 ■r 11 "a a .2 1 i o 1 o < s "o CO Father a doctor 379 252 146 24 16 27 19 12 7 19 12 21 8 7 10 16 7 21 12 20 10 Mother a doctor or nurse... ...... 8 7 12 Total ... . 777 22 14 13 14 11 1 4 18 8 Neither parent medically trained.. 2,463 23 16 16 8 32 7 7 5 23 11 60 The Health of Missionary Families in China Figure 26. Mortality of children from various causes by medical training of parents. (Illustrating part of Table 46.) We turn with interest to the cause of death among the medically trained, shown in Table 46 and Figure 26. As be- tween father and mother who are trained, we are prepared to find as we do, that intestinal infections are less in the families in which the trained mother has charge of the kitchen. Even more marked, however, is the reduction in deaths from major infections. Presumably this is not because the doctor-wife or nurse-wife is better in curing disease, but because she is more successful in preventing infection. Comparing the last two lines of the table we see that the children of the medically trained have suffered less than the untrained from the major (mostly air-borne) infections and less from pre-maturity (presumably because of better pre- natal care). No children of this class have died of smallpox. It is disappointing to find that children of the trained die from intestinal infections almost as frequently as children of the untrained. RECENT AND REMOTE PERIODS Table 47 MORTALITY OF CHILDREN FROM VARIOUS CAUSES BY NUMBER OF YEARS PARENTS HAVE BEEN MARRIED Number of Deaths Per 1,000 Living Births From specified Causes NUMBER OF YEARS Total c« ll i 3 -o PARENTS HAVE BEEN MARRIED Number of Living b 9 £ •1 6 CD Births -g ^ ^ D. 's.2 Q'a rt 3 •Z g t o. 03 s s ■s-^ a o § Q 5 « CC ■^'" ^^ £ :s < 0-9 986 21 8 8 3 14 9 8 5 10 5 10-19 1,209 2T 16 16 7 23 9 5 5 16 11 20-29 672 27 25 27 12 50 6 6 1 36 9 30plua.- 249 32 28 16 4 44 28 60 32 The Health of the Children 61 Figure 27. Mortality of children from various causes by number of years parents have been married. (Illustrating part of Table 47.) In Table 47, all groups, except those associated with birth, show diminished deaths for families married the shortest length of time. As this is for deaths at all ages, naturally the younger families have had fewer deaths. The percentage reduction from the highest to lowest rate is 60%. Dysentery has shown less than the average reduction (34%). Deaths connected with birth have increased in the younger families rather than diminished. All other groups show a large reduc- tion in the younger families of from 70% to 87%. ORDER OF BIRTH Table 48 MORTALITY OF CHILDREN FROM VARIOUS CAUSES BY ORDER OF BIRTH Total Number of Deaths Per 1,000 Living Births From Specified Causes C8 -o S •o ORDER OF BIRTH No. Living m I « Births % 1 o o a "S ° ll 3 .2 o 'S. CO o a .tj c« 3 S3 & ca ^ s ■2'a S o 3 Q (3 u tf ^ CO m fi S < 1,122 854 569 518 151 25 25 33 15 20 12 21 19 6 33 14 13 12 23 26 2 5 9 6 33 27 38 21 29 20 10 3 9 8 7 10 4 2 7 4 3 3 8 7 20 25 14 25 59 11 2nd born. - 8 3rd born . . 10 4th and 5th born,.. 10 Born Gth or later. 13 62 The Health of Missionary Families in China *° 0. 1 1 ll 1 ■ 1 -■■■■ lull BORN t3T|2 »b|5jo|4-5J6 + IJT 2«I!|i*o|4-5|6«- 1 ST Izwolssoj* 5^1 6t- 1 iTJ2«D|jno|4-5|6» CAU2£ OF oeATd DIARRHEA, • ETC- iMALL POX SIX MAJOR lU FECTION3 fREMATURt BIRTH MftCT- MAlHOTRinOII Figure 28. Mortality of children from various causes by order of birth. (Illustrating part of Table 48.) Table 39 showed a gradual reduction in deaths among children through the fifth bom. In looking for the cause of this reduction, in Table 48 we find that the premature group is the only one shomng a steady decline, but that the diarrhoea and major infections group show fewer deaths among the third to fifth born than among the first and second bom. Parents learn somewhat with experience how to guard against these infections. What is the cause of the sudden rise in rates for the sixth or later born children? There are only 151 of this group. The rise is almost entirely due to four groups, %"iz., miscellaneous causes, smallpox, diarrhoea, and respiratory infections. Small- pox causes six times the number of deaths in these later bom children that it causes in the first to fifth born. Can it be that parents with six or more children find the task of providing protective vaccination for the last born children too burden- some? Dysentery and major infections, be it noted, diminish in power over the last bom. Is this because of better preventive measures learned through experience, or because of acquired resistance? The Health of the Children 63 NUMBER OF CHILDREN IN FAMILY Table 49 MORTALITY OF CHILDREN FROM VARIOUS CAUSES BY NUMBER OF CHILDREN IN FAMILY Total Number of Deaths Per 1,000 Living Births From Specified Causes NUMBER OF 2 a S "S CHILDREN Number "o , 3 a IN FAMILY of Living 1 >. a s CQ Births a 1 o. 1 a ■rt.a ^1 £ 3 a 1 O o Q Q Pi t/2 M 03 PL, »a -< o 1 _ 264 380 6S9 625 490 523 11 18 27 24 20 38 4 8 16 19 16 29 4 18 36 35 24 48 4 16 6 10 6 8 19 3 7 6 ...... 4 13 2 6 11 16 22 22 35 29 24 2 26 14 14 16 23 8 1 6 2 21 5 3... 7 4 6 5 14 6 or more- 19 .1 II. I m mnr ra J 4 5 £H D Y 5 t N T £ ^V DIARR-HEA CHOLe.R.A MAJOR. INftCT10N5 HLKVTKl riON Figure 29. Mortality of children from various causes by number of children in families. (Illustrating part of Table 49.) Table 40 showed a three-fold increase in total deaths for the families with six or more children over the families with one child. In Table 49 and Figure 29 we see that this increase is due to the principal infectious diseases. Deaths from dys- entery increased 3.6 times, diarrhoea 7 times, major infections 12 times, and smallpox (average of first five groups) nearly 7 times. On the other hand, deaths from respiratory infec- tions, birth, malnutrition, etc., have not increased with the increasing size of the family. This means that quarantine within the family, especially for the air-borne infections, has been at fault. Deaths from dysentery and diarrhoea have been twice the average increase, but deaths from the group of diphtheria, scarlet fever, mala- ria, tuberculosis, meningitis and typhoid have been four times the average. This is in spite of the fact that deaths from these infections among later born children are less than among earlier born. Study of individual reports shows infec- 64 The Health of Missionary Families in China tions, once started, run through families as they would not in communities where isolation and quarantine are strictly enforced. CAUSES OF DEATH BY INDIVIDUAL DISEASES Table 50 gives the number dying from these various dis- eases, and the ages at death. Figure 30 shows the percentage of the total deaths, in which a cause was given, due to the various diseases or groups of diseases. Dysentery alone has caused nearly a fifth of the deaths. Dysentery together with the acute intestinal infections (diarrhoea, enteritis, cholera, etc.) have caused nearly a third of the total. Sixty-nine per cent of the deaths from dysentery and 81% of those from diarrhoea occurred during the first two years of life. Table 50 CAUSES OF DEATHS OF CHILDREN WITH AGE AT TIME OF DEATH Total All Ages Number of Deaths at Ages Specified DISEASE MONTHS YEARS 0-1 1-2 3-5 6-11 0-1 1 2 3 4 5 -10 -20 N.S. 77 1 ( 19 26 27 11 6 3 4 47 1 3 6 11 21 17 4 1 1 2 1 51 2 2 5 12 21 14 10 2 3 1 24 2 2 7 6 3 6 19 2 1 4 3 10 3 4 2 Meningitis 17 2 3 5 4 2 1 2 1 2 Scarlet Fever . . 16 1 1 1 4 9 Typhoid Fever . 12 1 1 3 1 1 1 3 2 10 2 2 1 3 2 2 10 2 2 2 1 1 2 2 20 2 2 3 7 3 3 1 4 2 19 18 1 19 10 9 1 10 Birth Defect 12 6 1 3 10 1 1 14 2 1 4 4 11 2 1 5 3 1 1 5 17 1 3 4 8 2 3 3 1 9 1 1 2 1 1 2 2 War_. 11 4 6 1 44 20 2 3 8 33 3 1 --- 2 1 2 2 Total--- 444 67 11 41 75 194 87 48 17 19 41 19 17 2 *Age not stated. The Health of the Children 65 CAUM Of OtATH PERCENT Of BEATHS } hhhhhhhT^riy^ OVitHTERY REiPIRATOR'T RIHTM OErtCTS ^ INJURIES rtlSCELLANEOUi INFECTIONS WAX 4 AlCCIOENT mSCEU-ANEDOl CONOniONk f^ALNOTUlTION iCAHLET PEVER TYPHOID FEVER TUBERCULOil!, Figure 30. Percentage of deaths of children from various causes. (Derived from Table 50.) In the table "diarrhoea" includes all cases of acute intestinal infection other than dysentery and typhoid fever. Seven cases were listed as cholera. "Respiratory" includes, besides pneumonia, six cases of bronchitis and six of whooping cough. Of the children dying of whooping cough, five were aged one year or under, one was five years old. "Diphtheria" includes three cases listed as tonsilitis. "Other Infections" include fever three, appendicitis three, vaccination two, erysipelas two, measles two, and one each of liver abscess, typhus fever, sore throat, influenza, sprue, kalaazar, infantile paralysis, and blood poisoning. "Miscellaneous" includes heart trouble three, nephritis two, hardship two, and one each of intersusception, spinal disease, diabetes, jaundice, cir- cumcision, poisoning, sunstroke, sewage gas, myxedema, and seasickness. "Accident" includes three killed by bandits, two by drowning, one suffo- cated by quinine pill. "Premature" births were, in one case each, said to be due to eclampsia, dysentery, malaria, and quinine. Three of the ten deaths from tuberculosis were due to tuberculous meningitis. 66 The Health of Missionary Families in China Table 51 PERCENTAGE OF DEATHS OCCURRING AT SPECIFIED AGES, DUE TO VARIOUS CAUSES, COMPARED WITH UNITED STATES AND ENGLAND CAUSE OF DEATH Missionary Children United States 1918 (Native White Parents) England and Wales 1917 0-1 Year Under 5 Years 5-9 Years 0-1 Year Under 5 Years 5-9 Years 0-1 Year Under 5 Years ^9 Years Typhoid Fever. . _ .6 2.1 7.5 .03 .16 2.7 .001 .01 .4 Malaria 1.3 2.5 5. .09 .15 2.7 Smallpox.. 6 3 5.2 5. .01 .02 .04 Measles. . 1.2 .8 1.3 2.9 3.4 2.8 8.9 7.5 Scarlet Fever. . 2.1 22.5 .08 .55 3.3 .05 .4 1.8 Diphtheria and Croup 1.3 5.6 10.5 .5 3. 13.7 .2 2.2 13.8 Dysentery. 16. 23. 10. .4 .6 .5 .01 .01 .03 Tuberculosis 1.3 1.5 2.5 1.5 2.7 7.4 2.9 6.1 22. Syphilis . 1.2 .9 2 2.1 1.4 .06 Meningitis. __ . 3.1 4. 5. .8 1.3 2.7 1.4 2. 4.4 Bronchitis, Pneumonia and Whooping Cough 13.3 14. 7.5 16.6 18.8 9.9 23.4 26.8 13.2 Cholera, Diarrhea, Enteritis 13.5 13.5 2.5 23.1 22.2 10.7 8.9 2. Premature Birth 11.3 5.5 20.4 14.4 19.9 12.2 Injury at Birth 6. 2.4 4.1 2.8 1.2 .7 Total 75.2 82.4 78. 70.1 70.5 46.5 64.6 09.6 65.1 All other causes 24.8 17.8 22. 29.9 29.5 53.5 35.4 30.4 34.9 Table 51 compares the principal causes of death among missionary children, the white population of America,** and the general population of England and Wales."^ The figures are the percentage of the total deaths for the ages specified. It should be noted that diagnoses given by parents are oftentimes inac- curate, as their idea of the doctor's diagnosis may be in error, or there may have been no doctor in attendance. In government statistics, on the other hand, diagnoses are nearly always made by the physician in attendance. For this reason, no emphasis is laid on any but the well marked differences in Table 51. Again, the figures, being percentages of the total number of deaths for the various ages, would total 100 for each age group. Other diseases not named in the table (mainly those classed under "other fevers" and "miscel- laneous") would show higher percentages for England and America than for missionaries. In the table, percentages for respiratory infections, prematur- ity, measles, tuberculosis, and syphilis are lower among missionary children than among children in England and America. The Health of the Children 67 Figure 31. Percentage of deaths under one year of age from various causes among Missionary Children and children in the United States and England. (Illustrating part of Table 51.) The most significant differences are shown in the three following charts. Figure 31 gives the deaths under one year. Three points stand out: (1) The high black tower represent- ing deaths from dysentery, 40 times higher than the corre- sponding column for England and Wales, and 1,600 times that for the United States. (2) The black gravestone standing over smallpox — a monument to lives needlessly sacrificed. (3) A death rate from prematurity only one-half the standard (for which the absence of venereal disease may largely ac- count), but a death rate from obstetrical disasters of twice the standard — probably the result of insufficient medical attention. 68 The Health of Missionary Families in China Figure 32. Percentage of deaths under five years of age from various causes among Missionary Children and children in the United States and England. (Illustrating part of Table 51.) The deaths under five years from dysentery (Figure 32) show an even higher proportion of the total (23%). Small- pox shows a rate 260 times that for the United States and infinitely above England, as that country had no deaths at these ages from smallpox in 1917. The comparative infrequency among missionary children of deaths from respiratory infections is striking for all three age groups. The relative immunity of adults to influenza during the pandemic of 1917 is noted elsewhere (p. 91). The Health of the Children 69 OEATMb 5-9 YEARb MlbblONARX CMILDRtN CH\N/\ N UNITED STATES [wMlTEi] ^ ENC^LAND if WALES Figure 33. Percentage of deaths five to nine years of age from various causes among Missionary Children and children in the United States and England. (Illustrating part of Table 51.) As there are only 40 deaths of children aged 5-9 recorded, Figure 33 has not as great value as the other charts. Besides the persistently prominent position of dysentery and small- pox, the figure shows the comparative deadliness of scarlet fever at this age. Typhoid fever is given as cause of death in 7.5% of the cases. This points the need of typhoid inocu- lation for children of this age. Table 52 DEATHS OUTSIDE CHINA CAUSES OF DEATHS OCCURRING OUTSIDE OF CHINA CAUSE OF DEATH Number Ages at Death SOCIETIES Infantile Paralysis Dysentery Diarrhea. 1 2 3 1 2 3 1 2 1 2 1 1 1 2 1 2 1 10 3 days 1.2 1 2 1.4 4, 8, 21 19 19,21 4 mo. 10 mo., 26 6 4 2 5 mo., 8 mo. 6 days 14, 15 8 mo. 18, 19 (3) 20, 21 (2) 23, 25, 26 Swed. All. Miss. Swed. Miss. Soc, Danish Lutheran. Y. M. C. A., Baptist No., Pres. South. Pneumonia Whooping Cough Typhoid Fever.. . Yale. Presbyterian, South (2) Baptist, South. (3) American Lutheran. Tuberculosis Other English. Other English. Meningitis .. Swed. Miss., Bapt., South. Scarlet Fever.. European C. I. M. Appendicitis Septic Sore Throat Other English. American Board. Y. M. C. A. (2) Premature C. I. M. Other American, Pres. No. "Seasickness". Other European. Killed in War London Miss. (2); Other English (2). Eng. Bapt., C. I. M. (5) Total 37 70 The Health of Missionary Families in China Thirty-seven deaths are recorded as occurring outside of China, This is 8.2% of the total number of deaths. Of these, five children died on board ship going to or from China. Two others died while in Korea and Japan. So that only Q.Q% of the deaths occurred while children were in the homeland. If the deaths from war are excluded, this leaves only 19, or 4.4% of the total deaths. About 33% of the children's life was spent at home. As only 6.6% of the deaths occurred there, there are about five chances of the child dying in China to one of his dying in the homeland. It must be remembered, however, that most of the "homeland" years were those of later child- hood, when mortality is lower than in early life. Sometimes missionaries are accused of a lack of patriot- ism. Eleven children of English missionaries died in the war, one of disease, and ten killed in battle. In the four societies represented, one-third of the children who have died, aged five years and over, have died while in the service of their country. MORBIDITY AMONG CHILDREN So far this study has been concerned with the deaths of children. Many sicknesses, however, do not result in death, and yet prevent robust health. The statistics concerning morbidity are not so reliable as those con- cerning mortality. Sicknesses not resulting in death are more likely to be forgotten. Furthermore, for malaria, dysentery, bronchitis, worms, tonsilitis, the report was often "many times," "occasionally," "not often," etc., in which cases the illness in question was recorded but once. Though the total ill- nesses are certainly well above the 5,744 here recorded, the figures are of value for comparative purposes within the group. In order to make the comparison as accurate as possible, the sicknesses reported are reduced to the number per 1,000 years of residence. The tables concerning morbidity and general health are based on the histories of 3,036 children only. This gives an average of 1.9 illnesses per child. The Health of the Children 71 Table 53 ABSOLUTE NUMBER OF CASES OF PRINCIPAL INFECTIONS AND NUMBER PER 1000 YEARS OF RESIDENCE BY PROVINCES. SICKNF.SS .2 1 to 1 1 03 d CO 1 3 a -a a < a a '■% a a W M 1 & -a 1 tS a 3 w a 3 a 1 a Total Years of- Residence 3S1 1527 1448 569 593 470 2359 651 1083 1263 476 1069 850 1672 886 1321 Number of Sicknesses per 1000 Years of Residence Total per 1000 yrs.. 300 245 216 348 200 257 301 203 263 254 247 214 306 203 184 226 Dysentery __ 60 21 18 12 .3 3 24 13 10 10 5 8 41 9 15 7 9 5 0.7 13 5 12 10 30 7 21 21 9 69 17 12 "9' 19 4 21 4 10 26 45 10 35 52 14 32 23 11 11 2 12 15 6 6 6 2 17 42 9 9 12 8 2 18 7 12 6 ""3' 6 "is' 6 47 16 24 26 1 21 7 12 6 6 4 .9 7 3 39 11 32 11 39 56 9 58 5 4 7 10 2 ..... 3 14 5 51 11 30 32 16 50 6 8 4 2 2 2 8 2 38 6 39 21 29 21 8 23 12 12 9 ..... 4 4 10 23 8 33 13 14 24 11 43 16 17 11 8 "'8 6 4 13 8 63 6 47 43 2 23 8 10 9 1.8 5 1 11 2 19 2 47 7 16 26 12 16 10 6 7 6 7 .... 33' 4 31 4 13 30 14 28 g Bronchitis g Pneumonia... 5 Diphtheria 5 Smallpox. 1 Meningitis 7 30 3 12 21 42 12 27 21 12 24 6 5 7 32 18 26 31 22 17 11 13 "28" 7 20 13 8 34 "I' 61 25 21 42 4 13 7 35 6 47 16 36 35 15 2 Typhoid Fever Malaria 2 35 Influenza 5 Measles 19 Mumps. . 13 Chicken Pox Whooping Cough Tonsilitis 38 37 15 Nui tfBER OF Si 3KNES JES Total Sicknesses 99 373 313 198 119 121 712 136 284 320 118 229 260 340 163 299 Dysentery 20 7 6 4 1 1 37 21 15 15 7 13 59 14 21 11 14 7 1 20 7 17 15 44 10 30 30 13 39 9 7 4 5 11 2 12 2 6 15 26 6 20 30 8 19 14 6 7 1 2 ""9' 7 8 "17" 4 12 8 5 7 3 3 5 1 8 1 16 "2" 31 12 10 20 2 101 22 22 29 19 4 4 31 16 81 14 111 50 86 83 36 12 5 88 4 "2 4 12' 4 31 11 16 17 7 23 8 13 7 6 4 1 8 3 42 11 35 11 42 60 10 66 7 6 8 13 3 ""16' 4 18 7 65 14 38 41 20 24 3 4 2 1 1 1 4 1 17 3 19 10 14 10 4 25 14 13 10 ..... 4 4 11 26 9 36 14 16 27 12 37 14 15 9 3 '3" 5 4 11 7 54 6 38 37 16 38 13 17 16 2 8 2 19 4 32 4 80 13 28 44 20 14 9 5 6 5 6 .... '29" 4 28 4 12 27 13 37 Diarrhea, etc... . _ . 13 Bronchitis.. 11 Pneumonia g Diphtheria . . .. g Smallpox 2 Meningitis 1 Scarlet Fever Typhoid Fever 10 1 4 7 14 4 9 7 4 37 9 8 10 48 28 39 50 35 3 3 46 Influenza .. 7 Measles .. 26 18 Chicken Pox 51 Whooping Cough Tonsihtis.. 49 20 Table 53 shows both the relative and the absolute number of the principal sicknesses for each of the provinces. It will be observed that the provinces with the largest number of illnesses are not, necessarily, the ones with the highest mor- tality, i.e., those with the highest absolute number of cases, may not have the highest percentage of cases. For instance, Kiangsu reports 101 cases of dysentery — half again the num- ber of the next highest province. But it stands only sixth in the number of cases in relation to the number of years spent in China. The density of the missionary population in the 72 The Health of Misslonnry Fdnillies in China Ymigise valley gives that section the reputation of an unduly hii!:h dysentery rate, which reputation, so tar as the children are concerned, is undeserved. y //^m'ancnur'ia* j p/^ /::::?::•/ ^rf^ ' 'cHiHu * ' I*/ y' 'y Y'. % : '\\ \'y V ^*"'/ 1 >v 1 • \*'"'^S-^'' \. . ./ iHANTUNQ ^^^ >v^ • ^^"^"^ • • ^ yy^ ^ ^ KANSU \ • '\'.'.\\'J--\' X^^* ^^^ 1 * '* ' '^^ ' ' 1 * y^' • ' • •^s-^-^ ' * \ • ^'sHENs' V: .' '. ^HONAN [ ^ ' \^'/'i'^»V • • • -^'' • '•^' 'Jx- • • '-' • -s ' * C'^' ' \ • • ^ C T^^^'^'>Ll-L_L.* * ' ■ •yA'^'^'''^' ^^^-v*-.^!/ / • • • • • •>— ^ • ^„j^,p^„ .1^.— ^_J<:n-MANQ [**.'■'' ■ ' ' ^ --. -^ ^^ ' f ' 'l\' ' \ S2ECHWAN /_ r^^' rT^T^^C^^' J\* ' ' \ ' 2"«3 * l/'" • • • • • M iT ^'^"y ^^""^Z, 'h*.u^4"! \ './.K'4n«s'i J ' ' ' r '*^ ' /'~^ f^' . • • . *^. . . V ■ '^° ' '[ I V^ ^V ■ ' y • "It^ \ , '. ' / f'^'^'^'* 1 \ ' *V / *r~7 KWEICHOW * ^ ^ p~v ^ A- ■'•'.'. ? / \iy^.^y K*wANG*ruN<3 '/ ■^ YUNNAN* * ' ' NWAN05/ .... ^Q^^^y^ \ y^-^ jy^ L: c^^'^^^y^ L, . . . . j^x'"'^ Figure o4. Number of cases of dysentery per 1,000 years of residence among children by provinces (from Table oo). Number of dots represents num- ber of cases per 1,000 years" residence per unit square of surface, e.g., 100 square miles. The figures indicate simply the number of cases per 1,000 years of residence. Absence of boundary lines between provinces indi- cates that data from these provinces lu-e combined. The distribution of dysentery shown in Figure 34 is of interest. Provinces reporting most dysentery per 1,000 yeai^ The Health of the Children 73 are: Shansi, 69; Manchuria, 60; Honan, 58. A wide gap sep- arates these from the provinces reporting least, viz.: Che- kiang, 11; Kansu, 15; Fukien, 16. Shansi and Kansu have the distinction of reporting the most cases of smallpox. Kansu, Manchuria, Shantung and Shansi have far more scarlet fever than the other provinces. Chekiang, Kiangsi, Kiangsu and Kwangtung report the most malaria. Of the total sicknesses tabulated, Shansi reports the most, P^ukien the fewest. Round worms are not classified in the table. Various provinces reported infection per 1,000 years as follows: Fukien, 41.7; Hunan and Kweichow, 40.4; Kwangtung, 33.3; Hupeh, 29; Chekiang, 26; Kiangsu, 25.8; Honan, 23; Shan- tung, 21; Szechuan, 20; Cliihli, 13.1. Definite sickness from round worms was named but once (jaundice, with death); 13.4% of the children were reported as having had round worms. The chief diseases for the sections are shown in Figure 35. Besides the sicknesses listed in the table, the following are reported, the number beinjj too small to make division into provinces of value: Round worms, 402; hook worm, 12; pin worm, 31; operation, tonsil or adenoid, 157; mastoid, 4; hernia, 9; difficult feeding, 90; malnutrition, 29; heart disease, 24; tuberculosis, 23; appendicitis, not operated 11, operated 23; rheumatism, 19; rickets, 13; trachoma, 13; kidney disease, 8; relapsing fever, 5; cholera, 5; tapeworm, 4; St. Vitus dance, 4; cyclic vomiting, 3; erysipelas, 3; men- tally defective, 3; kalaazar, 1; infantile paralysis, 2; miscellaneous, 14; total, 812. Table 54 NUMBER OF PRINCIPAL INFECTIONS BY SECTIONS OF CHINA, AND OCCURRING OUTSIDE OF CHINA. North Central South All China Outside China SICKNESS Number ok Years of Residence Province or Years of Residence Not Stated 4940 9436 2227 16,573 8748 Nci IBER OF Cases of Specified Sick VE88 TOTAL 1227 2425 462 4,114 708 110 Dysentery 181 68 59 46 29 42 4 104 26 43 49 180 64 120 145 66 326 85 98 85 44 28 17 85 43 242 59 462 129 278 319 125 51 22 16 12 11 8 1 4 3 75 11 54 22 63 76 33 558 175 173 143 84 78 22 193 72 362 119 696 215 461 540 225 14 12 6 17 12 ...... 38 10 9 3 232 68 91 171 19 23 e, Bronchitis 7 Pneumonia ... f, Diphtheria 2 Smallpox 5 Meningitis Scarlet Fever 7 Typhoid Fever 5 Malaria 11 Influenza . Meaales 3 Mumps .. 11 Chicken Pox ... 8 Whooping Cough 11 Tonsifitis 5 74 The Health of Missionary Families in China Table 54 gives the total number of sicknesses by sections, together with the sicknesses contracted outside of China. Diseases contracted outside of China not named in Table 54 are the following: Infantile paralysis, 6; malnutrition, 2; appendicitis, 6; rheuma- tism, 3; heart trouble, 1; kidney, 1; tuberculosis, 1; round worms, 1; pin worms, 2; erysipelas, 1; total, 24. The only disease which is not the more common in China is infantile paralysis ; two cases were reported from China, as against six reported from outside China. Table 55 NUMBER OF PRINCIPAL INFECTIONS PER 1000 YEARS OF RESIDENCE, BY SECTIONS OF CHINA AND OCCURRING OUTSIDE OF CHINA. Number or Cases per 1000 Years op Residence SICKNESS OccDRRiNO IN China Occurring Outside OF China North China Central China South China All China TOTAL 248 257 209 249 81 Dysentery .. .- 37 13 12 11 6 9 .8 21 5 9 10 36 13 24 29 13 34 9 13 9 5 3 2 9 5 25 16 49 14 28 33 13 23 9 7 5 5 4 .4 2 1 33 5 24 9 28 34 25 34 11 9 8 5 5 1.4 12 4 22 7 42 13 28 33 14 1.6 1.4 .6 2. 1.4 Smallpox Meningitis _ -_--. .5 4.3 1.1 Malaria.. _........ 1.0 .4 26.6 Mumps 7.0 10.0 19.9 Tonsilitis . ......... 2. Figure 35. Number of infections of various diseases per 1,000 years' residence' by sections of China. (Illustrating part of Table 55.) The Health of the Children 7S Table 55 gives the sicknesses of Table 54 expressed in number of sicknesses per 1,000 years of residence. Central China has a slightly higher morbidity than North China, due to excess of malaria and measles. South China exceeds other sections only in the amount of malaria, tonsilitis and whoop- ing cough. Its total rate would be higher if cases of round worms and all cases of malaria were included. Figure 35 illustrates a portion of Table 55. Figure 36. Number of cases per 1,000 years' residence of various dis- eases contracted in China and outside of China. (Illustrating part of Table 55.) Figure 36 shows the comparative number of sicknesses contracted in China and outside of China. The highly con- tagious children's diseases, scarlet fever, measles, mumps, chicken pox, and whooping cough, are contracted while the children are home more frequently than the other diseases. The comparatively low rate of sickness of children while at home is to be accounted for in part by the fact that children are home for school during the later years when they are less susceptible to the serious infections. PERCENTAGE OF MORTALITY We have seen that more children die in the north than in the south. This is partly because more serious diseases are prevalent in the north. But it is also (Table 56 and Figure 37) due to the fact that, for practically all the diseases, the 76 The Health of Missionary Families in China north shows a higher percentage of mortality than the south. This may be because of greater virulence of the disease, or because of less provision for medical care. It is not because children in the north are less robust. (See Table 61.) Table 56 PERCENTAGE OF MORTALITY FOR VARIOUS DISEASES, BY SECTIONS DISEASE North Central South All China 12.1 20.8 3.3 28.2 34.3 28.5 75.0 12.5 17.2 46.5 0.5 1.4 10.4 26.7 2.0 17.7 25.0 35.7 58.8 2.3 9.3 0.8 7.8 4.5 "io"o" 10.0 21.7 2.2 20.2 25.0 28.1 63.6 7.7 12.5 2.2 0.1 0.37 Figure 37. Percentage of mortality for various diseases by sec- tions of China. (Illustrating part of Table 56.) MAJOR AND MINOR INFECTIONS Because of the evident importance of the infections, vari- ous infectious diseases are divided, in Tables 57-58, into two classes, and comparison made among provinces and societies as to the number of cases per 1,000 years of life. The major infections include dysentery, diarrhoea, cholera, etc., pneu- monia, tuberculosis, meningitis, typhoid fever, scarlet fever, smallpox, typhus, cholera, malaria, and infantile paralysis. Minor infections include measles, mumps, chicken pox, bronchitis, intestinal worms, etc. Infections contracted both in China and at home are counted. The Health of the Children 77 GEOGRAPHICAL LOCATION Table 57 NUMBER OF INFECTIONS OF CHILDREN BY PROVINCES PROVINCE No. OF Infections Number of Infections per 1000 Years of Life Major Minor Major Minor 53 191 147 99 104 55 56 307 258 137 75 94 83. 61. 78. 128. 130. 85. 94. Shantung,. . _. 134. Chihli. 124. Shansi-.. . . 161. Shensi 96. Kansu 145. North! 649 927 83. 128. Kiangsu ..... 376 54 144 129 50 121 79 23 172 622 114 250 299 S3 172 188 27 288 116. 62. 106. 67. 81. 75. 83. 125. 61. 192. 131. Honan _ . .. 184. Chekiang ... 156. Kiangsi 134. Hupeh 107. Hunan . ... 200. Kweichow 156. Szechuan . 102. Central 1148 2043 84. 149, Fukien. 91 171 8 252 342 8 61. 77. 85. 170. Kwangtung 154. 85. South 270 602 71. 159. All China.. 2067 3572 81, 144. The major infections are equally frequent in North and Central China, but less frequent in South China. The minor infections, on the other hand, increase from north to south. (This tabulation includes intestinal parasites.) Table 58 MISSIONARY SOCIETIES NUMBER OF INFECTIONS OF CHILDREN BY SOCIETIES SOCIETY Number of Infections per 1000 Years Major Minor English Baptist 123. 113. 103. 93. 89. 84. 84. 81. 80. 79. 75. 70. 70. 67. 62. 58. 56. 163. American Church Mission . . 261. Scandinavian Societies. . 102. Y.M.C.A.... 294. American Baptist, South 115. American Lutheran Societies . 172. American Board.,, 135. Other English Societies... . . . 117. Cand. Methodist . . . 145. Other Am. Soc- 159. Am. Methcdist, No 163. German and Swiss . 56. Am. Bapt., North 117. China Inland 122. Church Mis. Soc. _. 83. London Miss _ 121. Am. Pres., No. 147. All Societies .. 76. 132. 78 The Health of Missionary Families in China In Table 58 the infections are rearranged by societies (the division into societies is somewhat different from that used in previous tables.) The societies with the smallest number of major infec- tions are not necessarily those with the lowest mortality. This may be due partly to comparative lack of medical care, inland location of stations, etc. It may be, also, that the members of some societies have been less careful than others in naming aU the sicknesses. Note that minor infections do not decrease at the same rate as major infections. Here again the neglect of mention- ing the trivial diseases may be a large factor. AGE AT TIME OF SICKNESS It is important to know at what ages children are most liable to contract the various diseases. Age at time of sick- ness was not recorded for many of the sicknesses. Data con- cerning nine of the more important diseases, totaling 1,291 sicknesses, are recorded in Table 59. Children aged two {i.e., during the third year of life) show the largest number of infections. As has been remarked previously, this is the year of greatest susceptibility to un- healthy conditions. During this third year, dysentery and malaria are most common. Diarrhoea and smallpox are most prevalent in the first year — pneumonia in the second, scarlet fever in the sixth. Table 59 AGE OF CHILDREN AT TIME OF SICKNESS. Number of Infections Occurring at Ages Specified. SICKNESS 0-1 1 2 3 4 6 6-10 11-15 16 and over Total Dysentery Diarrhea 63 45 23 6 17 5 4 12 2 103 43 37 10 10 5 9 13 2 112 21 24 9 15 10 5 36 1 54 9 10 6 5 15 4 32 43 6 6 14 9 17 4 20 2 31 4 4 12 3 19 9 27 1 41 2 10 21 U 46 16 51 3 11 1 1 7 1 15 17 12 2 459 132 Pneumonia Diphtheria 116 86 72 Scarlet Fever Typhoid Fever Malaria . . _ 134 72 207 Tuberculosis 13 Total 177 232 233 135 121 110 201 65 17 1291 The Health of the Children 79 MORTALITY RATE IN RELATION TO AGE Table 60 shows the percentage of the diseases which re- sulted fatally at various ages. In general, the younger the child, the greater the danger of death. During the first year, for instance, 60% of those contracting smallpox, 47% con- tracting infectious diarrhoea and 41% contracting dysentery died. These figures are unnaturally high for the reason that practically all the ages at death are known, whereas many of the ages for non-fatal sicknesses are not known. Table 60 PERCENTAGE OF SICKNESSES RESULTING IN DEATH AT VARIOUS AGES. Age at Time of Sickness SICKNESS 0-1 1 2 3 4 5 and Over Per Cent 41 47 39 33 60 ""25"' 16 100 Per Cent 26 40 29 70 "26'" 33 8 100 Per Cent 9 20 33 66 20 10 20 9 100 Per Cent 11 11 10 ...... 25 6 Per Cent 7 "~2\" 44 24 25 Per Cent 5 Diarrhea, etc 44 13 Diphtheria 14 Smallpox 16 11 Typhoid Fever . .... 11 Malaria 2 62 GENERAL HEALTH OF CHILDREN GEOGRAPHICAL LOCATION Under certain conditions of climate, malnutrition, etc., children may not have had any definite illnesses and yet be in poor health. To cover this point, parents were asked to specify if the past general health of children has been robust, good, fair, or poor. Since these terms are open to individual interpretation, the tabulation of answers received on this point is of value in only the broadest way. 80 The Health of Missionary Families in China Table 61 PAST GENERAL HEALTH OF CHILDREN— BY PROVINCES Total No. of Children Percentage Reporting Health op Children as PROVINCE Poor Fair Good Robust 71 232 224 83 131 67 3 3 1 4 5 3 13 17 9 6 14 3 54 45 47 52 53 40 30 35 Chihli... 43 38 28 54 North China 808 3 10 47 38 368 78 186 170 167 56 156 22 273 3 1 4 ---- 1 4 9 2 11 10 9 9 9 18 17 19 11 44 36 42 47 44 52 47 50 47 41 53 44 44 Hupeh _ . . . . 45 30 Hunan . . 32 Kweichow 27 43 1476 3 12 44 40 Fiikipn 167 255 15 -___ 9 11 51 53 73 40 33 Yunnan 27 South China 437 1 7 59 33 Total All China 2721 2 10 50 37 In Table 61 is given the tabulation by provinces. South China shows the smaller proportion of children whom the parents specify as robust, 33%, as against 38% and 40% for North and Central China. (See Figure 41.) Though death is less common in the south, robust health is also less frequent. The explanation for this apparent con- tradiction lies in the fact that diseases of the south are those (such as malaria and intestinal parasites) which cause inva- lidism rather than death. Also, the climate is more debili- tating. MISSIONARY SOCIETIES Table 62 is arranged by societies with those reporting the highest percentage of robust children at the top. There is considerable variation (41%) betw^een the highest and low- est. Only 14% of all children are considered by their parents to be in less than good health. The Health of the Children 81 Table 62 PAST GENERAL HEALTH OF CHILDREN BY SOCIETIES No. of Children Reported Percentage Reporting Health AS Poor Fair Good Robust 67 114 119 109 158 81 519 281 92 253 73 204 381 99 65 12 10 7 10 11 7 9 12 14 11 8 12 11 16 23 36 42 47 43 44 43 47 45 46 48 53 49 51 51 61 52 48 45 Y. M.C. A Am. Meth. No Ch. Mis. Soc. Other Am. Soc Am. Vrea. No 2 2 5 1 2 2 3 3 6 4 5 5 45 44 44 43 40 38 Other Eng. Soc 37 London Mis. Soc Scandinavian Soc. 36 33 33 Am. Baptist So _ 27 11 Total 2615 3 11 47 39 MISCARRIAGES AND STILLBIRTHS An important phase of the problem, but one concerning "which little is said, is the number and cause of pregnancies which terminate disastrously. Such miscarriages, and still- births, are a heavy drain on the health and spirit of the mothers. "Were it not for difficult living conditions, missionaries should have a very low miscarriage rate because of their free- dom from syphilis. In the Babies' Hospital, New York City, among 193 syphilitic mothers 22.4% of the 427 pregnancies resulted in stillbirth or miscarriage. Among another 150 syphilitic women, 17.2% of 1,001 pregnancies resulted in miscar- riage or stillbirth, while in another 150, with 826 pregnancies, who were known to be free from syphilis, the percentage was only 9.4.22 Another authority23 states that 30% of pregnancies in which a parent is syphilitic result in the death of the foetus, which is three times the rate observed in non-syphilitic families. He states also that 3.5% of infant deaths are due to this disease. The pregnancies among missionary women which do not result in a living child form 15.2% of the total. This is sev- eral per cent higher than we might expect. The excess is accounted for by the unusual amount of travel and work to which missionary wives are subjected. 82 The Health of Missionary Families in China GEOGRAPHICAL LOCATION Table 63 NUMBER AND PERCENTAGE OF STILLBIRTHS AND MISCARRIAGES BY PROVINCES PROVINCE Number Living Births Stillbirths MiSCARRIAGEE Total Per Cent Number Per Cent Number Per Cent 85 289 270 154 84 76 1 4 5 4 2 2 1.17 1.38 1.85 2.59 2.38 2.63 9 26 37 25 5 15 10.6 9.9 13.7 17.6 5.2 19.9 11.8 Shantung 11.3 Chihii.... 15.5 20.2 Shensi 7.6 22.5 North China.. . . 958 18 1.87 118 12.7 14.6 94 299 448 176 216 196 70 311 ...... 4 4 2 6 7 7 'i'74' .87 2.27 .92 3.06 1.0 2.25 U 24 46 20 32 25 15 42 11.6 11.3 10.5 10. 11.4 13.3 23.7 13.5 11.6 Honan . 13. 11.4 Chekiang... 12.7 Hunan . ... 12.3 Hupeh ._ 16.4 Kiangsi 24.7 15.7 Central China 1740 34 1.95 215 12.8 14.7 Fukien 182 324 "-"4" '\.'2i 25 57 14.1 19.3 14.1 Kwangtung- Yunnan _ .. 20 5 South China 506 4 .79 83 17.6 18.4 All China 3204 59* 1.84 416 13.4 15.2 *In three cases province not specified. Table 63 gives the number of miscarriages and stillbirths in relation to the number of living births. Stillbirths formed 1.84% and miscarriages 13.4% of the births. (Data concerning miscarriages was taken from 1,165 histories, which reported 3,044 living births.) South China has fewer stillbirths and more miscarriages than the other sections. The total percentage for South China is slightly above North and Central China (18.4%, against 14.6% and 14.7%). As stated before, 15 deaths of which the parent wrote merely ''died at birth" are classed as stillbirths. If these were living at the moment of birth, the rate would be 1.38% in place of 1.84%. In the general population of the United States stillbirths average about 4% of living births. Four families reported 2 stillbirths, 2 reported 3, the rest but 1. The Health of the Children 83 Table 64 NUMBER OF MISCARRIAGES— BY PROVINCES PROVINCE Number of Families Reporting Specified Number of Miscarriages Total Families Total Mis- carriages Number Mis- carriages 1 2 3 4 Marriage Manchuria Shantung Chihli _.. 19 78 84 18 41 15 5 11 17 3 9 8 ...... 5 1 2 2 2 ...... 1 1 ...... 25 95 109 22 56 26 9 27 37 5 25 15 .36 .28 .34 Shensi .23 Shansi. _ .44 Kansu. _ .59 North 255 53 13 10 2 333 118 .35 Anhwpi 23 57 126 49 64 61 21 82 4 14 18 10 10 7 5 22 2 2 11 5 4 6 2 7 1 2 2 2 ...... 2 2 1 30 75 157 64 82 75 30 113 11 24 46 20 32 25 15 42 .37 Honan .30 .29 Chekiang Hunan and Kweichow .32 .39 .32 Kiangsi .50 Szechuan .37 447 89 38 11 3 626 215 .34 Fukien. 61 86 71 7 28 2 3 2 5 2 2 74 124 8 25 57 1 .34 Kwangtung Yunnan . . .46 .12 South .. 163 37 6 7 4 206 83 .40 Total- 892 179 57 28 9 1165 416 .36 Table 64 shows the number of wives having certain num- bers of miscarriages, with the average number of miscarriages per family, by provinces. By this method of comparison, also, South China has a higher rate than other sections (40, as against 35 for North and 34 for Central China). 23.5% of the wives reported having had one or more mis- carriages. Among 1,618 working women questioned in Man- chester, New Hampshire,'* the percentage was only 12. Table 65 SUMMARY OF MISCARRIAGES— BY SECTIONS SECTION Percentage REPORTiNa Specified Nitmbbr 1 2 3 4 76.6 15.9 77.4 14.2 3.9 6.2 2.7 3.0 1.7 3.2 0.6 Central China 0.4 South China 75.1 17.0 1.8 All China 76.5 15.3 4.8 1.1 0.7 Table 65 shows that three-fourths of the wives have not had a miscarriage, and of those who have had, two-thirds have had only one. There is no great difference in the number by sections. 84 The Health of Missionary Families in China Table 66 MISSIONARY SOCIETIES NUMBER AND PERCENTAGE OF STILLBIRTHS BY SOCIETIES SOCIETIES Stillbirths Number Number per 100 Living Births American Baptist, North American Church Mission American Methodist, North London Mission Y. M.C.A.- ... 1 2 5 1 3 2 1.01 2.56 2.53 1.22 2.50 .45 Total, First Group .. . 14 1.37 Canadian Methodist 1 4 3 2 12 2 .74 Church Missionary Society American Presbyterian, North American Lutheran Societies.. 4.25 .95 1.45 American Board Mission 4.12 English Baptist 1.45 Total, Second Group 24 2.16 Other English Societies . . . . ........ 1 3 ........ China Inland Mission 2.89 American Presbyterian, South Other European Societies . .94 1.75 American Baptist, South European China Island Mission . 2.82 Total, Third Group... 21 1.94 All Societies 59 1.84 Table QQ gives the number of stillbirths by societies. The first group has the fewest. Only two (3%) of the stillbirths occurred outside China. Cause of stillbirth was stated in only 17 cases, as follows: difficult labor, 8; overwork, 3; sickness, 4; fall, 1; travel, 1. In the question blanks sent out, persons were asked to make a check mark in case they did not care to answer the question concerning miscar- riages. Only one or two blanks were so checked. For the many blanks, therefore, on which nothing was written in the space for miscarriages, it is assumed that there were none. Unrecorded miscarriages would lower the miscarriage rates below the true figure. It is possible that some of the figures in these tables should be higher than they are. CAUSES OF MISCARRIAGES Table 67 gives the parents' statement of the principal causes of the miscarriages, occurring in China, and the num- ber of the pregnancy for each. Sixteen of the 377 are dupli- cates, two causes being assigned for one miscarriage. Miscarriages occur slightly later than living births. 35 per cent of living births were first births, while only 23% of miscarriages were first pregnancies. Five per cent of the liv- The Health of the Children 85 Table 67 CAUSES OF MISCARRIAGES WHICH OCCURRED IN CHINA Total Number OF M1SCARRUQE8 Occurring During Specifibd Pregnanct Ist 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Not Stated Geotiral Co>n)rriONs Overwork- 65 37 11 10 9 7 10 6 .... 2 2 15 13 2 1 "2 11 7 1 3 2 6 6 1 2 1 5 3 2 1 1 1 8 1 .... 3 1 .... 1 "2" --- 1 5 Overexertion and Exercise. Debility... Nervousnesa. . . Revolution . . Fright and Anxiety Phtsical Agents A Fall or Injury. 21 11 10 3 3 7 3 3 6 1 1 2 8 3 3 2 1 1 2 .... 3 1 "2 2 "2 2 2 .... "V - - 2 Travel— Cart or Barrow... —Litter or Chair. . . — Steamer. — Rickshaw — Not Specified .... Pelvic Organs Abnormal.. 43 10 6 5 8 5 5 3 — 1 Sickness Typhoid 9 7 6 4 10 2 3 1 1 4 4 1 2 "3" 1 2 "2 2 1 .... .... .... 1 1 .::: 1 .::: ;;;; :::: Eclampsia Malaria. . ... Dysentery.. 1 Miscellaneous Causes 8 68 28 2 16 9 3 12 3 1 8 5 1 8 2 1 6 4 "9" 3 "3' "2 1 .... .... 3 Cause Not Stated 377 84 83 56 50 36 31 12 7 2 3 11 Percentage of Total 99 23 23 16 13 9 8 3 2 1 1 .... ing births were sixth births or later, whereas 15% of the mis- carriages were sixth pregnancies or later. Overwork and over-exertion seems to cause later miscar- riages in larger proportion than travel or sickness. Eighty-seven per cent (362 out of 416) of all miscarriages occurred in China. Eighty-two per cent of married years were spent in China. Therefore miscarriages were slightly more frequent in China than at home. Table 68 compares the cause of miscarriage (in the cases in which a cause was assigned) in China and out of China. In spite of the fact that 27 of the 55 miscarriages due to physical injuries in China were thought due to peculiar modes of travel (cart, rickshaw, etc.) an even higher percentage of this class of miscarriages occurring at home, i.e., 8 out of 11, were assigiied to travel as a cause. Practically one-half of all miscarriages, in the opinion of the persons themselves, were due to overwork, debility, nervousness, fright, etc. 86 The Health of Missionary Families in China Table 68 SUMMARY OF PRINCIPAL CAUSES OF MISCARRIAGE, OCCURRING IN AND OUTSIDE OF CHINA CAUSE OF MISCARRUGE OCCURRING IN CHINA OCCURRING OUTSIDE CHINA Number of Miscarriages Per Cent of Total Number of Miscarriages Per Cent of Total 139 55 43 36 49 21 10 14 21 11 5 6 49 25 11 16 Total - 273 100 43 100 Twenty-five per cent of miscarriages in China were blamed on "overwork," while 30% of those occurring, at home were laid at the same door. This would indicate that furlough is not a time of rest and recuperation for the wife, but one ot increased labor. CONDITIONS OTHER THAN HEALTH The welfare of children involves many more considera- tions than those of physical health. Though this study does not attempt to deal with these, their importance should be recognized. In some points, such as long separation from parents, lack of contact with large groups of other children, scarcity of high grade schools, missionary children are the losers. In other no less important respects, such as growth in an atmos- phere of religion and service, intimate family life, freedom from the dangers of our too complex social life (including attendance on moving picture shows), the broad education of travel, the growth of the cosmopolitan outlook, missionary children are the gainers. The social and religious condition of adult children of missionaries w^ould make an interesting study. The pictures on the two following pages show groups of missionary children in Peking. The majority are children of doctors. All of the third group have had protective inocula- tion against typhoid, paratyphoid, and diphtheria. Prospective missionary candidates — celebrating a birthday, at the Zon Missionary children have the finest of playmates — other missionary children. They do not always have as good a play place as have these children The camel train has arrived, witli sod for the playground. Children in China see many interesting things denied to their stay-at-home relatives A tree about which missionary children have played for fifty years — the only object in the compound left standing by the Boxers The Health of Married Adults 87 PART II — Health of Married Adults INTRODUCTION This study is concerned principally with children because (1) of the writer's interest in missionary children and because of the lack of any previous study of them, (2) because the ques- tionnaire method is applicable for the collection of mortality statistics concerning children, as it is not for adults (since most families in which a parent has died are not now on the mission rolls), and (3) because the study of the adult body is too large an undertaking for one person. It is realized that the good health of adults is of more importance to the missionary cause than the good health of children. The writer has, in a previous paper"^ presented some of the reasons for modern medical care of the missionary body. It is encouraging to note that some of the boards have undertaken the study of the health of their workers (see pages 95 and 112). Such studies are, however, rare and it seems worth while to present such facts concerning adults as are furnished by this questionnaire. Fifteen hundred and seventy-seven adults, about 60% of those who returned the question blanks, made statement con- cerning their own health. These had spent some 17,600 years in China, during which time they had contracted nearly 1,500 cases of sickness. There are some duplications due to the fact that some parents are also children of missionaries still on the field. Though a number of these duplicates have been eliminated, probably a few remain. 88 The Health of Missionary Families in China FACTS CONCERNING RESIDENCE AND MARRIAGE Table 69 (based on 1,064 reports) shows the average length of married life and the proportion spent in China. Those in the north have been married longer than those in the south. The proportion of married life spent in China is nearly the same for the three sections. Table 69 AVERAGE NUMBER OF MARRIED YEARS AND PROPORTION SPENT IN CHINA— BY PROVINCES. PROVINCE Number Reporting Total Since Marriage No. Married Years In China Average No. Married Years Per Cent of Married Life In China Since Marriage In China Manchuria . 23 77 101 25 23 264 1166 1098 330 335 337 890 883 277 299 11.4 15.1 10.9 13.1 14.5 10.3 11.6 8.7 11.1 13.0 90 76 Chihli... 80 84 89 North China. - 297 3744 3006 12.6 10.1 80 Kiangsu 150 26 71 64 23 62 67 9 99 1858 392 672 932 289 660 550 128 1127 1517 323 593 801 241 561 430 121 913 12.4 15.0 9.5 14.5 12.6 10.6 8.2 14.2 11.4 10.1 10.9 8.3 12.5 10.5 9.0 6.4 13.5 9.2 73 Anhwei . 72 Honan _ 88 Chekiang... . . . . . 86 83 Hupeh- 85 Hunan . . . . . 78 95 Szechuan. . 81 Central China 571 6608 5500 11.5 9.6 83 168 110 18 727 1216 64 570 971 49 10.7 11.0 8.0 8.4 8.9 6.2 73 80 Yunnan. 77 South China 196 2007 1590 10.2 8.1 79 All China. 1064 12359 10096 11.6 9.4 81 Table 69 referred to Married years. Table 70 gives the years — whether married or unmarried — spent in China. Since the average years in China are 11.2, and the married years but 9.4, many persons must have been married after being on the field for a period. Here, as in Table 69, the missionaries in North China have been the longer on the field. This would indicate that the average missionary life in South China is shorter than in the north by 20%. This proportion holds good for both married years and total years. Not only have couples in North China been in China longer, but also they have been married longer. This means that the percentage of married life spent in China is about the same for the three sections. Married years in China are exclusive of periods in which both parents were on furlough. The Health of Married Adults 89 Table 70 AVERAGE NUMBER OF YEARS ADULTS (NOW MARRIED) HAVE BEEN RESIDENTS IN CHINA— BY PROVINCES PROVINCE Number I uEPORTINQ Av. Yr3. m China Total Husband and Wife Total Years Husband Wife Husband Wife Number Reporting Av. Yrs. in China 10 42 63 34 16 15 12 46 62 32 13 15 10.9 12.9 11. 12.8 10.8 16.5 9.2 13.4 10.4 11. 9.8 17.1 22 88 125 66 29 30 10. 13.3 10.7 11.9 10.3 16.8 222 1171 1338 788 316 497 Shantung Chihii Shansi . .... Shensi... . Kansu North China . . - 180 180 12.5 11.8 360 12.2 4388 Kiangsu 86 13 22 49 26 28 36 32 62 88 9 22 45 35 21 38 31 54 11 17.3 16. 11.5 12.2 14. 8.1 11.5 12.3 9.8 14. 15.2 9.8 14. 11.8 7.7 9.6 12.3 174 22 44 94 61 49 74 63 116 10.4 16. 15.6 10.6 13.1 13.2 7.9 10.6 12.3 1817 351 687 1004 791 638 583 667 1426 Anhwei... Chekiang. . Honan ..... ...... Kiangsi Hupeh ... Hunan .... . Kueichow ... Central China 354 343 11.8 10.9 697 11.4 7933 50 76 5 42 73 8 8.1 10.5 21. 9.4 9.5 12.6 92 149 13 9.7 10. 15.8 805 1497 207 South China. .. 131 123 10. 9.5 254 9.8 2494 For All China 665 646 11.6 10.8 1311 11.2 14663 Table 71 NUMBER OF YEARS ADULTS (NOW MARRIED) HAVE BEEN RESIDENTS IN CHINA— BY PROVINCES PROVINCE Number Resident in China Specified Number of Years 0-5 6-10 11-15 16-20 21-25 26-30 31-35 35-39 Total 3 19 49 21 4 2 9 23 23 12 10 4 8 14 15 13 4 4 2 11 17 10 4 5 1 9 9 3 2 5 "io' 5 5 2 5 "2 7 .... 23 88 125 Shantung ChihJi... 65 26 25 North China 98 81 58 49 29 27 9 1 352 55 6 8 37 2 21 24 17 49 2 4 15 24 5 60 44 25 "Y 15 20 1 37 24 29 3 13 13 7 8 7 13 13 8 8 10 5 9 5 11 4 3 2 2 2 1 2 3 1 "2 1 1 "2 "2 176 22 44 94 61 46 135 114 170 203 129 93 69 19 7 2 692 36 46 24 53 19 31 10 15 3 4 3 6 ""3" 95 158 82 77 50 25 7 9 3 .... 253 All China— Husband Wife 167 183 172 189 132 105 82 85 64 41 30 25 13 6 2 1 662 635 All China— Husband- and Wife. 350 361 237 167 105 55 19 3 1297 90 The Health of Missionary Families in China Table 71 presents the number of years adults have been resident in China, exclusive of time on furlough, by provinces. Fifty-five per cent have been in China ten years or less, and but 13% for 20 years or more. Table 70 showed that wives had spent 7% less time in China than their husbands. This table shows that the wives who have been in China ten years or less are relatively more numerous than the husbands. Table 72 NUMBER AND YEARS OF MARRIED LIFE AND PERCENTAGE OF MARRIED LIFE SPENT IN CHINA— BY SOCIETIES Total No. Married Years Number Married Years Spent in China Per Cent OF Mar- ried Yrs. SOCIETY No. Fam- ilies Re- porting No. of Years Average No. of Years No. Fam- ilies Re- porting No. of Years Average No. of Years IN China American Baptist, North.. 44 518 11.7 44 403 9.1 77 American Church Mission. . 44 335 7.6 38 185 4.8 55 Am. Methodist, North 73 961 13.1 72 824 11.4 85 34 426 12.5 29 287 9.8 91 Y. M.C.A..-. 63 465 7.3 63 290 4.6 62 Other American Societies. . 22,5 2194 9.7 214 1613 7.5 73 4S1 4S99 10.2 453 3436 7.5 70 Canadian Methodist 47 437 9.2 45 316 7.02 72 Church Miss. Society. 38 431 11.4 30 335 11.1 81 Am. Presbyterian, North.. 125 1532 12.2 113 1254 11.09 82 Am. Lutheran Societies 53 353 6.6 46 264 5.7 75 Am. Board Mission _ 51 607 11.9 51 479 9.4 77 34 400 11.7 29 209 7.1 52 Total 2nd Group 34S 3756 10.9 314 2856 9.1 76 Other English Societies 103 1398 13.4 97 1112 11.4 79 China Inland Mission 151 2091 13.8 139 1733 11.7 82 Am. Presybterian, South. . 28 436 15.5 28 382 13.6 87 Other European Societies. . 63 720 11.4 61 607 10.0 84 Am. Baptist, South 41 638 15.5 38 448 11.7 70 European C. I. M 41 484 11.8 38 399 10.5 82 Total 3rd Group 429 5768 13.5 406 4681 11.5 81 Societies Not Stated 2 28 14. 2 26 13. 92 Total 1259 14450 11.4 1179 10996 9.3 77 MARRIED; years not stated (average taken) 40 456 11.4 122 1133 9.3 Grand Total 1300 14906 11.4 1300 12132 9.3 81 The Health of Married Adults 91 Table 72 (based on 1,300 reports) shows the married years, and the portion spent in China according to societies, arranged in the order of child mortality, the lowest at the top. For the three big groups, child mortality, as has been seen, varies with the average age of the children. This table shows, as one would expect, that mortality varies also with the length of time of marriage. It also shows (last column) that mortality for the big group varies in- versely with the time spent on the field, i.e., the first group, in which parents have spent only seven of ten married years on the field, have a lower rate than the group which have spent eight out of ten. This may mean that the first group has had more frequent furloughs, or a larger period of marriage be- fore coming to the field. A separate tabulation (table not printed) for families with and without children, shows that families with children of group 1 have been married 10.7 years; of group 2, 11.3 years, and of group 3, 13.5 years. Those without children have been married only about half this number of years. MORTALITY AMONG ADULTS As has been explained, this questionnaire method is of no value for arriving at a mortality rate for adults. However, the list of diseases of which parents have died is of interest. Of 72 married adults who had died, the following are the stated causes of death. Dysentery, 9; typhoid, 6; cancer, 6; tuberculosis, 5 ; childbirth, 5 ; 4 each of smallpox, typhus, and malaria ; 3 each of pneumonia, puerperal fever, cholera, sprue, and kidney disease; 2 each of apoplexy, heart trouble, and appendicitis, and 1 each of fever, sunstroke, blood poisoning, hemorrhage, operation, meningitis, diarrhoea, and urasmia. Fifty — more than two-thirds — were due to infections. Eight mothers died of diseases caused by confinement, of whom three died of childbirth fever. Of missionaries who died during 1917, as reported by the China Mission Year Book, 28 of the 56 deaths in which cause of death was recorded, died of infectious diseases. The list includes: typhus fever, 5; typhoid fever, 4; dysentery, 3; smallpox, 2. An interesting fact is the comparative immunity enjoyed by missionaries in China during the influenza pandemic of that year. 30% of missionaries dying outside of China died of influenza, whereas only 2% (viz., one) of those dying in China succumbed to that disease. MORBIDITY AMONG ADULTS Table 73 shows the number of illnesses in order of fre- quency for husband and wife by provinces. 92 The Health of Missionary Families in China Table 73 GEOGRAPHICAL LOCATION INCIDENCE OF PRINCIPAL INFECTIONS AMONG ADULTS BY PROVINCES PROVINCE SICKNESSES CO 5 la 1 a 3 a "a CO 1 .a CO 1 2 1 a < d 60 '■% W D. ja % a 03 a X e 3 ja CO 3 a l,v„o(fOR. |20 ,JO ^ rtr. too 000 |4o VE*R3 IN CHI ISO KA) ,60 HIiJIOWARY CHILD- REK AUD PARENTS 1880 1918 1 1 1 1 ' ' 1 ■ 1 1 ma • QEHERAL POfULATlOK reos. I»i7 UmTED STATES t5>OA tOOO Figure 44. Mortality from smallpox in missionary families and in England and the United States. (Illustrating Table 81.) Table 81 and Figure 44 show the relative mortality among missionaries' families in China and the general population of the United States and England for closely corresponding periods. It has been pointed out, already, that most of the loss from smallpox has been borne by three groups of societies. Among adults, 28 cases of smallpox are reported from China and 3 from outside; 90%, therefore, were contracted in China — during only one-third the life-time. The likelihood of the missionary getting smallpox has been about 30 times as great in China as at home. One missionary writes : *'0f 26 missionaries of one board who have come to this district, 12 have been attacked by smallpox." The high incidence of smallpox immediately raises an important question. How many of these cases were contracted in spite of the person having been vaccinated? 104 The Health of Missionary Families in China To determine this point, the writer sent a question blank to 50 families, which had reported cases of smallpox. In an- swer, 30 families reported 51 cases of smallpox, 37 of which were not fatal and 14 fatal. The answers are summarized in Table 82 : Table 82 CASES OF SMALLPOX, WITH REFERENCE TO PREVIOUS VACCINATIONS Number of Successful Vaccinations ATTACK FATAL ATTACK NOT FATAL Age at Attack Age at Attack 0-1 Year 1-4 Years 5-19 Years 20 Plus Years 0-1 Year 1-4 Years 5-19 Years 20 Plus Years Not Stated None. . 8 1 1 5 2 1 11 3 2 2 3 6 3 1 3 One Two _ Three Total 9 1 5 3 14 4 13 3 Seventeen of the persons had been vaccinated, 35 had not been. In 12 of the 14 fatal cases vaccination had not been attempted. One other (a baby of eight months) had had an unsuccessful vaccination three months before. Out of the 14 cases, there is record of only one case dying from smallpox after being successfully vaccinated. In this case (a seven- months-old baby) the vaccination had been done three weeks previously. Of these 14 fatal cass, eight were among, infants, and five among adults. Of the 37 cases which did not end in death, 21 had not been successfully vaccinated. Of the 21, in seven cases vacci- nation had been attempted, but had not ''taken." Sixteen cases had had successful "takes." Of these twelve had had one "take;" three, two "takes;" and one had had three "takes." In these cases it is important to know how long a time had elapsed between vaccination and contraction of the dis- ease. In those who had had one "take," the interval was in one case only a few days (a child exposed when the mother developed smallpox). In three cases the interval was a year; in one case, four years ; three cases, between five and fifteen years, and in four cases, more than fifteen years. Of the three cases which had had two "takes," the inter- val in one case was one year, and in two cases, ten to fourteen years. Only one case developed after three "takes." Here the last "take" was but a few days before. (Vaccination done just before the disease breaks out will not protect.) Some Factors in Prevention of Disease 105 Eight cases of smallpox occurred less than five years after vaccination. Two of these were only a few days after, so that immunity had not had time to become established. One would expect the six other cases to be protected. Three of these cases were in one family. Vaccination had been done fifteen months before, and all three had large scars to show for it. Of 17 cases, then, which followed successful vac- cination, six were within a period in which the individual should have been immune. The information collected, though meagre, serves to em- phasize the importance of vaccination. Every death, with the exception of one, came in unvaccinated persons. The non- fatal cases which occurred in vaccinated individuals would indicate that vaccinations should be repeated at shorter inter- vals in China than in countries where smallpox has been almost eradicated. Several of the reports blamed the vaccine used for unto- ward results — eczema, epilepsy, even smallpox itself. Though the vaccine was not to blame, arrangements should be made so that the missionary body may be sure of a pure, fresh supply. Eight cases developed smallpox after failure to get a "take." In one case — a baby — the attempt had been made three times, the last one but three months before the attack. This points to the need of repeated attempts at vaccination. The writer knows of a successful vaccination of a baby after fourteen unsuccessful attempts. It is of interest to look at larger figures on this subject collected in the United States. Among 134,669 vaccinated persons exposed to smallpox, 619, or .46%, contracted the disease, of whom 13, or 4.2%, died. Among 147,941 unvaccinated and exposed persons, on the other hand, 4,056, or 2.7%, became sick, of whom 282, or 12.6%, died. That is, the sickness rate among unvac- cinated is six times what it is in the vaccinated, and the death rate three times as great, or the chances of dying of smallpox are 18 in the unvacci- nated to 1 in the vaccinated. •''^ in another investigation in New York City"-! of 534 vaccinated persons who were exposed to smallpox, none became sick, while of 7,567 unvaccinated persons, 161, or 2%, contracted smallpox. These three diseases have been mentioned because they are most destructive (dysentery), or have a specific means of prevention (smallpox and typhoid). The evidence concerning other diseases (e.g., malaria, scarlet fever, diphtheria) might be analyzed with profit. CAUSES OF INFECTION Correspondents were asked to state, whenever possible, the cause of the sicknesses. A great variety of factors were 106 The Health of Missionary Families in China named. Lack of medical attention was mentioned 37 times, usually in cases which resulted fatally. Inexperienced med- ical attention was blamed five times. Contaminated food, milk, water, unscreened houses, ignorant servants, boat travel (9 cases of dysentery, with 2 deaths, among 18 passengers on one trip of a Yangtse river boat), privation, poor houses, flies, over-medication, epidemics among Chinese, etc., were named from one to many times. METHODS OF DISEASE PREVENTION One hundred and eighty-six of those who filled out the questionnaire (about 14%) gave advice on the subject of main- tenance of health. The various points named are listed in the following table. The figures refer to the number of corre- spondents who mentioned the subject. Table 83 ADVICE CONCERNING HEALTH GIVEN BY MISSIONARIES Relating to Mission Boards: Institute comprehensive health survey 1 Provide thorough physical examination of candidates 1 Provide medical examiners conversant with conditions on the field. 1 Provide medical instruction to candidates 1 Provide information concerning conditions on the field 1 Provide more medical attention on the field 1 Provide professional and nursing care for women at childbirth. ... 2 Have a rule that women be on the field for a year before marriage 1 Increase the salaries 2 Have a shorter time between furloughs 2 Build better residences 1 Provide houses at summer resorts 1 Supervise the schools for children 1 Relating to Stations: Display real Christian spirit 1 In assignments, consider compatibility of dispositions 1 Each family should board separately 1 Relating to Housing: Arrange in large compound 2 Have modern-style houses 6 Have Chinese-style houses 1 Sanitary plumbing, etc 4 Proper screening 26 At a distance from the street 3 Drain neighboring pools 2 Have self-closing servants' closet 1 Have separate kitchen for servants 1 Relating to Missionary Doctors and Nurses: Give more careful attention to foreign patients 3 Advise early smallpox vaccination 4 Warn community of sickness 1 Give better prenatal care to missionary wives 1 Examine wives after illness 1 Maintain stricter quarantine 1 Give furlough for sickness before death is imminent 1 Some Factors in Prevention of Disease 107 Relating to Yacations and Travel: Go to summer resort 22 Don't go to summer resort 2 Avoid summer travel 1 Take extra care in traveling 2 Don't travel third class 1 Be careful of food on river steamers 2 Relating to the Family — General Points: Study elements of medicine before coming 8 Don't worry 1 Get to feeling at home 2 Maintain a confident attitude 2 Acquire common sense 1 Keep regular hours 1 Daily exercise and recreation 13 Daily bath 1 Go to bed with clean mouth 1 Expectorate after bad smells 1 Don't worry about germs 3 In sickness, trust the Lord 2 Live as the Chinese do 1 A little private income important 1 Rest after tiffin 1 Take life easy at first 1 Listen to advice of older missionaries 1 Older missionaries should advise 1 Have a family game before bed-time 1 Have proper bowel habits J Have comfortable beds 1 Carry mosquito essence 1 Control flies 2 Have regular medical examination 1 Take typhoid and paratyphoid vaccination 2 In cold weather wear nightcaps 1 Relating to Parents: Avoid children too often 4 Have a small family 1 Avoid early child-bearing on the field 3 Learn duty of refusing to do good at family expense 1 Relating to the Mother: No language study during pregnancy 1 Learn the language 1 Get "Holt" 1 Exercise extra care during pregnancy 8 Avoid cart travel when pregnant 3 Stay in bed a month following childbirth 1 Give less time to mission work and more to children 1 Relating to Housekeeping: Learn how to cook 1 Be a good housekeeper 4 Personally supervise the kitchen 4 Provide more proteids in diet 2 Provide more fats 1 Eat fresh bread ( to avoid sprue) 1 Scald and then bake bread bought on the street 1 Scald fruit 1 Use only boiled water 24 Use only boiled milk 12 Use only cooked vegetables 4 108 Th e Health of Missionary Families in China Relating to the Care of Children: Personal supervision of children by the mother 2ti Personally prepare babies' food 5 Personally feed children 5 Use care in preparing food 1 Serve plain food 5 Cow's milk important 3 Keep your own cow 1 Use goat's milk 1 See that the milk is not watered 3 Use tinned milk 1 Use wet nurse if mother's milk fails 2 Let children eat only at table 4 Don't allow them to eat servants' food 1 Don't allow them to eat Chinese food 3 Don't allow them to eat Chinese candy 1 Serve only cooked foods 1 Serve plenty of fruits 2 Send children home between 5 and 10 years 4 Send children home between 10 and 15 years 2 Send children home between 15 and 20 years 2 Keep children's fingers out of the mouth 2 Boil bath water 1 Have daily mouth gargling 1 Relating to Children's Bleep and Play: Follow usual normal life 4 Provide exercise 2 Lead outdoor life •• Don't let the baby creep on the floor 2 Don't allow children to play in pools 1 Guard against loneliness (in isolated stations) 1 Put to bed by mother (to prevent bad habits) 1 Put to bed early 1 Provide mosquito nettings 4 Open windows 3 Sleep outdoors ? Use mosquito lamp i Keep inside after sundown in winter 1 Relating to Clothing: Dress warmly in winter 2 Wear cholera belt 3 Protect from sun 5 Use sun hats 4 Provide stout shoes 1 Don't allow the children to go barefooted on ground 1 Relating to Medical Attention: "Watch stools 1 Demand daily bowel movement 2 Provide glasses if necessary 2 Give periodic quinine 2 Don't give too much quinine 1 Give periodic santonine 1 Have semi-annual examination for worm eggs 1 Use prompt dieting on diarrhoea 1 Have circumcised 1 Early smallpox vaccination 1 Relating to Relations with Chinese: Keep from Chinese visitors 1 Keep from Chinese children 2 Allow to play with Chinese children 1 Some Factors in Prevention of Disease 109 Servants — The fewer the safer 1 Instruct servants 6 Watch servants 2 Keep children from servants ;; Keep children from other people's servants 1 Have servants examined by doctor 1 Watch for tuberculosis 4 Watch for dysentery ] Watch for malaria 1 Watch for syphilis 1 Watch for trachoma 2 Relating to Amah: Have none 3 Select with care 1 Don't change often ] Require to bathe regularly 1 Provide with clean garments 1 Watch for teaching immoral practices 1 Relating to Schools: They are not properly heated -. 2 Exercise and play neglected ] Children from south should go north 1 Health in China and at Home: Chance for health in China — Better than in homeland 3 As good as in homeland (if certain precautions are taken) 29 Worse than in homeland 18 Many of the collaborators in this study wrote feelingly on certain phases of this subject. There is not space to reproduce these letters, but some of the more striking sentences are set down. "Health of children not so good in China? Rubbish." "Some missionaries would be happier if they knew more about the interior of China and less about the interior of themselves." " 'Trust in the Lord and do good — so shalt thou dwell in the land.' " " 'Take cheerfully the spoiling of your goods.' " "Don't let your people send you funeral orations by every mail." "The excessive care necessary makes the children selfish and self- absorbed." "During the nursing months I live more nearly the life expected of a good cow." "A properly trained, trustworthy, Christian amah is better than a mother." "I (reared in China) know that some missionary children are allowed to learn vileness from bad servants. No mother ought to be so absorbed in the souls of the Chinese that she lets the devil get the bodies of her children." "Health is largely up to the housekeeper." "It ought to be language first then babies, or babies first then language, but certainly not both at the same time." "Don't let young missionaries presume on God's almightiness to nullify rashness." "The worm (round) that dieth not." "Our doctors pay no attention to prenatal examinations." "At home, the people who have the best doctors money can engage do not get the good attention I have had on the field, because these best doctors are so busy." 110 The Health of Missionary Families in China "Microscopes are time consumers, but life preservers." "Have a physical examination once a year by a physician that will do a good job of it and take some time to it." "Get a 'fool-proof closet stool cover; keep the place whitewashed and clean-looking, so they (the servants) will be proud of it. Put a self-closing screen door on it in summer and hang a fly-swatter in it and encourage its use." "In one sample of cow's milk there was 75% of water." "Wanted, a 'Holt,' adapted for feeding in China." "Put play Into your schedule as religiously as you put work or Bible study." (From a physician) : "I would keep every pregnant and every nursing woman from language study. No one will believe in the necessity of such regulations unless she first transgresses them, and then the fat is in the fire." "One cannot expect the children of mothers to be well when the mothers . . . permit the ignorant and dirty Chinese to feed and care for the chil- dren's wants." (From a physician) : "When children do get sick they get much Inferior care, on the whole, than they would get at home. Everybody is so busy making statistics that foreign patients do not count. All appear to be affected with the Bacillo coccus statistinitis. Quantity instead of quality is the watchword." THE RESPONSIBLE AGENCIES Considering all the difficult circumstances of the past, missionaries and mission boards have doubtless done the best possible for the health of the workers. Mortality rates are doubtless pigmy sized in comparison with the huge physical difiBculties faced. However, in the light of important new medical knowledge, in the light of the present tremendous urgency for the missionary program, in the light of freshly opened reservoirs of funds, in the light of growing unity among Christian forces, — the health record for the past will not do for the future. The problem of the health of the work- ers needs to be handled in a new and bigger way. The purpose of this study is to set forth the facts con- cerning the health of a certain portion of the missionary force in China. It does not aim to present a detailed health pro- gram. That can be done only by the mission boards. This study would be incomplete, however, if the agencies concerned in the safeguarding of health were not indicated. 1. The Individual Missionary. Most of the 161 items of Table 83 are concerned with the precautions which the indi- vidual should follow. In a country where one must be his own board of health such individual measures are most essential. 2. Missionary Doctors. Doctors are supposed to bear the same relation to the missionary body that the medical corps of the army bears to the force in the field, but they cannot fully live up to that relationship without either large rein- forcements, or a decrease in their work for the Chinese. Some Factors in Prevention of Disease 111 3. Groups on the Field. United efforts by mission sta- tions, the China Medical Missionary Association, union lan- guage schools, and other union organizations can assist greatly in making health measures effective. An encouraging feature is the coming of the China Medical Board. With the opening of the Peking Union Medical College hospital, mis- sionaries in China have at their disposal the advice of special- ists who are supplied with all the up-to-date equipment for the diagnosis and treatment of disease, 4. The Individual Missionary Boards. In such matters as the securing and dissemination of accurate information concerning sickness on the field, the best methods of disease prevention, in the matter of salaries, housing, period of serv- ice, schools for children, etc., the responsibility rests not with the missionaries, but with the boards for which they work. The China Medical Missionary Association at its last con- ference held at Peking, in February, 1920, after considering some of the facts of this study, unanimously passed the follow- ing resolutions : Whereas, the health of the individual missionary and his family is essential to the success of the missionary enterprise, and, Whereas, the war has demonstrated the possibility of greatly reducing disease among the forces in the field through the use of modern methods of prevention and cure; and. Whereas, preventable sickness and death constitutes a continuing drain on the Christian forces in China; therefore, Resolved, that the China Medical Missionary Association should and hereby does call the attention of the missionary boards doing work in China to the need of an energetic, comprehensive, co-operative program, looking toward the physical well-being of the workers in the field. Among other items, such a program should include: "First, the tabulation by the boards of their health statistics for the past, and where the records are inadequate, the installation of a system of vital bookkeeping by means of which they and the doctors on the field may be in possession of the basic facts necessary for intelligent action. "Second, a thorough physical examination of candidates, with a greater degree of co-operation between examining physicians at home and physicians on the field. "Third, the more complete instruction of missionaries in the best means of guarding against disease in the section of the country in which they are to work. "Fourth, the securing for the missionaries of all the up-to-date means for the prevention of disease, such as yearly physical examinations, regular vaccination against typhoid, paratyphoid, and smallpox, proper housing, screening, etc." The China Medical Missionary Association especially offers its support In the planning and in the execution of any such forward looking program, and it hereby directs its executive committee to lay this matter before the missionary boards doing work in China, and to act with the boards in any measures which they may adopt. 112 The Health of Missionary Families in China It should be pointed out that some of the boards have had already in force policies which cover most or all of the points enumerated in the foregoing resolutions. As an example, the plans of the Methodist Episcopal, North, board may be mentioned. In this board there is a medical department headed by a returned medical missionary, Dr. J. G. Vaughan. The health policy of the board includes, besides other lesser items, the following: A thorough physical exam- ination of candidates made by certain, well-trained, well-paid examiners in various centers in the country; examination blanks made in quadruplicate and a copy sent to the physician on the field; a health efficiency study based on health reports received trimesterly from each missionary on the field; a card index with complete health record of each missionary; the issuance of Life Extension Institute Bulletins; typhoid inoculations every two years; and supervision of activities of missionaries on furlough with special refer- ence to the requirements of health. This policy was adopted two years ago. The policy also recognizes the importance of co-operation between boards in such common problems as proper examinations, health surveys, etc., but unfortunately little in this line has been accomplished. The writer understands that in this respect British societies are considerably ahead of American societies. The Young Men's and Women's Christian Associations, though they have no practicing physicians on the field, are particularly careful concerning examinations, requiring yearly physical examinations on the field and such a thorough overhauling as is given at the Mayo Clinic when on furlough. Certain other boards take a lively interest in the health of their workers. Yet, considering China as a whole, as this study does, it is evident that many of the boards are far too lax. In order to gain an idea of the thoroughness of the atten- tion paid to the physical life of the successful candidate, a brief questionnaire was circulated in January, 1920, among the students of the North China Union Language School. Sixty-eight adults, all but two of whom had come to China within a year, filled out the question blank. Fifteen mission boards were represented. Of these 68, 30% had been exam- ined by doctors of their own selection, 23% had been given no advice concerning the maintenance of health on the field, 20% had not been inoculated against typhoid fever, 6% had not been vaccinated (none of these were protected by recent vaccination), 9% had not had their urine examined. All but one had had a chest examination. Most of the neglected cases belonged to a certain few of the boards. 5. Co-operation Behveen Boards. There are certain measures which individual boards cannot put into operation, at least not without wasteful duplication of effort and expense. The most important word in the C. M. M. A. resolutions is "co-operative." Not only at home (in ways suggested in the above-mentioned policy), but also on the field, more active co-operation is possible. For example, this study shows Some Factors in Prevention of Disease 113 the overshadowing importance, even in the families of the medically trained, of the intestinal infections, dysentery, diarrhoea, cholera, etc. For the prevention of these diseases better sanitation is essential. But the sanitation of mission stations and Chijiese cities cannot be directed from New York, London, Stockliolm, and Copenhagen. Missionary doc- tors have neither the time nor the special training for this. There is needed a staff of health officers and sanitary engineers on the field, working under some union body such as the Joint Council on Public Health or the China Continu- ation Committee, Such a staff could compile vital statis- tics for the whole missionary body, advise stations and sum- mer resorts concerning sanitation, provide vaccines, conduct researches into the problems of health and promote public health measures among the Chinese in the cities in which mis- sionaries reside. As an instance of a minor problem in which missionaries can be helped, the following example is mentioned: At the Peking Union Medical College, under the leadership of Dr. J. H. Korns, 400 servants in the families of missionaries and other foreigners have been examined for chronic communicable diseases. Eleven per cent were found to have a positive blood test for syphilis, 11% had trachoma, 48% round worms, 1.8% hook worms, 1.7% were meningitis carriers, and 1.2% diphtheria carriers. Through treatment of servants who are diseased, through lantern lectures on home sanitation, as well as through the emphasis placed on good health, it is felt that the danger of infection from household servants in Peking is considerably lessened. For those employers whose servants have been found free of infectious disease, one cause of worry is removed. Because of the necessity of using boiled vegetables and milk, and expensive butter, the supplying of the growing child with a properly balanced diet, containing necessary food ele- ments, is a problem. (121 cases of difficult feeding and mal- nutrition and 13 cases of rickets were reported, but no case of scurvy.) Wilson,"*" and Adolph and Kiang" are studying the nutritive value of Chinese foods. Taylor"*^ has presented work on the feeding of the foreign baby. Mills^® has pointed out the value of chloride of lime for the sterilization of water in country traveling. Van Buskirk**^ has made a thorough study of the climate of Korea with reference to its effect on foreigners. The practical applications of these studies," and many others which should be undertaken, should be placed in the hands of all missionaries, either directly or through a column in the Chinese Recorder, For large undertakings, such as the building of schools, the institution of more complete sanitary measures in cities and at so-called health resorts (which are often the play- ground for epidemics), for effective protest to operators of 114 Th e Health of Missionary Families in China river steamers, etc., there should be active co-operation be- tween the missionary body and the rapidly growing group of non-missionary foreigners doing business in China. THE EXTRAVAGANCE OF SICKNESS Back of mission boards lies the contributing, church, a church which seems sometimes to give best when its mission- aries are represented as suffering most of physical privation and hardship. In order that the boards may not be hampered in adopting "energetic, co-operative, comprehensive" health policies, there is need for an increased interest of the church in the physical welfare of missionaries and a realization of the fact that maintenance of good health is good economy. For this reason the facts of this study are not kept secret. Sickness anywhere is expensive, but w^lien the sick one or his successor has to be sent 10,000 miles, it is an extravagance. Things that make for health are not luxuries, but money- saving necessities. Modem preventive medicine has shown that, to a large extent, good health is purchasable. Pittsburgh,^" for example, has bought more than 300 lives a year (formerly taken by typhoid fever) by the erection of a $5,700,000 water filter plant, and considers the purchase a bargain. No man of busi- ness would spend several thousand dollars for an automobile and then let it go to the junk pile for lack of oil or for neglect of necessary repairs. Neither would the contributor to mis- sions, if the matter were presented to him, after spending a like amount for sending a family to the field, object to the additional expenditures necessary to keep it in health. Vac- cine, wire screening, proper medical advice, sanitary dwell- ings, adequate salaries, vacations, health surveys, etc., are ex- pensive, but not so expensive as sickness. It has been figured by a leading statistician that the periodic exami- nation of any group will save at least three lives per thousand per annum, apart from the dividends in increased health. If this is true, 20 lives a year would be saved to the missionary force in China through this one means. At the usual valuation of life, this would save at least $100,000 a year. Since some of the boards already provide for regular examinations (usually only at the time of furlough) a yearly examination would not reduce mortality to the extent named. However, it should save $40,00n-$50,000, which would more than pay the expenses of a dozen additional doctors to conduct the examinations. The purchase of health, like any commodity of value, requires careful planning and the aid of expert advice. The employment of a staff of experts such as has been suggested, would, in the course of a few years, save hundreds of thou- sands of dollars now wasted in poor health and death. Some Factors in Prevention of Disease 115 Such intelligent, scientific supervision of health would increase morale and make it easier to secure recruits among those who hesitate to expose children to the hazards of mis- sionary life. A missionary is not afraid of death, but he would rather be killed in battle, than tamely fall a victim of some easily preventable sickness. SUMMARY This is a study of facts concerning the health of 60% of the missionary families in China. Facts are tabulated con- cerning 1,300 marriages, and 4,831 persons (1,577 adults and 3,254 children). Facts concerning 451 deaths of children, 59 stillbirths and 416 miscarriages and nearly 7,500 cases of sick- ness are analyzed. The study represents a total of more than 35,000 years spent in China. The principal facts which have come to light are as follows : 1. Each marriage has resulted in an average of 2.5 chil- dren, which is at least 20% more than that for the average college graduate or college teacher in the United States. Only 13% of the marriages are childless, against 31% among Amer- ican college women. 2. American societies average 2.33 children per marriage, English and Canadian, 2.63 ; European, 2.88. 3. Three-fourths of the families have no children dead. 4. The children average SV2 years in age, 67% of their time has been spent in China. Ten per cent less time has been spent in Southern than in other provinces. 5. Mortality amog these children is considerably less than half what it is among Chinese children, but IV2 times greater than among children of missionaries in Japan. (139 in China to 95 in Japan.) The excess for China occurs in the group of children aged 1 to 5 years. 6. Infant mortality is only 60. The rate for the first six months is extremely low, lower than among professional men in England, but during the last six months it is two to three times as high, due largely to dysentery and other intestinal infections, which are, in turn, probably due to lack of breast feeding. 7. Death rates of children from the second to the fifth years are three times as high as in countiy districts in Eng- land having about the same infant death rate. 116 The Health of Missionary Families in China 8. Mortality, in general, decreases from north to south. It is more than twice as high in North China as in South China. This is due both to the greater prevalence of the infec- tious diseases, and to the larger percentage of deaths among those taken sick. Intestinal and respiratoiy infections and smallpox are most markedly deadly in the north. Consider- ing the societies individually, most of them show higher mor- tality rates in the north than in the south. 9. Mortality varies markedly in the various societies, the highest having three times the rate of the lowest. High rates are due to the general infections and intestinal diseases. Kates are higher in societies having the larger number of children per family. 10. Mortality is higher in the societies reporting less than 20 children. 11. Mortality is equally low in American and English societies, the high rates found in European societies are due to dysentery, diarrhoea, and smallpox, each of which is two to four times as deadly as in American or English societies. 12. Mortality is lowest when a parent is born in China, highest when parents are born in Europe. Of the latter class, 15% of the deaths are due to smallpox. 13. Mortality is lower in families where parents have had medical training, largely because of the decrease in general infectious diseases. Training of the mother is of more impor- tance than training of the father, as shown by decrease in in- testinal and general infections. This points to the advantage of education of the mother in home sanitation. 14. Mortality is, in general, lower in societies having the larger ratio of doctors to missionary force. 15. The decrease of mortality in the more recent years has probably not exceeded the rate of decrease in England and America. Infections other than dysentery have decreased most. 16. Mortality has decreased for successive children through the fifth child, after which it has increased. Smallpox is six times as deadly among children bom sixth or later, while dysentery is less deadly. 17. Large families have a considerabl}^ higher rate than small families. This is due to the general infectious diseases, including smallpox, and diarrhoea. This points to poor quar- antine within the home. Some Factors in Prevention of Disease 117 18. Mortality rates are slightly lower for children born outside of China than for those born within. They are lower in the groups of societies in which parents have spent the largest percentage of time off the field. 19. Dysentery has caused 19% of all deaths, diarrhoea 12%, respiratory infections 13%, diphtheria 6%, conditions ^^sociated with birth 10%, smallpox nearly 5%; 88% of deaths have occurred before the age of seven. 20. Compared with the United States and England, dys- entery, smallpox and injury at birth take a large toll for the first five years. After five years, scarlet fever is relatively deadly. The early appearance of typhoid (7.5% of deaths from 5-9) points to the need of early inoculation. 21. Less than 7% of deaths occurred in the homeland; 33% of the time was spent there. 22. Of the children dying aged five years or over in four groups of societies, one-third were killed in the late war. In general the various tabulations show that infant mor- tality is much less variable than mortality of childhood, also that rates due to birth, development and nutrition vary less than those due to infections. Since the diseases whose rates fluctuate most are most preventable, effort directed against the infectious (bacterial) diseases of early childhood will yield the largest returns. 23. Sickness rates, in contrast with mortality rates, are highest in Central and South China, due to increase of malaria and intestinal parasites. In South China also, fewer children have robust health. Dysentery in relation to years of resi- dence is less prevalent in the coast and Yangtse valley pro- vinces. The absolute number of cases is greater in these sec- tions because the number of missionaries is greater. 24. Scarlet fever, measles, mumps, chicken pox and whooping cough are contracted relatively more frequently outside of China than are the less highly infectious diseases. 25. The largest number of dysentery infections occur dur- ing the second and third years, of diarrhoea during the first and second. The younger the child, the higher the mortality. 26. Miscarriages number 13.4% of live births, the rate being highest in South China. The number of miscarriages per family is also highest in the south, 24% of the wives have had one miscarriage or more, a comparatively high rate. 87% of miscarriages occurred in China, against 82% of married 118 The Health of Missionary Families in China years spent there. Travel and overwork caused a larger pro- portion of miscarriages at home than it did in China. Over- work, disability, nervousness, etc., are thought to be respon- sible for one-half of the miscarriages. 27. Stillbirths were 1.84% of living births, a low rate, probably largely due to the absence of syphilis among mis- sionaries. 28. Missionaries have been married an average of 11.6 years. The average adult life on the field is 20% less in South China than in North China. 55% have been in China 10 years or less. 29. Most numerous diseases among adults in China in order of frequency are : malaria, dysentery, typhoid, nervous breakdown, influenza, diarrhoea, spine, appendicitis opera- tions, smallpox, typhus fever, tuberculosis. Central and South China show larger numbers of illnesses than North China. 30. Cases of malaria and dysentery are much more numer- ous among husbands than among wives. In the case of sprue, the reverse is true. 31. Forty-six per cent of the infections are contracted within the first three years after arrival in China. 32. More than half (53%) of adults have had serious illness in China. Fewer have been sick in North China than in Central and South China. The rate is the same for hus- bands and wives. 33. Only 20% of wives and 30% of husbands say they have been in robust health. For wives, the proportion is con- stant for the sections of China. For husbands, 33% in the north have had robust health, against 17% in the south. This is perhaps due to the especially high incidence of malaria among husbands in the south. 34. The proportion having robust health in various soci- eties varies widely, but in general, the societies with high mor- tality rate among children have a low percentage of robust health among parents. In general, though mortality among children is much higher in the north, the morbidity rate among adults and children is less, miscarriages fewer, the general health better, and the residence in China longer for those who live in North China. This is because the diseases of North China (dysentery, pneumonia, diphtheria, scarlet fever, smallpox) cause death. Those of South China (mala- ria, intestinal parasites) and the climate, cause invalidism. Some Factors in Prevention of Disease 119 35. Three-fourths of the deaths of children are due to infectious diseases, for which the ratio of preventability is high. Given knowledge and command of preventive measures, it is possible to save 200 of the 300 deaths from the infectious diseases here recorded. 36. Among adults and children here reported (about 41% of the total missionary body) dysentery has caused 808 cases of sickness and 84 deaths. 37. If the typhoid fever rate were reduced to that prevail- ing in the United States army since the introduction of com- pulsory inoculation, in ten years on the field there would be a saving of 56 lives and $336,000. Typhoid contracted by adults in China outnumbers cases contracted by them at home 12 to 1. 38. One hundred and eleven cases of smallpox, with 28 deaths, are recorded among children and adults, a rate 95 times that for the general population of the United States. No deaths have occurred in families in which parents have had medical training. In 51 cases in which the record of vac- cinations is known, six cases occurred in individuals who had ''takes" within five years, pointing to the need of more fre- quent vaccination. Only one death occurred in a person who had been vaccinated. Cases of smallpox contracted by adults in China outnumber cases contracted at home 30 to 1. Among the children, no case contracted outside of China was reported. For some of these conclusions, modifying sojrces of error, which have been named, should be noted. A closer com- parison of facts will be possible when statistics now being col- lected among missionaries in Japan and church members in America have been tabulated. In certain sections of China, or among certain groups, children of missionaries have as good a chance for life and health as children at home. Taking the missionary body as a whole, however, there has been an excessive loss of life among both children and adults. Much of this loss may in future be prevented. For such prevention, both intelligent vigilance on the part of the individual and a larger co-opera- tive health program on the part of the churches is needed. Increased expenditure, if based on facts, would result in great money-saving, and would aid in bringing nearer the longed- for coming of the New Day to China. 120 The Health of Missionary Families in China REFERENCES 1. Hill, J. A. Comparative Fecundity of Women of Native and Foreign Parentage in the United States. Quarterly Publications American Sta- tistical Ass'n. Dec, 1913. XIII, p. 591. 2. Smith, Mary R. Statistics of College and non-College Women. Ibid, 1900, 1901. VII. 3. Nearing, Nellie S. Education and Fecundity. 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Typhoid Fever in the American Army During the World War. Jour. American Medical Ass'n, Vol. 73, p. 18G3. 30. Gay, F. P. Typhoid Fever, 1918. 23. 31. Saper, G. A. Protective Value of Typhoid Inoculation. Am. Jour. Public Health. April, 1920. 32. Mortality Statistics, U. S. Bureau of the Census. 1909. 33. Musser and Kelly. Practical Treatment. Vol. IV. 34. Weekly Bulletin of Department of Health. City of New York, 1916. V. 65. Quoted by Musser and Kelly. 35. Wing, Frank E. Thirty-Five Years of Typhoid. Pittsburgh Survey — Russell Sage Foundation. The Pittsburgh District, p. 85. 36. Wilson, S. D. A Study of Chinese Foods. China Medical Journal, Sept., 1920. p. 503. 37. Adolph, W. H., and Kiang, P. C. The Nutritive Value of Soy Bean Products. China Medical Journal, May, 1920. p. 268. 38. Taylor, Harry. The Problem of Feeding the Foreign Baby in China. Paper read before the C. M. M. A. conference February 26, 1920. 39. Mills, Ralph. Use of Chloride of Lime in Sterilization of Water. 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