ID QW<^- MISSOURI TUBERCULOSIS ASSOCIATION Rural School Health Survey MISSOURI ELIZABETH MOORE Director of School Health Surveys .^^^ 702 Pontiac Building, St. Louis, Mo. November 1922 ... «..c .« « « »■' —-»"»'■»■■»■■»■■ ..» » " » »' » « MISSOURI TUBERCULOSIS ASSOCIATION Officers 1922-23 President, Hon. A. A. Speer Vice-President at Large, Dr. James Stewart Treasurer. Mr. A. O. Wilson Recording Secretary, Mr. E. M. Grossman Executive Secretary, Dr. Walter McNab Miller Board of Directors 1922-1923 Representing Congressional Districts: 1st Mrs. George A. Still, Kirksville 2nd Mrs. Walter Brownlee, ;!rookfield 3rd (Vacant) 4th Mrs. R. A. Brown, St. Joseph 5th Mr. Walter C. Root, Kansas City 6th Prof. W. E. Morrow, Warrensburg 7th Dr. A. J. Campbell, Sedalia Sth Dr. M. P. Ravenel, Columbia 9th Supt. B. H. Jolly, St. Charles 10th Dr. W. McN. Miller, St. Louis 11th Mr. E. M. Grossman, St. Louis 12th Dr. James Stewart, St. Louis 13th Mrs. O. W. Bleeck, Farmington 14th (Vacant) 15th Dr. C. T. Dusenbury, Monett 16th Supt. Robt. W. Crow, Salem Representing Senatorial Districts: 1st Mr. Bert Cooper, Maryville 18th 2nd Supt. J. W. Thalman, St. Joseph 19th 3rd Judge W. K. James, St. Joseph 20th 4th Miss Elizabeth Brainerd, Trenton 21st Sth Mr. George Melcher, Kansas City 22nd 6th Supt. C. C. Carlstead, Keytesville 23rd 7th Mr. F. W. LeClere, Kansas City 24th 8th Supt. Price L. Collier, Richmond 25th 9th Dr. A. G. Hildreth, Macon 26th 10th Mr. Thomas J. Walker. Columbia 27th 11th Mr. W. W. Fry, Jr., Mexico 28th 12th (Vacant) 29th '3th Supt. L. M. McCartney, Hannibal 30th 14th Supt. Chas. R. Mi'burn, Ca'ifornia 31st 15th Miss Marv W. Fisher, Marshall 32nd 16th Supt. A. C. Moreland, Butler 33-d 17th Mr. B. M. Little, Lexington 34th Supt. D. W. Clayton, Aurora Dr. W. J. Rabenau, Fordland Mrs. Wm. Ullman, Springfield Mr. Allan Hinchey, Cape Girardeau Mr. Wm. R. Haight, Brandsville Dr. J. R. Pinion, Caruthersville Mr. H. A. Buehler, Rolla Hon. Clark Brown, Union Dr. R. E. Donnell, DeSoto Hon. A. A. Speer, Jefferson City Mr. John H. Capelli, Joplin Mrs. Philip N. Moore, St. Louis Dr. J. F. Bredeck, St. Louis Dr. M. A. Bliss, St. Louis Dr. Borden S. Veeder, St. Louis Mrs. Ernst Jonas, St. Louis Dr. George Dock, St. Louis Representing Local Organizations: Kansas City Tuberculosis Society. Mr. Buchanan County Tuberculosis Society Col. Columbia Charity Organization Society... Mrs. Pettis Countv Anti-Tuberculosis Association..... Cooper Co. Health and Educational Association . .Mrs. Johnson County Tuberculosis Association Prof. Lafayette County Tuberculosis Association Miss Greene County Health Association Mr. Cole Countv Tuberculosis Committee Mr. St. Louis Tub"rculosis Society ....._ Mr. Cass County Tubercu'osis Association Mr. Jasper County Anti-Tubereulosis Society Mr. R. E. Parsons, Kansas City- Jos. A. Corby, St. Joseph W. E. Harshe, Columbia (Vacant) Felix Victor, Boonville E. B. Wood, Warrensburg Mary Marquis, Lexington M. D. Lightfoot, Springfield A. H. Sieve, Jefferson City A. W. Tones, Tr., St. Louis . W. E. Smith, Belton Frank L. Gass. Cartervilli Executive Staff Executive Secretary W. McN. Miller, B. Sc, M. D. Office Secretary - - — Etta F. Philbrook, A. B. Director, School Health Surveys Elizabeth Moore. A. B. Director, Modern Health Crusade Helen Guthrie Miller Field Representative _ Gladys Roberts, B. S. \H * CONTENTS Page Introduction _ j — _ _ _ 1-2 Purpose v , 1 Field , - 1 Scope and method _ _ _ _ — 1 Physical examination H _ 3-9 Grade school pupils _ - _ 3-8 Weight —* 3 Teeth .. - - 4 Tonsils and adenoids.- ■. - - * — 5 Eyesight _ — - - 6 Hearing — +. 7 Cervical lymph glands - — 7 Miscellaneous defects , __ 7 High school pupils t - - - 8-9 Weight + ,. _ _ 8 Teeth 8 Tonsils and adenoids- - 9 Eyesight _ _ •• 9 Home sanitation _ ^ - 10-12 Home congestion ► _ ^ 10 Water Supply _ * 10 Toilet facilities ,. - — — H Screening — _ — , - 12 Correlation with physical condition _ _ , - 12 Personal hygiene 13-16 Sleep ._ _____ - 13-15 B edroom ventilation _ _ - — 1 3 Crowding in bedroom _ _ * — - 13 Hours of sleep _ h __ _ 14 Cleanliness _ _ j _ 15-16 Bathing _... _ 15 Eating with clean hands __ , _ 1 5 Cleaning teeth_ _ „ 16 Diet + _ - ~~ 17-27 Diet grades ._ _ __ v .. _ _ _ 17 Use of milk >__ _ _ _ _ 19 Coffee drinking _ ,. 21 Excessive meat, eating __ _ t 21 Biscuits _ r _ 22 Pancakes _ _+ _ _ 23 Pie , _ 23 Excessive sweets „ _ _. _ 23 Cereal _ _ , 24 Eggs , 24 Fruit and vegetables __ ► * 24 Regularity in eating _ , 26 Summary _ _ 27 Conclusion: What to do about it_ , 28-33 Remedial measures _ _ _ 28-30 Physical examinations _ _ 28 Follow-up work „ _ _ 28 Children's clinics ,. __ 29 Preventive measures > _ : _ 30-33 Home sanitation ..._ , _ 31 Personal hygiene _ * 31 Diet , _ _ _ 31 School lunches _ _ _ __ _ _.. „ 32 Summary of recommendations , 33 Tables 34-46 Rural School Health Survey OF THE MISSOURI TUBERCULOSIS ASSOCIATION By Elizabeth Moore INTRODUCTION. PURPOSE. — This survey is a study of the health of rural school children in Missouri, based upon (a) their physical condition, as shown by a school physical examination, and (b) their health habits and environment, as learned through home visits and talks with parents. It was undertaken as part of the school health campaign of the Tubercu- losis Association, with the immediate object of interesting the community in providing health supervision for country children, and the ultimate object of preventing the development of future cases of tuberculosis through build- ing up better general health in the young people of the State. The survey was confined to rural children because the Association felt that they had been receiving less than their fair share of attention along public health lines. FIELD. — The survey was carried on in six counties in different parts of the State: to-wit, Greene, Johnson, Nodaway, Harrison, Livingston and Mis- sissippi. Mississippi County is situated in the Mississippi River bottom in the southeastern part of the State; Greene County, on the Ozark Plateau, in the southwest; Johnson County, in the Missouri River valley, south of that river, but in many respects resembling the northern rather than the south- ern part of the State; Nodaway, Harrison and Livingston Counties, in the northwest, fairly representing the whole clay-soil upland territory north of the Missouri River. The only important section not represented is the hill country of the Ozarks; Greene County is much more prosperous and more closely in touch with the rest of the world than is most of the Ozark district. All six counties have, in the main, distinctly fertile soil; in all except Mis- sissippi County, the majority of the country people are prosperous and able to live with reasonable comfort. Greene County is the only one of the list which includes any city as large as 10,000 population. The country population is predominantly Ameri- can, usually of native ancestry for* several generations. There were some colored families in the districts visited, but even in Mississippi County these were comparatively few. SCOPE AND METHOD. — Because of limitations of time and funds, the survey was made only in a sample of the rural and village schools of each county. These schools were selected after consultation with the county 1 superintendent of schools, and usually on application from the teacher. The list comprised forty-eight rural schools (i. e., in the open country) and eleven village schools, of which nine included a high-school department. With one exception (812 population) all of these villages were under 500 population; in other words, this survey was made in no town having as many as 1,000 inhabitants. In the six counties 2.298 pupils were examined — 1,934 grade pupils and 364 in the high schools. Seven-tenths (1,351) of the 1,924 white grade-school pupils with whom the survey deals, lived in the open country; and three- tenths (573) in villages (hereafter referred to respectively as "rural" and "town" children). With the exception of ten in one town, all the children examined were white. It seemed best to confine the study to one race, since it would have been impossible to cover both in any adequate manner. All following figures and tabulations refer to white children only. It was, of course, necessary to make the survey during the rural school term. Since country roads in Missouri are practically impassable during part of that period, the survey was carried on during parts of three years: 1919, 1920 and 1921. The physical examinations were made in co-operation with local physi- cians and in some cases with local dentists. The Missouri Tuberculosis Association furnished one or at times two social service workers who arranged for the examinations, assisted the physicians with routine work, and kept the records. In every county where there was an active medical association, its officers were most helpful in securing medical examiners. The physicians' and dentists' services were given free of 'charge, as a contri- bution to the campaign. The examination consisted of weighing and measuring the pupils and of tests of vision and hearing, done by the survey workers; of examination of the teeth, made by dentists or by the survey workers; and of a physi- cian's examination of nose and throat, heart and lungs, with notation of other defects which might be observed in a school-room examination. Following the school examination, the survey workers visited the home of each grade-school pupil (so far as possible) to talk over with the parents the results of the examination, explaining the advantage of corrective measures where necessary, and to secure information for the home records. Such records were secured for 1,499 grade pupils; this number includes practically all those examined in four of the six counties. In one county (Harrison) bad roads made it impossible to visit any homes outside the villages; in another (Livingston) lack of time and workers made it neces- sary to omit the home visits in two large school districts and part of a third. PHYSICAL EXAMINATION. I. Grade School Pupils. These physical examinations of rural school children in Missouri have confirmed those made in other parts of the United States in showing that the common physical defects of school children — malnutrition, decayed teeth, defective tonsils, enlarged adenoids, poor eyesight — are prevalent among country as well as city children. Different methods of classification make direct comparison difficult; but there is no question about the fact, nor about the need for preventive and remedial care for children in the open country and small towns, who are now receiving less health care than are the children of the city slums. WEIGHT. — Being as much as 10 per cent below weight i is considered by all authorities on the nutrition of children to be a danger sign of mal- nutrition, which means being seriously below par in general physical condition. Not all children who are even considerably underweight are undernourished; but most of them are. Malnutrition may have one or more of several causes, the chief of which may be classified as: (a) Physical defects, of which by far the most common are chronic infections, such as decayed or abscessed teeth or diseased tonsils and adenoids; and (b) bad health habits, including over-fatigue, lack of sleep, and unwisely chosen or poorly cooked food. (Actual lack of food — aside from lack of appetite — is not a frequent cause of malnutrition.) What the cause may be in the case of any individual child can be found out only by a thorough physical examination and a careful study of the child's environment and habits. Of importance to the tuberculosis prevention campaign is the fact that undernourished children are potentially tuberculous. For this reason, chil- dren who are markedly underweight are often called "pretuberculous," and efforts are made by tuberculosis associations to place them in special open- air schools or in "preventoria" in order to build up their general health and ward off possible disease. Of all the children weighed in the course of this study (1,897), one-fifth (20%) were 10 per cent or more below standard weight, i. e., in the "danger signal" group. The smallest proportion (11%) was found in Nodaway County and the largest (23%) in Greene and Livingston Counties. Nearly one-fourth (24%) of town children were seriously underweight, as compared with less than one-fifth (18%) of rural children. In fact, the large propor- tion of underweight children in Livingston County was mainly due to its town children, among whom 28 'per cent were underweight; in the largest village in that county, 40 per cent (two-fifths) of the children were 10 per cent or more below standard in weight. In Greene County many children, some of whom seemed to be in good health, were not only thinner than the average for their age and height, but also taller than the average child of the same age. A similar "lankiness" was conspicuous in adults also. It seems possible that there may be here in the Ozarks an instance of a taller, thinner breed of folk than the average, for whom different standards of normal weights would be necessary. On the other hand, the underweight l For ag-e and height. Standard tables compiled toy Dr. Thomas J. "Wood were used throughout. Livingston County children — especially in the village above mentioned — gave the impression of being actually in poor physical condition. TEETH. — Of almost 1,900 grade pupils whose teeth were examined, seven-tenths were found to have unfilled decayed teeth; half of them had decay in permanent teeth and half in temporary or "baby" teeth only. This is not an unusually large proportion, compared with other studies of school children's teeth; for example, the North Carolina State Board of Health reports that "examination of approximately 240,000 of these children by physicians, nurses and dentists themselves established the fact that about 80 per cent have defective teeth." However, it brings to our attention the fact that the teeth of Missouri country school children are shamefully neglected. Granted that decay of the permanent teeth is more serious than the same defect in temporary teeth, nevertheless an unfilled cavity in any tooth is an unwholesome condition, a breeding place for germs; and many of the badly decayed temporary teeth seen in children's mouths amply deserve their colloquial designation, "rotten." Furthermore, neglected decay in first teeth which goes so far that the teeth have to be pulled long before their natural time, very commonly leads to crooked second teeth. Seven-tenths of those children who still had some of their first set of teeth, had visible decay therein. This only feebly expresses the condition of many of these children's mouths; one boy, for example, had fifteen decayed temporary teeth. On the other hand, only one in twenty-seven had any fillings in temporary teeth. Another frequently neglected, unwholesome condition is the persistence, sometimes long after the second teeth have come, of broken fragments of "baby" teeth and their roots, colloquially called "snags." When we come to consider the permanent teeth, which should last these children the rest of their lives, we find that almost half (47%) of the children who had reached their tenth birthday, and fully half (50%) of those who had reached their twelfth, had unfilled cavities in their permanent teeth. Moreover, only 42 per cent of those children ten years old or over, and 35 per cent of those twelve years or over, had normal i (undecayed) permanent teeth; 21 per cent and 28 per cent respectively, of the two groups had already had dental work (either fillings or extractions) done on their permanent teeth; and of those under 10 years, one-fifth already had unfilled cavities in their permanent teeth. The moral of these facts is that decay of the second teeth begins early; that the permanent teeth must be watched constantly from their first appearance, if they are to be kept in serviceable condition. In this connection it is pertinent to emphasize the fact that the six-year molars (recognizable as the sixth in line from the center of the jaw) are permanent teeth. This is a fact of which many parents are ignorant; and because these teeth, unfortunately, are especially liable to decay, this ignor- ance does much harm. Parents who intend to be careful often neglect these "No. 6" teeth on the mistaken assumption that they are temporary and will soon be replaced. At all ages, the town children's permanent teeth were in worse condition i Disregarding- irregularity. than those of the rural children. While more of the former (by 25% against 20%) showed evidence of having visited a dentist, this attention did not offset what seems to be a greater liability to decay. In spite of their 5 per cent excess in dental care, 52 per cent of the 10-years-or-over group in the towns had unfilled cavities in second teeth, as compared with 45 per cent in the country. There are some noteworthy variations among the different counties in the matter of dental decay and care (See table, page 35). Mississippi and Nodaway Counties showed the highest percentages of children with normal permanent teeth, and Greene County the lowest. On the other hand, Greene County showed the largest percentage of children who had had dental care, and Mississippi County by far the lowest. Because of such lack of care, Mississippi County's percentage of children with unfilled cavities was practically as high as the average; while Nodaway, with more children seeking the dentist, had much the lowest proportion with unfilled cavities. TONSILS AND ADENOIDS. — There are no recognized standards of what may be called pathological (abnormal or unhealthy) adenoids or tonsils. Reports on these points are inevitably based on the examiner's individual standard, and therefore the findings of different examiners are not strictly comparable. Consequently too much stress must not be laid on the figures pertaining to these conditions given in this report. The co-operating physicians examined 1,831 grade pupils. In this large group, nine-twentieths, or nearly half (45%), were reported to have defective tonsils, i. e., either enlarged, submerged, or diseased. The percentage ranged from 37 per cent in Nodaway County to 54 per cent in Johnson. (At the time of the Johnson County survey, an unusual number of children were suffering from colds, which possibly influenced the findings as to tonsils.) Adenoids, being located in the rear of the nasal passages above the soft palate, cannot be seen by the examiner as can the tonsils; and because an examination with the fingers or a mirror is out of the question in the schoolroom, the physician must base his report upon symptoms, such as shape of the nose, mouth-breathing, voice resonance, etc. Different physi- cians vary in their standard of judgment regarding adenoids even more than regarding tonsils. Some report adenoids probable whenever the tonsils are enlarged, while others make an affirmative report only when the adenoid is so greatly enlarged that it can be seen hanging down into the throat; in one county the examiners reported practically all the mouth-breathers to have adenoids, and in another, less than two-thirds. Consequently, figures summing up the work of different examiners are ill-defined. In the whole survey group of grade pupils, one-third were reported to have adenoids either suspected, probable or manifest. Adenoids and tonsils are similar glands of what physicians call lymph- atic tissue, growing in different parts of the throat. As long as they are normal, no harm will come from them; but unfortunately they are often abnormal. Then they may do harm in two ways: (1) By becoming so over-grown that they block the breathing passages, or (2) by harboring chronic "nests" of germs and pus, thereby poisoning the body. It so hap- pens that adenoids more commonly misbehave in the former way (hence their frequent association with mouth-breathing), and tonsils in the latter (hence "diseased" tonsils); but otherwise there is no essential difference. In children, if one of these glands is unhealthy, the other is apt to be likewise. If the condition is such that it is evidently harming the child, either by obstructing his breathing, or by causing frequent head-colds or sore-throats, or by pus-poisoning, the removal of the offending gland usually will benefit the child. Mouth-breathing was observed in two-ninths of the children examined, ranging from 19 per cent of Johnson County children to 27 per cent of those in Harrison County (the attempt being made not to count children in whom the condition was merely temporary, due to a cold). Eighty per cent, on the average, of these 409 mouth-breathers were judged by the examiners to have adenoids. Some of the remainder were found to have obstructions in the front nasal passages (usually enlarged turbinates); but so few physicians made nasal examinations that no figures were compiled on this point. Among young children, over-grown adenoids are so far the most common cause of mouth-breathing that a child who habitually breathes through his mouth should always be suspected of having adenoids. Whatever the cause may be, breathing through the mouth is an unwhole- some condition, a danger signal of something wrong with the nose or pharynx, which calls for action. Fortunately it can be remedied if taken early enough. If allowed to run on too long, the breathing passages them- selves may fail to grow and become permanently deformed. Similarly, the evil effects of poisoning from diseased tonsils and adenoids may become so serious as to be beyond repair if neglected too long. In this connection, the number of children who had had these glands removed is of interest; viz., 74, adenoids, and 73, tonsils. This is 11 per cent of those reported to have enlarged adenoids, 9 per cent of those re- ported to have defective tonsils. The tonsil removal was found to have been complete in three-fourths of the cases. EYESIGHT. — In order to save the time of the examining physicians (who, with one exception, were not eye specialists), routine Snellen vision tests were made by the survey workers. Children and teachers were also questioned as to symptoms of eyestrain; and the results of the vision tests were considered in connection with such indications of strain. It is quite possible — as was strikingly illustrated early in the survey — for a child to make a good distance vision test, and nevertheless have serious trouble with his near vision. On this basis, 1,876 children were examined. Forty-five (2%) wore glasses. Sixty-one per cent had apparently normal eyesight; 8 per cent had questionable eyesight (questionable symptoms, with no definite indica- tion of defect) ; and 29 per cent gave evidence of more-or-less defective eyesight, uncorrected by glasses. With the exception of Greene County, which had only 16 per cent defective, defective vision was remarkably uniform in occurrence in the different counties. It was 6 per cent more prevalent among town than among rural children. If the records are classified simply on the basis of Snellen distance vision tests, without regard to other indications of eyestrain, we find that nearly one-fifth (19%) of the children made a test below standard (20/30 or worse) with one or both eyes. This percentage, also, was much lower in Greene County than in any of the others. Poor tests were made by 3 per cent more of town than of rural children. The close connection between eyesight and school progress was illus- trated by one of the survey children. In spite of being able to read the distance test chart correctly, his eyes were so poorly adjusted to close work that reading or writing was extremely painful; naturally, he was doing very poorly in his lessons. As a result of the survey, his parents were persuaded to have him examined by an oculist and to get glasses for him. His teacher reported that within two days thereafter, there was a remarkable improvement in his work. Disregard of proper lighting was much in evidence in the school rooms where the survey was carried on. Windows in the front wall were seen in a few rooms; but the most common mistake in arrangement was the old-fashioned box-car schoolhouse with windows along two opposite sides, resulting in crosslights. Blackboards at the front of the room were often so poorly lighted as to be difficult for the pupils to see. Some rooms were so dark, especially in cloudy weather, that the pupils could hardly see even their desk work. A common cause of such poor lighting is window-shades which will not roll, so that they cannot be raised on dark days or winter afternoons. In the darkest room seen — a room too wide for lighting from one side only, with the windows on one side cut off by an addition to the building and insufficient window space on the other side — twenty-three of the fiftynone pupils had defective vision, and half of those sitting on the dark side of the room were troubled in this way. HEARING. — Defective hearing was much less common among the chil- dren examined than was poor eyesight. Only 5 per cent had hearing def- initely below standard (20/25 or worse) and only 2 per cent were seriously below par (15/25 or worse). CERVICAL LYMPH GLANDS.— Enlarged lymph glands are of impor- tance as indications of infection which usually originates elsewhere; those of the neck are frequently associated with decayed teeth or diseased tonsils. Twenty-one per cent of the children examined had enlarged neck glands; 10 per cent, slightly enlarged, and 11 per cent, markedly enlarged. While there is always a chance that swollen lymph glands may be due to tuberculous infection — this is one of the common forms of tuberculosis in children— it is impossible to tell whether this is the case with any indi- vidual child by a single examination. All other possible sources of infection must first be removed, and then the glands watched for several months, before such a decision can be made. The fact that 70 per cent of the children with enlarged glands had decayed teeth, and 65 per cent had defective tonsils, points the moral that such defects should be remedied before other sources of infection are inferred to be present. MISCELLANEOUS DEFECTS.— The foregoing sections deal with the physical defects which were frequently found. Various others were reported in a few children, or by individual examiners. Only four examiners turned back the children's eyelids to look for "granulated lids" or trachoma. One physician in Greene County found thirteen cases of "granulated lids" among fifty-one pupils whom he exam- ined. Three examiners in Mississippi County discovered fifty-one such cases among 152 pupils. (These latter physicians used the terms "granu- lated lids" and "trachoma" interchangeably.) Ninety-eight pupils in the different counties were reported to have some abnormality of the heart.. Forty -one were reported as too rapid (in some cases accompanying enlarged thyroid), twenty as irregular, twenty-one as showing a murmur, and four as hypertrophied. Seventy-eight were found with some impairment of the lungs; forty- three of these were "rales," nine reported as "bronchitis," four "dullness," four "bronchial breathing." Seventy-seven children were mentioned as having a poorly developed or abnormally shaped chest. II. High School Pupils. A limited number i (364) of high, school pupils were included in the physical examinations because of their desire and that of the teachers that they might have that privilege. The younger children always were given the preference whenever the available medical or dental service was limited. The results of these examinations are of interest in comparison with those for the grade pupils. It must be remembered that high school pupils represent a picked class in comparison with grade school pupils. Children who are in really poor health are rather unlikely to go on into the high school; and as a general rule, the parents of high school pupils are those of the community best able and most likely to give their children a good chance physically — to have physical defects corrected, for example — as well as mentally. In view of this, a marked superiority in physical condition of high school pupils might fairly be looked for. But so far as this small group is concerned, though some superiority was in evidence, it certainly was not great. WEIGHT. — Fourteen (14) per cent of the high school pupils were 10 per cent underweight, as compared with 20 per cent of grade pupils. TEETH. — Forty-three (43) per cent had unfilled decayed permanent teeth, as compared with 50 per cent of the older' grade pupils (those who had passed their twelfth birthday). However, this difference is evidently due to the fact that a larger proportion of those high school pupils whose teeth needed dental care had received it, rather than to intrinsically better teeth. In other words, of the "over-twelve" group of grade pupils, 35 per cent still had normal permanent teeth (i. e., teeth which had never decayed) ; but only 24 per cent of the high school pupils had such teeth. This is about such a deterioration as might be expected from the greater age of the high school group. The survey findings for the different groups may be conveniently summarized as follows: PER CENT OF PUPILS HAVING PERMANENT TEETH AS SPECIFIED. Normal (no decay) Decayed all attended to 11.5 14.6 33.0 Decayed partly attd.to Decayed no work done Grade pupils: 12 years or over 41.7 35.2 23.8 9.7 12.9 23.4 37.1 37.3 19.8 l In only three counties, Johnson, Harrison, Livingston, were as many as fifty high school pupils examined. TONSILS AND ADENOIDS. — A somewhat smaller proportion of high school pupils than of grade pupils were found to have defective tonsils: to-wit, 38 per cent as compared with 45 per cent. The difference in regard to adenoids seems to be much more striking — i. e., 13 per cent of high school pupils reported affirmatively as against 38 per cent of the younger children. But the fact that in Johnson County, where the nose-and-throat examination of high school pupils was made by a specialist, one-third (35%) affirmative reports on adenoids were made, throws considerable doubt upon the much lower proportions reported in other places for the high school students. However, less than half as large a percentage (10%) of the high school group were found to be mouth- breathers, as of the younger children (23%). Since these figures were made on the same basis of non-medical observation, they are fairly com- parable, and corroborate the averages of the physicians' findings, as given above. Both agree with the common opinion of physicians that obstructive adenoids do have a tendency to shrink as the child grows older, though often leaving bad effects behind. There were indications that a considerable proportion of mouth-breathing among high school pupils was due to enlarged turbinates and other nasal obstructions, rather than to adenoids. EYESIGHT. — The total proportion of defective eyesight, including pupils wearing glasses, was practically the same for the two groups (32% in the high schools, 31% in the grades). But owing to the fact that more of the high school pupils were wearing glasses, the percentage of uncorrected defective vision was reduced to 22 per cent as against 29 per cent in the grade schools. HOME SANITATION. As part of the survey home-records, certain information about sanitary conditions of the home was secured, covering crowding, water supply, toilet facilities and screening. These data cover 825 homes; 247 in the villages and 578 in the open country. No home records in the open country could be secured in Harrison County. HOME CONGESTION. — On the whole, crowding is not a serious matter in the territory of the survey. An average of two or more persons per room in the dwelling is a commonly accepted standard of over-crowding. On that basis only 11 per cent of the families visited were found to be living in congested quarters. Very few cases of extreme crowding — whole families living in one room, for example — were found. The greatest amount of congestion was in Mississippi and Greene Counties (22% and 17%); in all the others, less than one-tenth of the families were living two or more to a room; in Nodaway County only three out of eighty. Crowding was a little more common, comparatively, in the villages than in the open country, but the difference was not marked. (The question of congested sleeping quar- ters will be taken up later.) WATER SUPPLY.— The kind of drinking water used proved to be mainly a question of local possibilities and custom. Wells of one kind or another furnished the drinking water for three-fourths (78%) of the families visited; cisterns for one-fifth (19%); and springs for comparatively few (3% or about 1 in 35). Drilled wells were the commonest source in Greene and Harrison Counties; dug wells in Johnson, Nodaway and Living- ston Counties; driven wells in Mississippi County. Notation was made of any circumstances — e. g., nearness of stables or privies, slope of surface toward the well, waste water standing around the top of the well — which would create a presumption that contamination of drinking water might occur. Such conditions were, naturally, seldom found to cast suspicion on drilled wells, which are, as a rule, secure from surface contamination except in case waste is allowed to seep down around the casing; they comparatively seldom affected cisterns— i. e., practically only when the cistern wall was known to leak and admit ground water. On the other hand, the defects above mentioned were observed rather often in the case of dug and driven wells. Carelessness about the location and surroundings of the source of drinking water varied greatly in different counties. In the three northern counties, such conditions were observed at less than 10 per cent of the homes visited; in Greene and Johnson Counties, at 15 per cent and 13 per cent respectively; and in Mississippi County, at 29 per cent. Mississippi County is so low and level that drainage is extremely poor. Until drainage ditches were dug, much of the land was swamp; water stands on the surface after any hard rain. Practically all the houses are built on piles to keep them out of the wet. Obviously, this state of things, combined with the ubiquitous surface privy, gives every opportunity for well-contamination, especially as almost every family uses a driven well, the casing of which passes through no rock. In the sandy districts, such wells are commonly only from 15 to 20 feet deep, and there is ground to suspect that any contamination existing on the surface could easily reach the intake of the well. 10 In the gumbo-clay sections of the county, wells have to be driven much deeper — 60 feet or more — and the soil is almost impervious. But, on the other hand, unless unusual care is exercised, a mud-puddle of waste water forms and stands around the foot of the pump, and such puddles around the family's drinking-water pump are often converted into hog-wallows by the stock. There seems no good reason why seepage from such a wallow could not follow the casing to its opening, even if the soil does "hold water like a cup." In this connection, it is noteworthy that only in Mississippi County did the survey workers come upon patients sick with or just recovering from typhoid fever in the families visited. Another question about the water supply which is of importance to sanitation is its accessibility. If water must be carried or hauled a long distance, it is not humanly possible to provide for as many baths, or tooth- brushings and hand-washings, for that matter, as if a plentiful supply can be drawn in the dooryard, or from a kitchen pump or faucet. There are rural districts in the United States in which water must be brought long distances to many farm houses. In this respect, rural Mis- souri, so far as this survey shows, is fortunate. Practically all of the village homes and 97 per cent of the open-country homes had water within 200 yards; four-fifths (81%) of village homes and five-eighths (62%) of country homes had water either inside the house or within 25 feet. About one in eleven village homes, and one in twelve country homes had water inside the house. In the open country, the percentage varied from 2 per cent in Mississippi County to 19 per cent in Nodaway; the northern counties far outstripped the southern ones in this respect. Among village homes, however, Livingston County fell far behind. There was no indication of different economic conditions from those in Harrison County (practically neighboring), so that the difference between the two in regard to water in the house, 3 per cent as compared with 13 per cent, must have been due mainly to difference in standards of comfort. Of the forty-nine country families who had water in the house, half (24) had running water, and half (25) had only a kitchen pump. Ten of the twenty-four (1.7% of the total) had complete plumbing equipment, including water-closet and bath with running water and drain. Nine of the twenty-three village homes having inside water (3.7% of the total) had likewise the complete equipment; these were the only ones having any running water. TOILET FACILITIES. — As previously indicated, very few of these homes had water-closets; to-wit, 2 per cent in the country and 4 per cent in the villages. The largest proportions (6 and 7%) were found in rural Nodaway County and in the villages visited in Harrison County. No example was found of any of the modern types of sanitary privy, built with septic tank. Nine-tenths of all the homes visited had one of the two ordinary types of privy; either what is known as the "pit" privy, built over a hole in the ground, or the "surface" privy, in which excreta are deposited on the surface. In the three northern counties, pit privies were prevalent, while in the southern counties — especially Greene and Mississippi — they were practically unknown. Of the two types, it seems probable that the surface privy would be 11 the more apt to pollute surface water in its neighborhood. Furthermore, it is much oftener built open-in-back, with the result that chickens, rats and other scavenging animals may take part in spreading any contagion that may occur. Such open-backed privies were found at one-fourth of the country homes visited, but seldom in the villages. Finally, there was a small proportion of country homes in each county — rising to a large proportion in Greene and Mississippi Counties — which had no toilet facilities whatever. (This condition also was practically absent in the villages.) In Mississippi County 15 per cent, and in Greene County 20 per cent of the open-country homes visited had no place except the barn or the hen house for the deposit of excreta. Such a state of affairs is astonishing in a community as generally progressive as Greene County. In one school district visited in that county more than half the homes had no toilet. One home, in another district, of apparently good standards, had no "out house," although it had a newly built garage. SCREENING. — The need for screening the house is well realized in all the counties visited, but better heeded north than south of the Missouri River. All three of the northern counties showed more than four-fifths of the homes completely screened, with Nodaway in the lead, while the proportion in the three southern counties varied from three-fifths to two- thirds. This is, of course, unfortunate because of the fact that both flies and mosquitoes are worse the farther south one goes. Especially in Mis- sissippi County, where malaria is still prevalent, mosquito protection would be a real health measure; yet here were found the largest number and proportion (9%) of homes entirely unscreened. Entire lack of screens was rare in the southern counties, and almost unknown in the northern ones. Broken screens and incomplete screening, it is true, are of little practical service; but at least they indicate an attempt at sanitation and comfort, and a possibility of improvement. CORRELATION WITH PHYSICAL CONDITION.— An attempt was made to find out whether a better or worse health environment in the home would be reflected in better or worse physical condition, as indicated by deviatijn from standard weight; but in general, no such relationship could be shown. In two counties (Harrison and Mississippi) the proportion of 10 per cent underweight children was least in the most healthful homes and greatest in the most unhealthful; but neither in the other four counties nor in the average for the whole six did the figures come out that way. For the open country, the children in the distinctly unsanitary homes made the best showing as to their weight. 12 PERSONAL HYGIENE. Information about personal hygiene was obtained for 1,483 children, of whom 1,071 lived in the country and 412 in villages. All these were pupils in the grade schools. SLEEP, (a) Bedroom Ventilation. — The old-fashioned fear of night air as such has practically disappeared from rural Missouri, if this survey gives a fair sample. Only one child was found who slept with closed win- dows throughout the year; the custom in this case was due to a grand- mother, with whom the little girl slept, who did not approve of open windows. On the other hand, the appreciation of fresh, moving air, at all seasons, has still far to go before it completely wins the day. Almost half of all the children for whom reports were secured were acknowledged to be in the habit of sleeping with closed windows in the winter. Some of these, it is true, probably got much fresh air, as was often claimed, from loosely-built windows, floors and walls. Still, there was a real aversion to open windows in cold weather on the part of many parents and children. The belief is common in these communities that it is unhealthful to sleep in a room where there is a fire; but beyond that, no reason is acknowledged for not following the dictates of comfort and keeping as warm as possible. Nodaway County leads in appreciation of fresh air as well as at many other points. Four-fifths (80%) of Nodaway County survey children slept with Windows open the year around. Livingston, Harrison and Johnson Counties follow with 68 per cent, 64 per cent, 56 per cent respectively. Greene and Mississippi come at the end, with only 42 per cent and 23 per cent of winter-time open-window sleepers. In Mississippi County it must be admitted that there is an unusually large proportion of houses which hardly need open windows in order to secure ventilation; but, on the other hand, the winter climate there offers the least excuse for shutting up as tight as possible. (b) Crowding in Bedroom. — An appreciable amount of bedroom crowd- ing was reported, to a large extent due to choice rather than to necessity. That is to say, parents often keep two or three children in the room with them at night, when there is plenty of room for them to sleep elsewhere. That this is the case is shown by the fact that over half (55%) the chil- dren actually did sleep in the room with two or more other persons, while in only about one-fourth (.28%) of the households would this have been neces- sary if the members had been evenly distributed among the available bed- rooms. Or, going further, 11 per cent of the children slept with four or more others in the room, while all but 4 per cent of the homes had bed- rooms enough to make such crowding presumably unnecessary. In spite of the fact that Nodaway ranked first in absence of general house-crowding and Mississippi County ranked last, these two counties stand together at the bottom, on the score both of homes with an average of at least five persons per bedroom, and of children sleeping with four or more others in the room. The explanation of this is probably that in the larger dwellings of Nodaway County not so many rooms were equipped and used as bedrooms as might well have been, again a matter of choice rather than necessity. 13 It is notable that 6 per cent of all the survey children slept with four or more others in the room with the windows closed in winter. This figure was, again, considerably higher in the southern than in the northern coun- ties, rising to 13 per cent in Mississippi County. The ideal sleeping arrangement would be that each child should have a room to himself; this was true of only one-eleventh of the survey children. Failing that, a separate bed for each child is desirable, and was provided for about one-fifth of the total. Probably no serious objection exists to two children sleeping in one bed, and this was the plan followed in the case of more than a third (35%) of the children. The common arrangement (reported of nearly another third) of having a child sleep with one of his parents, or a young child with an adolescent brother or sister, is distinctly less advisable. Three or more sharing the same bed creates a condition unquestionably unfavorable to quiet, wholesome sleep, yet one-seventh of all the survey children slept with two or three bed fellows (often, one of them an adult). On this count, Mississippi, Johnson and Nodaway Counties fall below the average; Mississippi County was the worst of the three. There was, on the whole, somewhat less crowding, both of bedrooms and of beds, in village than in rural homes. (c) Hours of Sleep. — Probably authorities would agree that eleven hours up to eight years of age, ten hours up to twelve years, and nine hours during the rest of the growing period, is a fair estimate of the amount of sleep needed by school children. Using this standard, we find that nearly two-thirds (64%) of the youngest group of survey children — those under eight years old — failed to get the necessary eleven hours' sleep. On the other hand, nearly two-thirds (65%) of the next older group— between eight and twelve years old — met the requirement of at least ten hours' sleep; and seven-eighths (87%) of those between twelve and sixteen years old had at least nine hours' sleep. (It should be remembered that these figures are based on parents' state- ments.) The fact that the youngest children are the ones most often getting inadequate sleep, agrees with the observation of the interviewers, that, as a rule, no attempt was made to fit children's time of going to bed to their ages. Customarily, in these families, all children went to bed at the same time; in most families, the children stayed up until the grown-ups were ready for bed. Any adjustment of sleep to age was customarily made at the other end by allowing the younger children, whose help was not needed with the work, to sleep later in the morning. That there was some such adjustment is shown by the figures; to-wit: on the average the younger children slept a little longer than the older ones. There was a decrease in hours of sleep of about an hour between the "under eight" and the "fourteen to sixteen" group, but this difference was by no means enough to counter- balance the greater sleep-needs of the younger children. Through all the age-groups, the rural children had slightly shorter hours of sleep than town children, and as a result more of them fell below the standard. This is in spite of the fact that practically all of the records were taken at the time of year— from October through April— when nearly all farm families sleep later in the morning than they do during the months of rush work. If records of sleep were taken during the summer, the 14 country children would undoubtedly make a much poorer showing than they do from these winter records. On the whole, country families kept earlier hours, both for going to bed and for getting up, than village families. This is distinctly to the advantage of the rural children, since they sit up with their parents in any event. On comparing the various counties, on the basis of the proportion of all children under sixteen years old who lived up to our standard of sufficient sleep, Mississippi and Greene Counties appear once more with the worst records; Harrison County with the best record for town children, and Nodaway for country children. CLEANLINESS, (a) Bathing. — At least one bath a week in winter and two in summer may be taken as a reasonable standard of cleanliness. By "bath" is meant an all-over wash, not necessarily in a tub; that can be managed in homes without bathtubs, even though it may take some planning in winter time. The only really serious difficulty comes when the home is badly overcrowded; and, as we have seen, such conditions were rare in the territory covered by the survey. Taking all counties together, seven-tenths of rural children and eight- tenths of village children were reported to get at least a weekly bath through the winter. The proportions vary in the different counties, however, from three-eighths (37%) in Mississippi County and seven-tenths (69%) in Greene County to over eight-tenths in the other four counties. Again we find Greene County and especially Mississippi County children falling below the average. Livingston County heads the list in regard to winter bathing (89% weekly bathers). A little more than one-fourth (27%) of all children were reported as taking a bath less often than once a week in winter; mostly these children bathed every two weeks, or once a month, or irregularly. Only twenty-one (1.4%) in the whole survey were acknowledged to take no baths in the winter; fifteen of these were in Mississippi County (5.5% for that county). On the other hand, sixty-three (4.3%) children were said to take two or more baths a week. The comparison with our standard for summer (at least two baths a week) is even more favorable, "passing" nearly eight-tenths of rural chil- dren, and more than eight-tenths of village children. Moreover, many of these children exceeded the standard; about one-fifth of the total took daily baths in summer, and a great many took as many as one every other day. For the summer season, Greene County falls to the bottom of the list (61% meeting the standard), with Mississippi County second (72%), and Harrison County in the lead (92%). (b) Eating With Clean Hands. — This is probably the most important of all habits of cleanliness, from the point of view of preventing the spread of contagious disease. Health authorities are convinced that contagion is often carried from the mouth of a person who has or has had the disease to his hands or to some object, then to the hands of another person, and thus to his mouth, either directly or by way of his food. As a matter of fact, washing the hands before meals is a cardinal point of good manners with country folk, no matter whether its importance as a health protection is understood or not. In practically every one of these Missouri families visited, the children were required to wash their hands 15 before coming to the table. So uniform was this report that no figures were set down on the point. Naturally, mothers spoke of differences between one child and another, as to whether he or she could be trusted to wash without a reminder; but there was seldom any doubt about the enforcement of the rule. When it comes to the question of whether children wash their hands before eating at school, that is "a horse of another color." Mothers usually expressed doubt about it; and the investigators' observation was that in most cases it certainly was not done. Most schools had no means of washing except at the pump; a few had a wash basin; in still fewer did the teacher establish a routine of hand-washing before the noon meal; in only one school were any individual towels seen in use. Under the circumstances — i. e., with a common basin and usually either common soap and towel or none — it seems questionable whether much would be gained, from the health point of view, by urging the children to wash at school. It is difficult to see how practical and sanitary means of washing could be provided in the absence of running water. (c) Cleaning Teeth. — As might perhaps have been anticipated, parents reported much more interest in keeping the teeth clean on the part of girls than of boys. Almost twice as large a proportion of girls (42%) as of boys (23%) cleaned their teeth regularly at least once a day. Likewise, only half as large a proportion of girls (11%) as of boys (21%) never cleaned their teeth. Among both boys and girls, Greene County children made the poorest record for regular teeth cleaning and Nodaway County the best. But while Mississippi and Greene County boys were especially remiss to the extent of never brushing their teeth (44% in Mississippi County never did so), it is surprising to find that among the girls, those of Johnson County were most prone to such neglect — followed by Mississippi and Greene. In Harrison County all the girls and practically all the boys were reported to clean their teeth at least occasionally. The record for regular cleaning of teeth is about the same for town and country children; but the former did much better than the latter on occasional cleaning at least. Only 9 per cent of town boys as compared with 26 per cent rural, and only 5 per cent town girls as compared with 13 per cent rural, neglected their teeth entirely. 16 DIET.i A child's diet is one of the most important influences in determining his physical condition, and at the same time one of the most difficult mat- ters about which to secure satisfactory information. In these surveys, the attempt was made to secure a statement of what each child had eaten during the preceding twenty-four hours, unless for some reason that period was not fairly representative of the child's eating habits. It proved possible in nearly all families to secure reports of the kinds of food eaten (so long as the previous twenty^four hours could be taken), but not of quantities except in the case of milk drunk. DIET GRADES. — In conference with the food experts of the agricultural extension service of the University of Missouri and with the head of the Department of Home Economics, the following standards were worked out for classifying these diets: GOOD: No coffee nor tea. Pie not more than once a day, and none under 12 years. Meat not more than once a day. Biscuits not more than once a day. No meal exclusively of sweet food. Must include: 1 pint milk (milk used in cocoa, milk soups, custards, milk gravy, etc., may be included in estimate). Cereal. Fruit or vegetables at least once a day. (Preserves, jam, jelly, etc., not counted as fruit; white potatoes, dried beans and peas, not counted as vegetables; canned vege- tables and fruit are included.) FAIR: Those diets which fall between GOOD and POOR. Must include at least 1 cup (% pint) of milk if under 12 years. POOR: Coffee or tea. Insufficient milk: No milk at all — any age up to 14 years. Less than 1 cup — under 12 years. Negligible at 14 years or over, if butter is used, or milk in food. (Condensed or evaporated milk counted as none.) Meat three times. Biscuits three times or to the exclusion of other bread. Excessive sweets. Pancakes under 14 years. Frequent and irregular "piecing." Any meal omitted or practically omitted. INADEQUATE: Clearly insufficient nourishment. (The presumption is that any meal omitted will make the diet inadequate, unless the contrary appears.) On this basis, out of 1,431 children under 16 years old for whom diet records were secured, only fifty-six, or one in twenty-five, could be counted l The discussion of diets is confined to children under 16 years of age. 17 as having a good diet. Yet the standard for a "good" diet cannot be regarded as too exacting; in several respects, it falls short of what a child ideally should have. Nor does it require anything which is out of the reach of country families of limited means. Summary of diet grades: Good 4% Fair 29% Poor ' 63% Inadequate 4% To put the matter in another way, approximately one-third of all chil- dren had good or fair diets, while two-thirds had poor or inadequate diets. Mississippi County has much the worst diet record — 90 per cent, poor or inadequate. Livingston County has the best record (47% good or fair), fol- lowed in order by Nodaway, Harrison, Greene, Johnson. The question at once arises, what was the matter with all these chil- dren's diets? As has been said, 4 per cent of the total (56 in number) were judged to provide an insufficient amount of nourishment (not always, by any means, because of poverty). Among the 912 diets which were graded as "poor" nearly half (48%) fell into that class because of more than one of the several specifications given in the standard. On this score, also, Mississippi County diets made a very bad showing; not only were nine- tenths (89%) of them poor, but of these nine-tenths, two-thirds were poor on two or more counts, and three-eighths on at least three counts. Taking all counties together, insufficient milk was the commonest reason for assigning a poor grade to the village diets; excessive eating of biscuits was the commonest cause in the rural homes, followed by excessive meat, coffee, and insufficient milk with nearly equal frequency. These four causes were dominant in both town and country; in the country, each of them overshadowed all other causes combined. However, it was only in the three southern counties, especially Mississippi and Greene, that eating biscuits was a common failing; in the three northern counties biscuits fell back among the comparatively unimportant defects of diet. About one-ninth of all the poor diets were in that grade only because of including coffee; another one-ninth, only because of insufficient milk; and a third one-ninth, only because meat appeared too often. It is interesting to find that the younger children (those under 10 years old) had a higher proportion of good and fair diets (36%) than their older brothers and sisters (only 28% for those between 10 and 14 years old). What the reasons for this difference may be, does not clearly appear from these records. On some of the points determining a poor diet the older children make a poorer showing than the younger ones, while on other points the reverse is the case; the items on which the older children make a markedly poorer showing are coffee drinking and the excessive eating of meat. On the basis of general impressions, the statement might be ventured that the older children are left somewhat more than the younger ones to their own devices as to what they shall eat: and that children under four- teen are too young to exercise good judgment in that matter. Poor diets were by no means confined to unsanitary homes; more than half the children in the most healthful homes had poor diets. Nevertheless, there was some correlation between general health standards and a whole- I 18 some selection of foods. To be specific: if the homes are classified on the basis of general sanitation, we find that nearly half (46%) of the children in the highest grade homes had good or fair diets; not quite one-third (29%) of those in the medium-grade homes had such diet; and less than one-fifth (19%) of those in the distinctly unsanitary homes. The children's weights show some relationship to their diet, though not very marked. The percentages of seriously (10% or more) underweight children in the different diet groups are as follows: Good diet 14% Fair diet 18% Poor diet 19% Inadequate diet 45% That nearly half the children with inadequate diets should be 10 per cent or more underweight is not so surprising as that the other half should have escaped that condition. Probably this is due to the fact that with the latter group, the deficient diet was only recent or temporary. On the other hand, we find that four-fifths of the children who were excessively over weight (20% or more), had poor diets. This is not at all surprising, since many of the poor diets erred through excess of certain types of food — e. g., of sugar and starches — -rather than through deficiency of food. Only one child on good diet was found to be excessively overweight. USE OF MILK. — One of the most important items in the diet of a growing child is a liberal amount of milk. Dietitians and physicians who have made a special study of the feeding of children are convinced that from two years old up to the end of the growing period, a child ought to have at least a pint of milk daily; many hold that the younger children ought to have at least a quart. Milk is important for several reasons: as one of the chief sources of lime for growing bones and teeth; as one of the most wholesome sources of protein for growth and repair of muscles and other tissues; and as one of the chief sources of vitamins, the newly dis- covered regulating substances necessary to growth and health. One of these vitamins, fat-soluble A, is more abundant in the fat of milk — and therefore in butter and cream — than in any other common food. (Because heating destroys more or less of the vitamins, evaporated milk is of less value to a child than is fresh milk; "condensed" skim milk has also lost its valuable fats, and contains more sugar than is wholesome as a steady diet.) For this reason, a pint of milk was made one of the requirements for a good diet. Up to 12 years of age, at least a cup of milk was required for even a fair diet; and some milk, up to fourteen years. Three-quarters of the village children and four-fifths of the country children in the survey had some fresh i milk or cream in the day's diet. Approximately half the children (somewhat more in the country and less in the villages) had milk to drink; a few additional had cocoa or soup made of milk. About one-fifth used only milk or cream as "trimming" on cereal or fruit, or in coffee or some other drink; these obviously got con- siderably less milk than the former group. Out of the remainder, a few— 5 per cent in the villages, but only 1 per cent in the country — used con- densed or evaporated milk, not to drink, but as flavoring for coffee or cereal, i As distinguished from condensed or evaporated milk. 19 etc. This leaves 18 per cent of the total who had no milk or practically none. The majority of these, however, did have butter, and therefore secured one of the valuable elements of milk. A few children got an almost negligible amount of milk cooked in such foods as gravy or custard (usually gravy only); and finally there remain only 5 per cent (1 in 20) who had no milk, cream, nor butter whatsoever. To recapitulate — the percentages of country and village children using milk in various forms are as follows: Country Village Milk to drink 56.6 46.7 Soup or cocoa made of milk 4.4 5.9 Milk or cream as "trimming" 20.6 22.7 Total of above... 81.6 75.3 Condensed or evaporated milk only (with or without butter) 1.1 4.8 Butter only 10.3 12.5 Milk cooked in food only (no butter) 2.3 2.8 No milk, cream nor butter 4.7 4.6 Over nine-tenths of the country children in Nodaway and Livingston Counties had some fresh milk or cream; six-tenths of them had milk to drink. The smallest proportion of country children getting any fresh milk or cream was in Mississippi County (68%). Of town children, the smallest proportion drinking milk or having any fresh milk was in Johnson County. There was a steady drop in the proportion of children drinking milk, from 60 per cent among those under 8 years old, to 48 per cent among the 14-to-l 6-year-old group. In most cases, complete absence of milk and butter from the diet was due to an actual lack of milk in the home. (This was true of sixty-one children out of sixty-seven. ) And every family but one which used con- densed or evaporated milk, did so because they had (and usually could get) no fresh milk. Among the children who ate butter but got no milk nor cream, about a third belonged to families where there was lack of milk; the others apparently might have had at least a little milk if they had wanted it. Altogether, only about one-tenth of the records show that a child was deprived of milk because there was none or not enough to go around. Nat- urally, this percentage was twice as high in the villages as in the country (16% as compared with 8%). In a great many cases, failure to drink milk, or even to eat milk or cream with other food, was acknowledged to be due to the child's dislike of milk. In a few cases, it was due to a belief that milk disagreed with the particular child. Instances were not infrequently seen where the adults of the family drank milk but the children did not. In this connection, it is pertinent that nine-tenths of country families kept at least one cow (most commonly, from 2 to 4 cows), while only two- fifths of village families kept a cow. Yet none of the towns included in the survey was large enough to make it really difficult to find space for a cow; and in several of them, it was reported to be almost impossible to buy milk. Generally, there was no lack of butter for sale in these villages; but in one 20 or two towns the use of vegetable butter substitutes was common, mainly as a measure of economy. Such vegetable butters do not contain the vitamin which makes real butter so valuable. The use of separated milk (which is robbed of practically all its fat) for family consumption was rare except in Greene and Johnson Counties — the only ones having any number of large dairy herds — and was not common there. Outside of Mississippi County, more than half (59%) the children who drank milk, had whole mink at least part of the time; but in Mis- sissippi County, only one in thirteen drank whole milk. Most of the other children drank hand-skimmed milk, which is, as a rule, about half-skimmed. In Mississippi County, and to a less extent in Greene County, buttermilk was a favorite beverage with the children. Buttermilk is unquestionably wholesome, but contains only about half as much nourishment as whole milk. Only among the children who drank milk (with one or two exceptions), were any found who could be accepted as meeting the requirements for a good diet, i. e., that they should consume at least a pint of milk a day. In the country, three-quarters of the children who drank any milk, drank at least a pint; in the villages, about five-eighths drank that much. Out of all the country children for whom records were secured, two-fifths (42%) drank at least a pint of milk during the day; among the village children, three- tenths (29%) consumed that amount. In the country, the largest proportion drinking a pint of milk was in the 8-to-10-years group; in town it was much the largest in the under-8-years group. For the whole survey, Ave find that 39 per cent of the children consumed at least one pint of milk, and therefore met that requirement for a good diet. Nearly three-fourths (73%) met the milk requirements for at least a fair diet, while one-fourth (27%) fell below even that standard. COFFEE DRINKING.— Nearly one-quarter (24%) of the" survey chil- dren were reported as drinking coffee; the percentages varied from 34 per cent in Mississippi County, and 30 per cent in Greene County, to 18 per cent in Nodaway and 16 per cent in Harrison. This is a poor showing, espe- cially for the two southern counties. Coffee (and tea also, though to a less degree) contains a stimulating drug which should not be given to children until they have ' reached their full growth. The harm done by coffee is usually the greater, the younger the child. It is therefore encouraging to find that the younger children were somewhat less subject to this habit than the older ones. By ages, the percentages of children drinking coffee are: Under 8 years 17.7% 8 to 10 years 22.6% 10 to 12 years 24.6% 12 to 14 years 29.1% 14 to 16 years 31.4% Nevertheless, it is deplorable that one-fifth of the children even under 10 years old were allowed to have coffee. EXCESSIVE MEAT-EATING.— As a rule, both country and village fam- ilies in the territory of the survey are in the habit of having meat at every meal; no meal is considered complete without it. Through the winter and 21 early spring — i. e., the period covered by the survey records — "meat" is usually cured pork of some kind: ham, fat bacon, or perhaps sausage. As against this custom, authorities on the feeding of children have come to the conclusion that children should not have meat more than once a day; that if they have plenty of other protein food — e. g., milks and eggs — they get along very well without any meat at all. The diet records show that more than half (53%) the children ate meat more than once a day, and therefore failed to fulfill, in this respect, the requirements for a good diet. Furthermore, between one-fourth and one- fifth of them (22%) ate meat three or more times a day, and thereby threw themselves into the poor diet class. Meat was eaten to excess (3 or more times a day) by a larger proportion (one-fourth) of country children than of village children (one-sixth). Up to 14 years of age, there was a marked increase in excessive meat- eating as the children grew older. The percentages eating meat at least three times a day are: Under 8 years 15.7% 8 to 10 years 16.9% 10 to 12 years 25.6% 12 to 14 years 29.8% 14 to 16 years 26.0% In comparing the different counties, it is interesting to find that the counties whose records appear well above the average in avoidance of too much meat for the children are Greene and Livingston, where the records were taken in the spring. At that time of year, country folks are thoroughly tired of salt meat, their winter supply is often exhausted, and meat is frequently replaced by eggs in the dietary. Accordingly we find in these same two counties a much larger proportion of children eating eggs than in the other four. Between the four "winter" counties there is no signifi- cant difference as to eating of meat, and it is likely that the better showing of the other two counties would disappear if records were taken at the same season. BISCUITS. — As previously mentioned, biscuits are a staple article of diet in the three southern counties, and most especially in Mississippi County. In Mississippi County, five-eighths (62%) of survey children, and nearly as large a proportion of families visited, used biscuits to the exclu- sion of all other kinds of bread; seven-tenths of the children (69%) ate biscuits three or four times a day. In Greene County, a quarter (24%) ate biscuits at least three times a day, and one-fifth (19%) ate no other bread; in Johnson County, one-tenth (10%) of the children ate no other bread, and one-ninth ate biscuit three times a day. In the three northern counties, from eight- to nine-tenths of the diets contained no biscuits at all, while only three children (in Nodaway County) had them for three meals. In that part of the State, when hot biscuits were served at all, it was usually only once a day, as a special treat. The importance of this item lies in the fact that hot biscuits, even if skillfully made, are held to be unwholesome for children because biscuit dough is apt to form indigestible lumps instead of being readily crumbled in chewing, as is stale yeastbread or cornbread. Furthermore, if there is too much soda in biscuit, as happens not infrequently, that destroys vitamins. 22 Therefore, the food, experts who drew up our diet standards laid down the rule that no day's diet containing biscuits more than once could be consid- ered satisfactory. Accordingly, we find that in the several counties, the following percent- ages of diets would be thrown out of the "good" class on the ground of biscuits, if for no other reason: Mississippi County 86.5% Greene County 40.2% Johnson County 31.2% Nodaway County 8.8% Harrison County 0.9% Livingston County 0.9% PANCAKES. — For similar reasons, and for the additional reasons that the batter cannot be thoroughly cooked and that fried food is indigestible as a rule, pancakes are regarded as unfit food for children; yet we find about one in twenty (5%) of the children, even the youngest, eating them. Rather surprisingly, much more than this proportion of town children in Harrison and Johnson Counties, and of rural children in Nodaway County (13% — 12% — 8%) had pancakes in their day's dietary, while in the other groups pancakes appeared very seldom. PIE. — Of similar nature are the objections to children's eating pie; although pastry is not fried, it ordinarily contains enough fat to interfere with digestion of the flour. And pie, unlike pancakes, proved to be a com- mon vice in all counties. In Greene County, two-fifths (42%) of the chil- dren were reported as eating pie in the sample day — one-seventh of them (14%) twice during the day. In the other five counties, from one-fifth (20%) to one-fourth (28%) of the diets included pie at least once. There again, we have an unsuitable article of diet just as frequently permitted to the youngest children as to the older ones. EXCESSIVE SWEETS. — Comparatively few (only 4%) of the diets, as reported, could fairly be charged with being excessively sweet throughout; more than two-thirds of these were in Johnson and Mississippi Counties, with very few in the other four. But a considerably larger proportion. (12%) of children were allowed to eat some one meal made up entirely of sweet food. This is a habit which children will fall into readily if not watched; and. it . undoubtedly tends to upset the stomach and lessen appe- tite. Children should be carefully taught that sweets should come only as dessert at the end of a meal, after other food (not sweet) has been eaten. An excessive proportion of such all-sweet meals was reported in John- son and Mississippi Counties, and likewise in Harrison County. The preceding sections, except that on the use of milk, deal with faults in diet which may be called "faults of excess," consisting either in allowing children to have something which they should not have at all, such as coffee or pancakes, or in allowing them to have too much of a food like meat, which is all right if eaten in moderation. The other class of mistakes — "faults of deficiency" — consists of omitting from the diet certain foods which the child ought to have. As has been explained, milk is the most' important of these requisites. Others are wholesome bread (see under "Biscuits"); and butter, which, with the exception of the 5 per cent already spoken of who had neither milk nor 23 butter, nearly every child in this survey ate. Still other desirable articles of food, which deserve further discussion, are cereals, eggs, fruits and vege- tables. CEREAL. — Dietitians believe that a child's diet should contain some kind of cereal — i. e., a grain food other than flour or meal — every day. Those made from whole grain — whole wheat, whole rice, whole oats, whole corn — are the best, because they contain vitamins and other food elements that are lost in milling or refining. Home-cooked cereals are more valuable than prepared "breakfast foods," because they provide much more nourish- ment and cost much less. We find that nearly half the survey children ate cereal of some kind; in Greene, Harrison and Livingston Counties, the proportion rose to over half, while in Johnson and Mississippi Counties it fell to about one-third. The proportions were practically the same in town and country homes, and in the different age-groups. EGGS. — Eggs are highly recommended as food for children, particularly as substitutes for meat. As has been mentioned, eating eggs in the country — at least in rural Missouri — is largely a matter of season. In early spring, almost everybody eats eggs and eats them often (one child was recorded as eating six in one day); in late fall and winter, practically nobody eats them. Accordingly, we find that where the survey was made in the spring, most of the children had at least one egg a day (half in Greene County, nearly two-thirds in Livingston County). But in the other four counties, only from one-tenth to three-tenths of the children ate eggs. On this count — providing eggs in the "off" season — Mississippi County heads the list. FRUIT AND VEGETABLES.— Fresh fruit and fresh vegetables 1 are further types of food whose use depends largely upon the season. This is especially true of green vegetables. A growing number of families appre- ciate the value of fresh fruit sufficiently to buy oranges or sometimes apples and other "store fruit" when they have no home supply; but comparatively seldom do they buy "garden truck." Canned fruit is also much more common than canned vegetables; appar- ently this is due partly to the greater ease of canning fruit, and partly to habit. However, tomatoes are canned in large quantities, which is fortunate, because they are one of the most valuable vitamin-containing vegetables. Fruit preserved with sugar (preserves, jam, jelly, fruit butters) appears almost regularly on the large majority of country tables. While such fruit may possibly be more wholesome than none at all, it contains so much sugar that it cannot fill the place which fruit ought to hold in the diet; it belongs more with other "sweets" such as molasses and honey. Consequently such preserves are not counted as fulfilling the fruit requirements for a good diet. Five-eighths (62%) of the survey children ate some fruit (exclusive of preserves) during the sample day; one-sixth (17%) ate preserved fruit only; a little more than one-fifth (21%) had no fruit whatever. Of those who had fruit, nearly two-thirds (39%, or about three-eighths, of the whole) ate some raw fruit, while the others ate cooked or canned fruit only. l As noted under Diet Grades, the term "vegetable" in this discussion means vegetables other than white potatoes or dried legumes (peas, beans), both of which are staple articles of diet in rural Missouri. 24 In order to make sure of having all the kinds of vitamins (some of which may be destroyed by cooking), children should eat regularly some raw fruit or raw vegetables. That so large a proportion in this survey did eat raw fruit, is distinctly creditable in view of the fact that the survey was made mainly outside the fruit-producing season. In Greene County only, was any fruit (berries) coming to maturity at the time the records cover; and Greene County had next to the lowest pro- portion (23%) of children eating raw fruit. In Johnson and Nodaway Coun- ties records were taken in late fall and early winter, and show 58 per cent and 68 per cent of children eating raw fruit; this is accounted for largely by the fact that at that season fall fruit crops, stored for winter use, are available, though apples were somewhat scarce that year in Nodaway, and more families than usual had to buy fruit. In Harrison and Livingston Counties, where records were taken later in the year, but too early for spring fruits, the lower percentages — 38 per cent and 41 per cent — reflect the exhaustion of such stores. In all these northern counties, much more fruit was purchased than in the far-southern ones. The survey was carried out in Mississippi County at the same season as in Johnson and Nodaway Counties; yet, contrary to the findings in the two latter, only one in nine (11%) of the Mississippi County children was given any raw fruit. This is due largely to the fact that ordinary orchard fruits — apples, pears, peaches — grow poorly in that district. There is much less fruit than in other parts of the State, and what there is — berries, grapes, plums — comes earlier in the year, and is not available as raw fruit in the fall months. Farm housewives "put up" much of such fruit; but with their best efforts, less than half as many Mississippi County children had any fruit as in any one of the other counties. Fruit proved to be somewhat more plentiful in country homes than in villages, simply reflecting the fact that farmers have better chance to raise their own fruit supply than do villagers. When we come to the question of vegetables, we find a less favorable situation. Only 42 per cent of the children ate vegetables, as compared with 62% who ate fruit. And only 10 per cent had raw vegetables (lettuce, cabbage, celery, onions, etc.) as compared with 39 per cent eating raw fruit. It is interesting to find that 40 per cent of the Greene County children took advantage of early spring vegetables that can be eaten raw; while, as might be expected, in the winter-survey counties, raw vegetables were almost wholly absent. Mississippi County was second only to Greene County in utilization of raw vegetables, and stands far ahead of any other county in use of cooked vegetables,! thereby partly offsetting its scarcity of fruit. In the three northern counties, from one-fourth to one-third of the children ate some vegetable (other than white potatoes or dried beans); in Johnson County, two-fifths; in Greene County a little more than half; and in Mississippi County three-fifths. Rather contrary to expectation, we find that in Livingston County village children had vegetables about twice as often as country children; but in other places, the balance was the other way. 1 In this territory, sweet potatoes, turnips and pumpkins were the common fall vegetables; but many families had greens of various kinds. 25 In connection with the requirement for a good diet, that it must contain either fruit or vegetable (as defined above), we find that four-fifths (79%) of the total met this requirement. Among rural children, this proportion was highest (about nine-tenths) in Johnson and Nodaway Counties, and lowest in Livingston and Mississippi Counties. A distinctly larger propor- tion of village diets failed on this point, than of those in the country. In other words, we have another case where village diets failed through com- parative deficiency. REGULARITY IN EATING. — In addition to containing the proper kinds of food, a really satisfactory diet should be eaten at regular hours, as a rule three times a day. It proved to be impossible to get reliable reports about hours for meals, especially in country homes. Meals on the farm are ordi- narily regulated by sun and season and by pressure of work, rather than by the clock. When children are going to school, that fact in itself exercises a regulating influence on their breakfast and dinner hour; but supper hours tend to be irregular, especially at busy times. About frequency of eating, however, considerable data were gathered. In the first place, it was found that about three-fourths of country children ate something when they came home from school — almost always a cold lunch chosen from whatever was left from the family dinner. This practice was also reported of five-eighths of village children. Many of these children habitually ate what amounted to a fourth meal at that time. It is natural enough that children who have a cold dinner, perhaps none too well relished, and, it may be, a long walk to and from school, should be hungry on reaching home. Indeed, some of the more careful mothers made a practice of having supper ready for the children when they came home, which is often as late as five o'clock. But in most families, this is impossible; and if supper must be late, it is desirable that hungry chil- dren should have something to eat — if only it could be selected with more judgment than is usually in evidence. The best solution of the problem would seem to be that something hot and wholesome be planned and ready, to take the place of the all-too-frequent "bread and butter and meat and pickles" or "bread and jam" or "pie." The records of what was eaten between meals furnish another illustration of the unwisdom of letting chil- dren choose their own food. Secondly, eating at recess is a common vice, especially among country children who take their dinners to school. The survey workers saw plenty of evidence of the prevalence of this custom. Many mothers expressed ignor- ance about their children's habits in this respect; but of those country children for whom the question was answered, fully half were reported as eating at recess. Among town children, this habit was naturally much less common (reported of only one-eighth). So far as the records show, the eating at recess habit was distinctly more prevalent among the younger childen, and decreased as they grew older. However, there is only a slight decrease in the habit of eating after school. Eating at both morning and afternoon recess, as well as at noon, puts the child's eating times only an hour and a half apart; and, with a lunch after school, means that he eats at least six times during the day. This is unquestionably too often. Thirdly, a certain proportion of children — about one-sixth — were reported 26 as eating between meals at other times than above mentioned. Further- more, about one in sixteen or seventeen was reported as given to "piecing" — i. e., frequent and irregular eating between meals, at any or all hours. This habit was more prevalent among country than among village children. It is one of the worst possible habits in eating, and one of the most unques- tionable reasons for classifying a child's diet as poor. Even the parents who acknowledged this failing in their children were aware that it was an unheal thful practice; those who made any serious attempt to oversee a child's diet usually affirmed, with pride, that he was "not allowed to piece." Fourthly, a number of children, about one in twenty, were found to have omitted i one of the three regular meals, either as a more or less regular custom, or sporadically without any particular excuse. The meal most often omitted is breakfast; some children refuse to eat any dinner when going to school; supper is the one least often neglected. For a school child to leave out any one of his three regular meals is almost sure to result in insufficient food-intake, and extremely liable to cause malnutrition. When it is breakfast or dinner that is lacking, the child's system is robbed of its proper nourishment during the hours when he is most active, at study and at play, and his whole body is most in need of replenishment. The foregoing discussion applies to irregularity in eating during the school term. In Greene County, diet records for 120 children were secured after schools had closed for the summer; from these, we can get some idea of what the children do when not attending school. The records show a little more than half the children eating between meals. This habit de- creased markedly as they grew older; under 10 years old, five-eighths (62%) ate between meals, but beyond that age only three-eighths (37%) did so. SUMMARY. — With a few exceptions, the defects of diet noted in this report were not due to poverty. Some country families are poor to the extent of having neither cow nor garden; but it would be difficult to prove that poverty was the only, or even the chief, cause of the limited diet upon which such families live. In the main, it may be said that the difficulty lies in ignorance; first, as to what constitutes a wholesome, properly balanced diet for adult or child; second, as to the fact that certain foods which are harmless for .adults are unsuitable for children. Country people know that young ani- mals — chickens, for example — must be fed differently from full-grown ones; but they fail to apply this knowledge to their own children. A secondary factor is the tendency — by no means confined to the country — to allow children to do pretty much as they desire, to go to bed when they wish, to eat what and when they want. Good health can never be built up on that basis. Marvelously much can be accomplished in enlist- ing the child's co-operation to that end; but there must be some parental control in the background. l Either omitted entirely or reduced to practically negligible food — e. g., a cup of coffee only. 27 CONCLUSION. "What to Do About It." Whenever an unsatisfactory condition in human affairs is discovered, the question arises as to what can be done to improve the situation. That physical defects among children cannot be counted upon to cure themselves is demonstrated by the great number of defects found among young adults whenever they are examined in large numbers; for example, by the Army Draft Examination in 1917 and 1918, which showed that one-third of Ameri- can young men in the prime of life were physically unfit for military serv- ice. It should be remembered that the examining physicians at that time found that a large proportion of the disqualifying defects could have been prevented or cured if they had received proper attention during the boys' early years. I. Remedial Measures. We are confronted with an enormous number of remediable defects among Missouri children — now, as an actual present condition. What can be done about it? This is fundamentally a medical problem, and must be worked out in co-operation with the organized physicians of the State. With this in mind, the following suggestions are offered as a tentative outline of a plan to meet the situation: (a) Physical Examinations for all school children, to be extended to children under school age when practicable. (Many defects — e. g., decayed teeth and infected tonsils and adenoids — 'develop and need attention before the child reaches school age.) This is the logical first step, for we cannot expect to remedy defects until we know, specifically and individually, where they are. But it is to be looked upon as only the first step in an effective remedial program. If this work is to be done regularly and for all children, it must be paid for, as is done in all large cities; physicians must not be called upon to donate such an amount of service, no matter how public-spirited they may be. In rural Missouri, outside of the cities employing city or school physicians, the full-time county health officer plan seems the most feasible way to secure such service. It naturally would be combined with the supervision of health conditions in the schools, which many part-time county officers now undertake. Eleven Missouri counties now (June, 1922) have full-time health officers, and it is to be hoped that the list will grow rapidly. (b) Follow-up Work. — Most places which have tried physical examina- tions without "Follow-up" have found that they did not get very far. Dis- covery of defect doesn't help much unless it is corrected. And everywhere, there is a considerable proportion of parents who do not take any action unless someone personally persuades them to do so. This neglect may be due to inertia, to lack of understanding, to disinclination to give the child pain, or to a feeling of helplessness; but it needs personal contact and persuasion, in many cases, to overcome it. The logical person to perform this service is the school nurse (usually in the larger towns), or the county public health nurse for the open country. It is a big job, but the county nurses do manage to handle much of it. And where no medical service is available, a public health nurse can do a 28 great deal of good in examining school children, as well as in her other lines of duty. A public health nurse is an investment in health which no public-spirited or truly thrifty county should be willing to do without. (c) Children's Clinics. — Nevertheless, with the best follow-up work pos- sible, the problem has not been fully met, because there are everywhere some parents, more or less numerous, according to local economic condi- tions, who cannot afford the expense customarily involved in such remedial work as may be needed. This is where country children are distinctly worse off than city children. No matter how poor a city child's parents may be, the school nurse in a place like Kansas City or St. Louis can arrange to get his tonsils removed, or his teeth filled, at an institution carried on for that purpose. But in none of the counties of the survey — and they were by no means poor or backward as Missouri counties go — was there any organized service of this kind at the time the survey was made. Unquestionably it would have been possible to have individual children cared for through an appeal to the charitable impulses of individual physicians; but that is a very different thing. In addition, dental service, and even more, specialized surgical or ocu- list's service, commonly means for country people a journey away from home, often a journey of considerable length; this is an additional expense, which city folks do not have to meet. Judging from the survey experience, the smaller country towns (under 500 population) in Missouri seldom have resident dentists, and only a few have the service of a visiting dentist. Many country people are within practicable driving distance only of such small centers. This is even more true of the rougher parts of the State, not reached by the survey. While all the survey districts had available the service of general prac- titioners, only very few of these physicians were prepared to undertake surgical work. In four out of the six counties, there were nose and throat specialists at the county seat, equipped to remove tonsils and adenoids; in the other two, a trip to the nearest urban center (outside the county) was necessary for such an operation. In the same two counties, a journey was necessary to secure expert oculist's advice. (Of course, a good many people in all six counties patronized home-town or itinerant opticians, but that is another story.). In respect to such specialists' service, the survey counties probably averaged well above rural Missouri as a whole. Under these circumstances, Missouri citizens should give heed to the fact that other states are forging ahead of Missouri in providing for rural children. For example, Kansas is planning a campaign for adequate medical care for children throughout the State; Minnesota sends out traveling rural clinics which devote much of their attention to children. North Carolina has actually in operation the most comprehensive service for country children which has come to the writer's knowledge. Finding among their rural children the same conditions which exist in Missouri — thousands who needed dental and surgical care for whom there was no prospect of securing such care — the North Carolina Board of Health set out to do something about it. What they have done is to provide free dental clinics and to arrange what they call a "club plan" for tonsil operations. 29 The dental clinic work is done by dentists employed by the State Board of Health, who travel by automobile through their assigned territory on itineraries arranged by the county school or health authorities, working in school houses, court houses, etc. The service is restricted to school children from six to thirteen years old, who are selected by the local authorities. As stated by the Board: "The clinics are open to all classes alike; * * it is a free clinic paid for out of public funds, just as the public school is supported"; because "poverty is by no means the most important cause of dental neglect." (Poverty is elsewhere listed as sixth in order of importance among causes, with ignorance first, and indifference second.) The Board reports that up to the end of 1921 (beginning apparently in 1919), 66,452 children in sixty-five counties received treatment in these dental clinics. The North Carolina tonsil-and-adenoid clinics, on the contrary, have been carried out on a pay basis; the reason given for this difference being: "We have considered that our basic effort should be the permanent introduc- tion of the capable operators of each section to the people who most need their service. * * * So we have employed men of established reputation in their communities." The surgeon is paid for this service; and for each child a fee of $12.50 is charged, except that a certain proportion (up to one- fourth of the total) may be accepted without payment. It is found that the expenses of the clinic may be met on this basis. The State Board of Health provides nurses to make arrangements, select patients, and care for the children at the time of the operation and afterward; and also an assisting physician to give preliminary examinations and act as anesthetist. Cots and other necessary hospital equipment are set up in a school or other suitable building; children are kept there in bed after the operation until at least the following day, under the care of a trained nurse. Under this plan it is reported that clinics have been conducted "in forty-eight counties, operating on 3,595 children, most of whom would never have had a chance otherwise." There seems to be no reason why eye clinics, operated on a similar "club-payment" basis, would not be of equally great service. Indeed, a plan similar in principle was suggested to the survey director by a local physi- cian in one of the Missouri counties lacking a local oculist, as a solution of the defective vision problem among school children. This physician rec- ommended that parents of children with eye trouble should club together and employ an oculist from the nearest city to come to their county seat, examine the children's eyes and prescribe as needed. But in practice it usually requires some interested outsider — for example, an active county nurse — to take the necessary first steps toward even such an informal co- operative scheme. Another way to make surgical service more available to country people would be to establish and maintain general hospitals from county funds, as is permitted by law in Missouri. Most of the counties included in this survey had at least one hospital, operated by individuals or by private organizations, at the county seat; but many Missouri counties have no such facilities. II. Preventive Measures. Of course, the ultimate aim of public health work is to prevent, rather than cure, physical defects and disease. Unfortunately there is still a great 30 deal to learn about why one child has sound teeth and another not; why defective tonsils and adenoids afflict one child and not another; why one child reaches school age with poor refraction and another with perfect vision. But some things seem well established: for instance, that proper food has a great deal to do with general nutrition, and probably, from the beginning of life, with teeth; that personal cleanliness does help in preser- vation of teeth and in prevention of contagious disease, including colds; that sufficient, wholesome sleep has much to do with growth and with pre- vention of nervousness, often an important factor in malnutrition; that better ventilation and avoidance of colds are our "best bet" so far in trying to decrease the number of tonsils and adenoids needing to be removed. Taking up such measures in the order in which the present status was discussed from the home records, the following suggestions are made: (a) Home Sanitation. — "What is needed here is the spread of knowledge about the fundamental principles of sanitation as applied to the country home, i. e., safe water supply, disposal of human wastes, screening as a preventive of fly-borne and mosquito-borne disease. These topics are in- cluded in the State course of study for elementary schools in the work on hygiene, though not given the importance they deserve. The problems of household water supply are also taken up under "Home Conveniences" in the agricultural course. This teaching should help, in time, to remove the deficiencies along these lines which the survey has revealed. The Home Bureau and the Farm Bureau, where they are established, are doing a great deal to further the physical improvement of rural homes. Such teaching, both for children and for adults, should be pushed as far as possible. But equally important is the economic problem; home improvements, unfortunately, cost money. By and large, the people who live in unsanitary homes are those who cannot afford better. The exceptional cases — e. g., failure to provide even the most primitive toilet facilities in the far-southern counties — must be reached by education. The main bulk of improvement must depend upon agricultural prosperity. (b) Personal Hygiene. — The most promising method of teaching the practical observance of health habits is the School Health Crusade, intro- duced in Missouri by the Missouri Tuberculosis Association and widely adopted among the schools of the State. The survey workers had many opportunities to observe and learn from parents that where the Health Crusade was being carried out in the community school, it made a marked difference in the children's attitude towards cleaning teeth, taking baths, going to bed early, etc. Parents, and others interested in better health, should see to it that some such plan involving actual practice of good habits is carried out in all schools. It is a wonderful help to parents who are trying to teach these same habits, and also enlists the efforts of many pupils whose parents are not especially interested. (c) Diet. — The problem of improving food habits is one of the most difficult phases of health education, because in many respects sound teaching goes directly contrary not only to established habits, but also to established likings. For instance, few people really prefer to be untidy or dirty — it is just too much trouble to keep clean; but many people really like hot biscuits and pancakes and fried meat and pickles. And as long as the adults of a community live on such things it is hardly to be expected that in the ordi- 31 nary home a different menu will be provided for the children. Here, again, we must be patient, and fall back upon education through all possible channels. The various Home Economics extension services, the county Home Bureaus and the Red Cross are doing much work along these lines — the only work that so far really seems to be "getting across." The routine school teaching on diet does not seem to make much impression; perhaps the subject as a whole is too complicated for children or perhaps — like much school teaching — it seems too detached from every-day life. On some one simple, concrete and practicable item, like the substitution of milk for coffee, the Health Crusade or similar scheme may, and often does, bring about a change. But it would do very little good to tell a child to eat light-bread instead of biscuits, if his mother never makes light-bread. School Lunches. — One concrete, practical way in which the school can make a dent in the food problem is by means of hot school lunches. In this way, not only may children be taught to eat and like wholesome dishes which perhaps they had avoided or had not known, but they also are given a hot and nourishing noonday meal. This is particularly valuable in rural schools, where few pupils can go home for dinner; and it is generally appre- ciated by thoughtful parents. The school lunch is a trying problem to a busy country mother, no matter how careful she may be; if she is not particularly careful, her chil- dren are often left to pick out and pack their own lunches from whatever they find on the breakfast table or in the kitchen cabinet. Consequently the "bread and ham, bread and jam, pie" type of lunch is all too common. Furthermore, the country family usually has its dinner at noon. The adults and small children then have a substantial meal; and a light supper requir- ing little cooking seems natural and proper. But meantime the school children have had, perhaps, cold biscuits and ham, a cold fried egg, pie or cake. With a cold "piece," say of bread and preserves, after school and the aforementioned light supper, a rather inadequate day's diet is bound to result. A "school lunch," consisting of some especially nourishing hot dish cooked and served at school — e. g., cream-vegetable soups or milk-cocoa — added to the "dinner" brought from home, helps the situation materially. The preparation and serving of a one-dish lunch has proved feasible in rural schools in many places. Most simply, the cooking equipment is bought from money raised at a school entertainment; the pupils bring their own dishes; and the food-materials are furnished co-operatively by the parents.* A group of parents actively interested in the health of their children could hardly do any one thing more helpful than to persuade the school teacher to have hot lunches, and help her carry out the plan. 1 Detailed suggestions for the management of school lunches may be secured from the Agricultural Extension Division of the State University at Columbia, Missouri, or from the United States Bureau of Education in Washington (Health Education Bulletin No. 7 — "The Lunch Hour at School"). 32 SUMMARY OF RECOMMENDATIONS. 1. Employ full-time county health officers, and include in their duties, giving physical examinations to all school children not already under the care of school or city physicians. 2. Employ county public health nurses, who (among their manifold duties) shall assist in school examinations and follow up children in need of treatment. 3. Establish some plan whereby children who need dental, surgical or oculist's care can get it, even if they do not live in a large city. 4. Develop the practical bearing of school instruction in hygiene, espe- cially along the lines of sanitation and food-selection. 5. Push the Missouri School Health Crusade. 6. Establish hot school lunches in country schools. 7. Back up and extend the health-education work of the Farm Bureaus, the Home Bureaus, the Red Cross Chapters, and the Missouri Tuberculosis Association. This survey has been paid for from the proceeds of the sale of Tuberculosis Christmas Seals. 33 Physical Examination I. WEIGHT DEVIATION Percentage of grade pupils deviating from standard weight as specified. County Total number weighed • >' , or more BELOW 10% or more 5 to 10% Within o /O o' ( or more ABOVE 5 to 10% 10 to 15% 15% or more All children: Total... Greene. . . . Johnson. . . Nodaway. . Harrison. . . Livingston. Mississippi. 1897 237 328 159 291 581 301 19.8 23.2 21.0 10.7 17.9 23.1 16.3 22 1 40.5 9.2 22.8 21.7 17.6 23.4 23.4 20.6 40.5 38.7 55.3 37.8 38.5 40.9 7.6 8.5 8.2 8.9 9.5 11.6 3.9 3.0 4.9 2.5 5.8 2.4 5.0 4.5 2.9 5.2 5.7 6.2 3.1 5.6 Rural children: Total Greene .... Johnson. . . Nodaway. . Harrison. . . Livingston . Mississippi. 1327 17.9 22 4 41.0 9.8 210 243 159 140 307 268 23.3 21.0 10.7 12.9 18.9 16.8 22.9 24.3 17.6 25.7 22.8 20.9 40.0 36.6 55.3 34 . 3 41.7 39.9 7.6 8.2 8.2 14.3 9.8 11.6 3.9 2.9 3.7 2.5 5.7 3.6 5.2 5.0 3.3 6.2 5.7 7.1 3.2 5.6 Town children: Total Greene*. . . Johnson. . . Nodaway. . Harrison. . . Livingston. Mississippi 1 570 24.2 21.4 39.3 7.9 27 85 151 274 33 22.2 21 .2 None i 22.5 27.7 12.1 22.2 14. 1 nclude 21 2 24.1 18.2 44.5 44.7 d in su 41.0 35.1 48.5 7.4 9.4 rvey . 4.0 9.1 12.1 3.7 3.7 8.2 6.0 1.1 3.0 3.5 2.4 5.3 2.9 6.1 Too few for reliable percentages. 34 Physical Examination II. CONDITION OF PERMANENT TEETH Percent of grade pupils of specified ages, having unfilled cavities, fillings or extractions in permanent teeth. 10 years of age or over 12 j^ears of age or over County Nor- mal Unfilled cavities Fill- ings or extrac- tions Nor- mal Unfilled cavities Fill- ings or Total Alone Total Alone extrac- tions All children: Total 41.7 46.8 37.1 21.2 35.2 50.2 37.3 27.5 32.6 40.2 51.6 48.9 34.9 35.3 32.5 24.5 22.4 32.4 59.2 53.9 36.8 34.3 40.8 Johnson 33.3 Nodaway 49.5 38.7 34.4 16.1 49.0 40.4 31.9 19.1 Harrison 44.1 46.4 40.1 15.8 37.1 50.9 43.1 19.8 Livingston 37.6 46.9 35.2 27.2 30.2 47.2 33.6 36.2 Mississippi 51.1 46.1 42.2 6.7 49.0 49.0 43.3 7.7 Rural children: Total 44.0 44.7 36.4 19.6 38.0 47.7 36.6 25.4 Greene 33.1 47.0 50.0 43.3 35.7 32.8 31.2 20.2 22.1 37.8 57.4 48.6 38.2 33.8 39.7 Johnson 28.4 Nodaway 49.5 38.7 34.4 16.1 49.0 40.4 31.9 19.1 Harrison 50.6 38.6 34.9 14.5 41.0 47.5 44.2 14.8 Livingston 37.1 46.2 35.5 27.4 32.4 43.5 30.6 37.0 Mississippi 51.0 47.2 42.7 6.3 49.0 48.9 42.3 8.7 Town children: Total 36.3 51.8 38.7 25.0 28.8 55.6 38.7 32.5 Greene* 28.6 64.3 28.6 42.8 25.0 75.0 25.0 50.0 Johnson 22.0 64.0 42.0 36.0 17.9 67.8 35.7 46.4 d in su Harrison 38.3 38.3 53.2 47.6 44.7 34.9 17.0 26.8 32.7 27.5 54.5 51.6 41.8 37.3 25.5 Livingston 35.2 Mississippi* 52.4 38.1 38.1 9.5 50.0 50.0 50.0 *Too few for reliable percentages. 35 Physical Examination Summary OCCURRENCE OF COMMON PHYSICAL DEFECTS Percent of grade pupils found to have specified defect. County l-i Ml as? 2*d ,2 o OT 6 tn «H «) c 3 — o (/-. TD J. — . ft |*S to °< a •a w "6 *£ 5 c H 0) »- « !D C a> o © ?£€ > ~ 0) 2 O t- ° 3 8 All children: Total 19.8 69.5 46.8 44.5 37.8 22.5 28.8 31.2 Greene 23.2 21.0 10.7 17.9 23.1 16.3 73.2 72.5 67.0 71.6 70.3 61.3 51.6 48.9 38.7 46.4 46.9 46.1 39.2 54.2 36.8 47.0 42.2 44.2 48.9 47.8 29.5 38.1 25.7 43.9 21.6 19.0 24.8 27.4 20.8 24.5 16.0 30.9 31.7 31.0 29.9 31.0 18.2 Nodaway Harrison Livingston Mississippi 34.7 32.3 31.7 33.9 31.7 Rural children: Total 17.9 67.6 44.7 45.3 38.3 21.8 27.2 29.2 Greene Johnson 23.3 21.0 10.7 12.9 18.9 16.8 72.2 70.2 67.0 70.4 67.5 60.6 50.0 43.3 38.7 38.6 46.2 47.2 39.0 56.1 36.8 45.4 45.8 45.0 51.0 43.3 29.5 38.5 25.4 43.5 21.5 17.2 24.8 27.7 19.7 23.7 15.6 29.4 31.7 28.2 28.9 29.3 18.0 31.5 Nodaway Harrison Livingston Mississippi 32.3 29.0 32.8 30.0 Town children: Total 24.2 74.0 51.8 42.6 36.3 24.2 32.5 35.9 Greene* Johnson Nodaway 22.2 21.2 81.5 78.5 64.3 64.0 None i 53.2 47.6 38.1 40.7 48.8 nclud e 48.4 37.8 37.5 33.3 60.7 d in su 37.8 26.0 46.9 22.2 23.8 18.5 35.3 18.5 43.5 Harrison Livingston Mississippi* 22.5 27.7 12.1 72.6 73.4 67.6 27.2 22.0 31.2 33.3 31.0 45.4 34.0 35.1 45.4 *Too few for reliable percentages. 36 Physical Examination: High School Summary OCCURRENCE OF COMMON PHYSICAL DEFECTS Percent of High School pupils found to have specified defect. -■ , CD u a "73 O CD.-H a > CD ds pr probab spected >> o County T3 S CD rj "*> CD T3 O CD V 4) w as Dnsils subn disea denoi sent, or st] O efecti sight recte o H Q e < S Q EH All Children: ■ ■•■ Total 13.7 43.2 38.4 13.3 9.5 21.6 31.7 Not Johnson 12.1 exam. 32. 7 3 34. 6 3 18.2 16.4 32.8 Harrison 12.1 57. I 2 52.8 10.6 11.4 20.8 23.3 Livingston 14.3 34.2 24.1 3.7 3.8 23.8 36.9 None i nclud e d in su rvey . . *Too few examined to calculate percentages, including those wearing glasses. 2 Dentist's examination. 'Examination by nose-and-throat specialist. 37 Home Sanitation Summary Percent of homes found to have conditions specified. £ S o o U. o CI * C u *-" CD 0) c k ° O— ' CD ,4 T) '5; C CD ^ 43 O O.J2 C/5 O 4) . V in O u >> > °C 44 s a O "0 +-> Screening County CD H a CD a All homes: Total 11.3 12.3 8.7 2.3 2.4 18.4 7.4 71.9 4.3 Greene 17.5 9.1 3.8 5.8 6.2 22.5 14.6 12.9 7.5 4.7 2.6 28.8 8.8 7.3 18.8 12.9 7.7 4.0 4.4 4.0 1.3 2.6 0.7 1.1 6.3 7.1 2.1 1.3 13.1 19.1 10.0 4.7 14.9 38.9 17.5 3.9 2.5 1.2 3.6 13.4 66.4 59.9 88.6 81.2 84.4 60.8 5.1 6.2 Nodaway Harrison 1.2 Livingston Mississippi 1.6 8.8 Rural homes: Total 12.1 14.4 8.5 2.9 1.9 24.4 10.0 67.6 5.2 Greene 19.0 7.0 3.8 15.7 13.0 7.5 8.3 6.1 18.8 . . No 5.0 5.4 1.3 recor 2.6 0.8 0.8 6.3 ds se 1.7 1.5 14.9 24.4 10.0 cured 23.4 42.7 19.8 5.3 2.5 64.5 54.6 88.6 5.8 Johnson 5.9 Nodaway Livingston Mississippi 3.5 24.0 3.5 28.2 11.3 2.3 4.3 15.3 82.3 57.7 1.8 9.2 Town homes: Total 9.3 7.3 9.4 0.8 3.7 4.1 1.2 82.1 2.0 Greene* 6.3 14.9 6.2 12.8 12.5 10.6 None 12.9 2.5 16.7 81.2 74.5 Johnson inclu 2.5 2.1 ded i 7.1 2.5 4.3 n sur 4.7 2.5 11.1 vey . . 4.2 Nodaway Harrison 5.8 10.3 11.1 4.7 1.3 33.3 1.2 2.5 81.2 87.3 83.3 1.2 Livingston 1.3 Mississippi* 5.6 "Too few for reliable percentages. 38 Personal Hygiene Summary I. SLEEPING CONDITIONS AND HOURS Percent of children having specified habits. Bed room win- dow open in winter Sleeping in room with Sleeping in bed with 2 or more others ... U QJ cc QJ County in as QJ !-. o a e ° O 4 or more others and wind ows closed i n winter a o All Children: Total 53.4 54.6 11.1 6.0 13.6 65.2 Greene Johnson Nodaway Harrison Livingston Mississippi 42.4 55.8 80.3 64.0 68.4 22.7 55.9 58.7 57.6 46.9 45.3 62.6 8.0 10.2 18.5 4.0 9.2 16.4 6.3 5.3 3.3 0.8 3.6 13.3 9.7 15.8 14.6 8.7 11.7 18.9 59.2 68.5 68.8 85.4 69.5 50.7 Rural children: Total 51.9 56.6 12.8 7.2 14.4 62.2 Greene Johnson Nodaway Harrison 38.1 58.3 80.3 57.3 59.2 57.6 No 8.1 11.3 18.5 records 10.6 16.6 7.1 5.5 3.3 secured . 10.9 18.1 14.6 59.4 66.5 6S.8 Livingston Mississippi 73.8 22.5 44.0 63.6 4.1 13.8 8.3 19.0 67.1 52.6 Town children: Total 57.1 49.6 6.8 2.9 11.9 72.8 77.0 48.8 44.4 57.1 7.4 7.1 included 4.0 7.0 15.1 57.7 Johnson 4.8 in surve 0.8 2.8 9.1 9.5 73.8 Harrison Livingston Mississippi * 64.0 60.0 24.3 46.9 47.1 54.5 8.7 16.9 18.1 85.4 72.9 36.4 "Too few for reliable percentages. 39 Personal Hygiene Summary II. PERSONAL CLEANLINESS Percent of children having specified habits. Baths per week Cleaning teeth Boys County Winter 1 or more Summer 2 or more Girls Regu- larly Never Regu- larly Never All children: Total 73.3 78.9 22.8 20.7 42.1 10.9 Greene Johnson Nodaway Harrison Livingston Mississippi 68.5 82.9 81.2 83.3 89.0 36.7 61.3 87.7 76.8 91.9 84.5 72.0 14.8 22.5 44.1 36.6 18.5 17.1 32.2 21.3 10.4 1.4 6.9 43.9 33.3 47.0 55.9 49.1 37.1 41.0 13.0 19.0 2.9 5.9 15.0 Rural children: Total 70.3 77.5 22.2 25.5 41.2 13.0 Greene Johnson Nodaway 66.9 84.8 81.2 64.0 90.6 76.8 12.5 25.6 44.1 No recor 17.7 17.5 35.6 22.4 10.4 ds secure 7.1 46.0 29.0 46.0 55.9 d 15.0 21.2 2.9 Livingston Mississippi 90.2 34.8 84.1 71.4 37.2 43.0 5.7 15.8 Town children: Total 80.8 82.4 24.3 9.0 44.4 5.3 Greene* Johnson 81.5 77.4 40.7 79.5 36.4 13.6 ncluded i 36.6 19.7 15.0 18.2 n survey 1 .4 6.6 30.(1 62.5 50.0 12.5 Harrison 83.3 87.2 51.5 «)1.9 85.2 75.8 49.1 36.9 23.1 Livingston Mississippi* 6.2 7 . 7 *Too few for reliable percentages. 40 Diet Summary I. DIET GRADE Percent of children under 16 years of age having diet of specified grade. County Total num- ber of reports Percent Good Me- dium Poor Inade- quate Good plus Me- dium Poor plus Inade- quate All children: Total . . Greene. . . . Johnson. . . Nodaway. . Harrison. . . Livingston . Mississippi, Rural children: Total Greene .... Johnson. . . Nodaway. . Harrison . . . Livingston . Mississippi. Town children: Total Greene*. . . Johnson. . . Nodaway. . Harrison. . . Livingston. Mississippi' 1431 3.9 28.5 63.7 225 310 148 116 350 282 4.9 1.9 4.1 4.3 7.4 0.7 28.4 28.4 37.1 31.9 39.4 8.9 61.8 66.1 57.5 53.5 48.9 88.6 1034 3.1 28.2 66.0 199 226 148 5.0 0.9 4.1 212 249 5.7 0.8 29.2 30.1 37.1 No rec 43.4 7.6 61.8 65.0 57.5 ords se 49.0 89.5 397 6.0 29.0 57.9 26 84 3.8 116 138 33 4.3 10.1 23.1 23.8 None i 31.9 33.4 18.2 61.6 69.0 n elude 53.5 48.5 81.8 3.9 32.4 4.9 3.6 1.3 10.3 4.3 1.8 33.3 30.3 41.2 36.2 46.8 9.6 2.7 31.3 4.0 4.0 1.3 cured . 1.9 2.1 34.2 31.0 41.2 49.1 8.4 7.1 35.0 11.5 2.4 d in su 10.3 8.0 26.9 28.6 rvey . . 36.2 43.5 18.2 67.6 66.7 69.7 58.8 63.8 53.2 90.4 68.7 65.8 69.0 58.8 50.9 91.6 65.0 73.1 71.4 63.8 56.5 81.8 "Too few for reliable percentages. 41 Diet Summary II. REASONS FOR POOR GRADE IN DIET Number of children whose diet was poor because of specified reasons. o to o O '{3 c "3 o C CO O o W 'Tr. '3 *<-> o * tS) o PQ 1- tu •'- p C G3 C rt g.3 « t- lH ID O O O cs t/2 1/1 o 'V o 1 c *c3 o o Eh Special County o .O E z Specifica- tion All children: Total 329 355 309 298 82 62 49 43 21 8< 5-pie 3 times 2-pie in even- ing. 1-6 eggs Greene Johnson Nodaway. . . . Harrison Livingston . . . Mississippi.. . 63 61 27 15 70 93 48 96 20 30 69 92 34 88 45 12 41 89 48 37 4 1 1 207 13 10 1 3 24 25 8 13 9 12 11 9 4 17 2 7 19 3 6 3 6 14 11 2 4 1 10 4 2 2 3 I 1 pie 3 times pie in evening 2-pie 3 times 1-6 eggs pie 3 times Rural children: Total 247 245 248 263 68 35 43 27 13 J I 3-pie 3 times 2-pie in even- ing Greene Johnson ..... Nodaway. . . . Harrison 53 44 27 45 66 20 34 67 45 45 29 4 No 1 184 11 12 1 reco 19 25 5 5 9 rds s 8 8 4 13 2 ecur 5 19 2 5 3 ed 2 3 2 2 pie 3 times pie in evening Livingston... . Mississippi. . . 43 80 30 84 28 74 10 ' 7 4 4 1 pie 3 times Town children: Total. 82 110 61 35 14 27 6 16 8 f 4 2-pie 3 times 1-6 eggs Greene* 10 17 d 30 21 Non 12 13 15 3 8 e inc 1 23 2 4 lude o 5 3 8 d in 12 3 1 4 sur 2 1 1 Johnson Nodaway. . . . 1 Harrison Livingston. . . Mississippi*. . 15 27 13 30 39 8 6 4 4 1 6 3 i 2-pie 3 times 1-6 eggs *Too few for reliable percentages. 42 Diet Summary III. USE OF MILK Percent of children under 16 years of age, using milk as specified. Countv Total number of reports PERCENT HAVING Milk to drink At least 1 pint of milk (esti- mated) Some fresh milk or cream 1 Milk sufficient for fair diet No milk cream, or butter All children: Total 1429 54.0 38.6 79.9 73.1 4.7 Greene Johnson Nodaway Harrison Livingston 221 312 149 115 350 282 53.8 48.4 62.4 42.6 56.5 56.8 38.0 31.2 51.4 21.9 39.8 45.7 83.3 73.4 94.6 73.1 88.0 69.2 75.5 66.7 85.3 67.0 79.2 66.7 5.4 3.2 0.7 5.2 2.6 10.3 Rural children: Total 1037 56.6 42.2 81.6 75.0 4.7 Greene Johnson 199 228 149 53.3 54.0 62.4 36.7 37.8 51.4 No recor 43.6 44.2 83.0 75.9 94.6 ds secure 92.9 68.2 74.4 69.4 85.3 d 5.5 2.6 0.7 Livingston Mississippi 212 249 60.3 55.0 85.4 65.5 0.9 11.7 Town Children: Total 392 46.7 29.1 75.3 68.4 4.6 Greene* Johnson 22 84 59.1 33.3 50.0 13.6 None inc 21.9 34.1 57.5 86.4 66.6 luded in . 73.1 80.4 75.8 86.4 60.7 survey . . 4.5 4.8 Harrison Mississippi* 115 138 33 42.6 50.7 69.7 67.0 69.5 75.8 5.2 5.1 *Too few for reliable percentages, including soup or cocoa made of milk. 43 Diet Summary IV. DEFECTS OF EXCESS Percent of children under 16 years of age, showing specified errors of diet. County T-t If} C u o cd Eh Eating Meat ■43 S Eating biscuit H W All children: Total... Greene. . . . Johnson. . . Nodaway. . Harrison. . . Livingston . Mississippi. Rural children: Total Greene. . . . Johnson. . . Nodaway. . Harrison . . . Livingston. Mississippi Town children: Total Greene*. . . Johnson. . . Nodaway. . Harrison . . . Livingston . Mississippi' 1401 24.2 53.0 22.4 50.0 217 298 147 112 346 281 30.3 20.2 18.1 16.4 21.2 34.0 40.7 58.9 65.3 56.3 40.8 63.4 16.7 29.6 30.6 12.5 11.9 31.7 75.2 56.7 17.0 9.8 19.4 95.0 1019 24.6 55.3 24.6 57.3 196 217 147 27.9 20.2 18.1 210 249 20.8 33.4 41.6 64.8 65.3 No re 43.3 62.2 18.5 31.0 30.6 cords 13.3 29.7 77.1 60.8 17.0 secur 18.5 95.6 382 23.1 46.6 16.5 30.6 48.1 20.2 112 136 32 16.4 21.7 39.4 33.3 43.2 None 56.3 36.8 71.8 25.9 inclu 12.5 9.6 46.8 57.2 45.6 ded 9.8 20.6 90.6 20.1 19.3 24.4 10 2.0 69.0 24.5 25.5 11.5 2.0 ed. 69.1 8.4 14.3 8.6 n sur 68.8 19.1 9 2.7 0.9 0.3 62.0 21.8 19.1 11.1 2.7 0.5 62.3 7.6 19.1 6.2 vey . . 0.9 59.5 5.3 4.1 5.7 8 1 13.4 3.2 3.6 4.0 3.1 3.2 8.1 3.8 3.6 8.3 1.4 12.4 13.4 2.2 3.1 25.9 41.9 27.9 23.1 25.7 19.9 20.3 27.0 41.8 27.6 23.1 19.0 22.9 23.0 42.8 25.9 25.7 21.3 "Too few for reliable percentages. 44 Diet Summary V. DEFICIENCIES IN DIET (Other than Milk) Percent of children under 16 years of age, eating specified articles of food. County Total number of reports Cereal Eggs Fruit other than pre- served Vege- table 1 Eating neither fruit vege- table All children: Total 1401 47.3 34.7 62.1 42.3 21.1 Greene Johnson Nodaway Harrison Livingston Mississippi 217 298 147 112 346 281 52.0 37.3 47.6 53.5 59.8 36.3 50.2 12.8 10.9 19.7 63.8 28.5 60.8 80.5 83.6 58.0 66.2 29.2 54.8 43.0 34.7 31.3 25.7 60.9 15.2 14.1 11.6 34.0 26.0 27.0 Rural children: Total 1019 46.3 36.9 62.8 43.8 18.9 Greene Johnson Nodaway 196 217 147 53.5 34.1 47.6 52.0 17.5 10.9 No recor 68.1 30.9 59.2 84.3 83.6 ds secure 70.0 28.5 52.5 48.0 34.7 d 15.8 9.2 11.6 Livingston.' Mississippi 210 249 61.0 37.0 16.7 61.4 26.7 27.3 Town children: Total 382 50.2 28.8 60.5 38.5 27.2 Greene* Johnson 21 81 28.6 45.7 33.3 None inc 19.7 57.4 9.4 76.2 70.4 luded in 58.0 60.3 34.4 76.2 29.6 survey . . 9.5 27.2 Harrison Livingston Mississippi* 112 136 32 53.5 58.1 31.2 31.3 39.7 56.3 34.0 25.0 25.0 *Too few for reliable percentages. 1 Other than white potatoes or dried legumes. 45 Diet Summary VI. IRREGULAR EATING Percent of children under 16 years of age, eating as specified. County After school At recess At other times Frequently and irregularly Omitting a meal All children: Total 70.3 39.3 17.8 6.0 4.7 Greene* Johnson* Nodaway Harrison Livingston Mississippi 73.2 65.8 68.0 49.1 76.4 76.2 .... No rec .... No rec 66.6 6.5 25.2 56.0 ord ord 20.4 6.2 11.2 29.2 6.0 5.6 0.7 2.7 7.2 8.9 3.7 3.0 2.0 6.2 6.9 5.3 Rural children: Total 73.4 52.4 21.6 6.7 3.9 Greene* Johnson* Nodaway 73.2 65.9 68.0 .... No rec .... No rec 66.6 No record 36.8 56.5 ord 20.4 5.1 6.0 0.7 2.6 3.7 2.0 Livingston Mississippi 79.6 77.9 11.9 30.6 9.0 10.0 6.2 4.4 Town children: Total 62.3 12.8 9.3 4.2 6.8 Greene* No records se .... No rec None inclu 6.5 8.8 51.6 cured ord ded in surv 6.2 10.3 18.8 14.3** 4.8 14.3** Johnson* 65.4 1.2 Harrison Livingston Mississippi**.. . . 49.1 71.4 62.5 2.7 4.4 6.2 8.1 12 1 *Records not in all cases specific as to when extra meal was taken, but pre- sumably after school. **Too few for reliable percentages. 46 LIBRARY OF CONGRESS 020 948 945 4