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   Malnutrition, (Innutrition, Undernutrition) is simply poor or inadequate or defective nutrition--slow starvation. The child is undernourished or is not well nourished. Such a person may be overfed. The cases of malnutrition in those who actually do not eat a sufficient bulk of food are comparatively very rare.

   Almost the whole of the American population is suffering from undernutrition. The discovery during the war that so many of the young men in this country are such miserable specimens of physical manhood occasioned a temporary interest in the subject of malnutrition, just as a similar interest in the nutrition of her young followed a similar discovery in the young men of England during the Boer war. Although, this temporary interest in the physical welfare of our future cannon-fodder waned as the patriotic fervor which gave rise to it lessened, with the passing of the war, malnutrition of our children and adults is as acute as ever if not more so. Routine examinations of school children have revealed that malnutrition is as prevalent in these as it was in the young men examined in 1917-1919 and 1933-1946.

   Sir Stephan Tallents, Secretary of the Marketing Board (England) in an appeal, in the first half of 1932, for a closer understanding of matters vital to the British Empire, declared: "Research workers have satisfied themselves that whole populations--indeed a scientist told me the other day that I might safely say whole continents--are suffering from malnutrition." He lamented the fact that it takes twenty years for the results of scientific research to percolate into practice.

   The United States Children's Bureau found that one-fourth to one-third of the children in this country are definitely malnourished according to medical standards. In some communities malnourishment is so common that it is hardly recognized as en abnormal condition. They found that the number of children of really superior nutrition is really very small.

   While a majority of these children manage to grow up, they carry the marks of faulty nutrition with them throughout their lives. Small bones, weak, receding, deformed chins, deformities, defective teeth, undeveloped bodies, flat chests, deformed spines, poor sight, anaemia, marked susceptibility to disease, and low mentality are only some of the more obvious results of malnutrition. Here in San Antonio, among our Mexican population, one scarcely sees a single Mexican who does not present unmistakable evidences of malnutrition.

   Malnutrition shows itself in a variety of ways. In young children growth is arrested, the teeth and eyes are defective, sore eyes and rickets, emaciation and deformity develop. In adults, anaemia, loss of appetite, underweight, constipation, pellagra, beri-beri, and nervous troubles result.

   Malnutrition manifests itself not only in a failure to gain in height and weight but in many other ways. Indeed many malnourished children are fat, while, others are as tall as the average child of their age. A child may be normal, meaning the median or average, as far as height and weight are concerned, and still present many evidences of malnutrition.

   The more common symptoms of malnutrition are a dry, delicate skin which is either pale or wax-like or else sallow, or pasty, or earthy in appearance; dry, rough hair, brittle nails; blue circles or dark hallows under the eyes, with a pale, colorless mucous lining of the eye-lids; loose skin, flabby, undeveloped muscles, round shoulders, projecting shoulder blades, fatigue posture, prominent abdomen, irritability, listlessness, inattention, "laziness," undue mental and physical fatigue, mental backwardness, a temperamental disposition, lack of natural inquisitiveness and a lessened power of concentration; the child is also likely to be finicky about his food. The undernourished child is usually underweight, although some of them are fat and flabby. Borderline conditions of malnutrition commonly pass for healthy conditions.

   Dr. Hess, of Columbia University, says that clear-cut disorders are not the most common or important results of food deficiency. Lack of vitamins, he says, "generally does not bring about typical pathological states but obscure alterations of nutrition, ill-defined functional disabilities which cannot be characterized or even recognized as disease."

   These ill-defined functional disabilities and obscure alterations of nutrition represent the initial beginnings and the subsequent so-called disease is only a further development of the same alterations and disabilities. It is of the highest importance that we realize that by reason of faulty diet, or other factors that impair nutrition, serious damage to the young may occur without the development of symptoms which definitely mark the condition as deficiency.

   The causes of malnutrition are commonly divided into three classes: physical, social and dietetic.

   The "physical causes" are diseases and various malformations. Among these are listed tuberculosis, chronic disease of the tonsils and sinuses connected with the nose, pyelitis, decaying teeth, adenoids and deformities of the jaw and nose. Chronic disease of the tonsils and sinuses connected with the nose are said to be "the most common of the diseases causing malnutrition in childhood." "Decaying teeth often cause malnutrition." "Adenoids and deformities of the jaw and nose are the most common of the deformities which produce malnutrition." Tuberculosis is not considered a common cause of malnutrition in childhood.

   Morse, Wyman-Hill say of malnutrition due to these causes: "The remedies are obvious: removal of diseased tonsils and teeth and of the adenoids, treatment of the sinuses and pyelitis, and correction of the deformities." This is a surgical program and is aimed at effects, not causes.

   K. B. Rich in a report of the work of the educational authorities in the Chicago Elementary Schools, showed that the treatment of enlarged tonsils, adenoids, carious teeth, and flat-foot are ineffectual in over-coming malnutrition, although the program had been undertaken with great expectations of success. Fresh air. sunshine, exercise, and improved diet and cleanliness were then tried and these proved effective.

   Decay of the teeth is due to malnutrition. So is tuberculosis. So are most deformities of the nose and jaw. The medical profession is so in the habit of getting the cart before the horse--of converting an effect into the cause--that they do it unconsciously. Take the one factor of decay of the teeth. This is so unmistakably an effect of faulty nutrition that we can hardly excuse those who say that the tooth decay causes faulty nutrition.

   In the discussion of the "social causes" we usually find more evidence of intelligence, although the treatment of these seldom goes far enough, due to the fact that our universities and research institutions are controlled by big business interests and to the further fact that these same universities and research institutions are large stock holders in oil companies, mining companies, cotton mills, etc., and are deeply interested in dividends from these. It is, therefore, more profitable to these institutions to vivisect animals, study germs, and endorse serums and surgery than it would be to tell the truth about the social causes of disease, where this might tend to decrease the incomes of these big business concerns.

   Under social causes we find listed lack of fresh air and sunlight, too hot or too cold houses, mental over fatigue and physical over fatigue. Physical over fatigue is said to be due, usually, to too much hard play. The more than two million children, employed in poorly ventilated, poorly lighted mills, factories and sweat shops in this great land of "progress" and "prosperity" are not likely to play too hard.

   There is no condemnation of the crowded slums of our larger cities where sunshine and fresh air are lacking. There is no condemnation of the low wages, high rents, and other economic factors that prevent parents giving their children the benefits of fresh air and sunshine.

   Other "social causes" are insufficient sleep, due either to excitement or improper food, or to the premature abandonment of naps and rests or to not putting the child to bed early enough; too much study, neglect at home, family friction, unsuitable books and stories, too many parties, movies, long automobile rides, and too much other such excitement or improper amusement.

   To these causes, let me add nagging, scolding and whipping and slapping of children, overclothing, too much handling, especially of infants, smoking by older members of the family in the house, drugs, serums, vaccines, surgical operations, etc.

   "The remedy," say Morse-Wyman-Hill, "is, of course, a simple rational, not too strenuous life, without undue excitement, and with plenty of fresh air and sunshine." The remedy must go beyond this prescription. It must take the children and their mothers out of the mills and sweat shops; it must remove them from the slums and crowded tenements; it must supply these children with an atmosphere of love and kindness. It must supply them with houses that are not "too hot or too cold." It must keep them out of the hands of the surgeons and the pus punchers and serum squirters.

   Under "dietetic causes" is mentioned "improper food" rather than a "lack of food." This means that the child is fed on foods that are inadequate in one way or another; that do not supply the child's body with all the needed food elements. Without indulging in the customary stereotyped chin music about ''calorie requirements," "balanced diets," "protein needs," "fat needs," "accessory foods or vitamins," etc., let me say that this means that the child is fed on white flour and its products, degerminated and demineralized corn meal, denatured cereals, pasteurized and canned milk, sulphured and canned fruits, jellies, jams, white sugar, candies, ice cream, cocoa, chocolate, soda fountain slops, cooked vegetables, mashed potatoes, pies, cakes, crackers, cookies, etc., to the exclusion of fresh raw fruit, fresh raw green vegetables, fresh raw milk (preferably its mother's milk) raw nuts, and whole grains, if grains are used.

   A child may be eating foods containing all the food elements required, and yet, due to indigestion from overeating or from any of the above mentioned "social causes," not be able to digest and assimilate its food. Many cases of malnutrition are due to this cause. Undernourishment from overeating is common in our oft-fed babies. Dr. George S. Weger rightly says that an: "Overcrowded nutrition means starvation, whether it be in the infant that is fed more because it cries from already having had too much, or in the adult who gluttonizes because he is drunk on food and craves more stimulation of the same sort." When parents and physicians accept this fact and act upon it, children will be more healthy and will develop more beautifully

   A common, but unrecognized cause of innutrition is toxemia resulting from impaired elimination. This toxic state of the blood and lymph is back of the chronic disease of the tonsils, adenoids and sinuses, which is listed as a "physical cause" of malnutrition. Toxemia deranges and perverts nutrition. It is due to anything that overtaxes the vital or nervous powers and checks elimination.

   There are all degrees of malnutrition ranging all the way from a near-normal condition where there seems to be no definite symptoms, but still the child appears to be in not quite normal condition, to a condition presenting all of the symptoms previously described and many more and worse conditions. Malnutrition lays the faulty anatomic foundation of various organic diseases in later life. The remedy is a complete overhauling of the child's life--social and dietetic. See chapter on Feeding of Children.

   What are classed as nutritive, or deficiency diseases have two groups of causes--namely:

   1. Deficiencies in diet, either in quality or quantity, usually, except in famine districts, in quality.

   2. All of those factors and influences, whatever their nature and source, which render it difficult or impossible for the body to utilize the elements of its food, even though the food is perfect.

   Dietitians rarely give any attention to this second group of causes. They experiment with healthy animals and seldom see any other factor than that of a studied and deliberately made dietary deficiency. They are easily misled by their one-sided, or as they call them, controlled experiments.

   In dealing with children and adults let us always keep in mind that we are not dealing with controls. The life of a human being, child or adult, is much more complex than that of any experimental animal in the laboratory. His environment is more varied, his contacts greater in number, the influences to which he is subjected more numerous, and the resources of his environment greater.

   Pregnant mothers that are fed on a good diet, if their nutrition is impaired by overwork, worry, fear, or other cause, will not be able to assimilate the elements of their food and their babies will be born with the "seeds" of some deficiency disease "in their bones." The babies will then be fed-up (stuffed) in an effort to force them to take on weight and their own weak nutritive machinery will be so impaired that, in spite of an adequate diet, deficiency will develop. Too much handling, drugging and any other cause that debilitates the infant and child will damage its nutrition sufficiently to bring on nutritive disease. Indeed there is an element of nutritive disease present in every so-called disease.

   The needs of children for vitamins, salts and proteins are relatively greater than those of adults. These things are absolutely indispensible for the processes of growth and a deficiency in any one of them during the growth period has nutritional consequences. For this reason it is during infancy and childhood that most careful attention to nutrition is essential.

   By slight alterations in feeding, it is possible to produce all degrees of muscular change, and "other physiological functions are undoubtedly interfered with by the same apparently small dietetic abnormalities."

   Many eye troubles are blamed on the teeth, when, as a matter of fact, it would be equally correct to blame the tooth trouble on the eyes. Dr. Howe says: "Now it is apparent that both tooth and eye-trouble may have the same underlying cause! Xerophthalmia (the disease that attacked the Roumanian children because of the lack of vitamin A in their diet) is one of the first signs of vitamin deficiency in experimental guinea pigs. Running eyes occur in vitamin-deficient feeding. Many of our skulls showed decalcified areas in the orbit (eye socket) usually at the base of the teeth.

   In young guinea-pig mothers on the vitamin deficient diet, many eye disturbances appeared, cloudy spots on the coatings of the eye, opacity of the lens in both eyes like cataracts. After feeding the cataract specimen with orange juice in large quantities, the trouble disappeared."

   "Vitamin deficiency" may mean anything such as deficiency in health. When the diet is properly balanced with regard to minerals, there is no likelihood of any deficiency in vitamins occurring. By shortage or deficiency the "orthodox" food scientist usually means a shortage sufficient to result in some "deficiency disease." If ordinary health is maintained they are satisfied; superior health is not worth working for. We want better health than just average or so-called "normal" health. Not merely freedom from "disease," however slight, but abounding, positive health is the goal every parent should set for his or her children.

   Sherman and Macleod found in their animal experiments, that a great abundance of "vitamin-rich" foods, far more than enough to eradicate evidences of deficiency, added to a diet that is fully adequate for the development of the normal size, produces a marked superiority in the appearance and condition of the animal. There is increased growth and weight, the animal matures earlier, has a longer adult life, increased reproductive power with more offspring, has a delayed senility, so that the whole life-span is increased about ten per cent. This improvement may properly be called super-health.