Spinal curvatures.--These are often due to vicious postures caused by improper desks, bad lighting, undeveloped musculature, congenital difference in leg length, etc. Besides distorting the figure and unfavorably influencing physical development by reason of the resulting asymmetry, the altered relations of the bones and ligaments, together with the faulty distribution of the body weight in the erect position, spinal curvatures may lead to pains and weakness of the vertebral joints. Moreover, the faulty relations of the bones and the joints of the spinal column prevent the proper development of the heart and lungs.

Besides this, spinal curvatures are frequently symptoms of Pott's disease or tuberculosis of the spine. As the disease must be comparatively far advanced before any deformity is produced, the necessity is apparent for a careful examination and determination of the cause in all vicious postures of children.

Flatfoot.-Investigation has shown that an unsuspectedly large number of children suffer either from weak arches (probated foot) or flatfoot. Flatfoot is a common cause of much suffering and loss of bodily efficiency. In most instances the foundations of the disorder are laid in childhood through the use of defective shoes, improper standing postures, lack of development of the foot and leg muscles, and lowered states of the general nutrition. In most instances the use of proper corrective measures where applied in childhood will overcome or arrest the defect, so it is important to detect commencing flatfoot in children before the changes in the relation of the bones and ligaments of the foot become permanent.

Defective teeth.-An astonishingly large number of school children have defective teeth. Most of us regard teeth merely as aids to mastication and as ornaments to the mouth. Their loss or unsightliness seems to be regretted only from the cosmetic standpoint. In reality, the integrity and proper development of the teeth and dental arches have a most important relation to the general health and physical development. The permanence of the teeth in the jaws throughout life depends in a large measure upon the "occlusion" or the way the teeth fit together when the jaws are closed and the amount of available chewing surface.

Teeth well opposed and their chewing surfaces all available for use last well, and the constant use strengthens them in their sockets. Faulty "occlusion" or lack of ability of opposing teeth to come in contact with each other leads to their early decay through disease and fermentation of accumulated food particles. Decay started in such teeth readily extends to the others.

Not only do defective teeth contribute to defective development and a depraved state of health by reason of malnutrition and indigestion from faulty chewing, but the presence of decayed teeth and

diseased gums greatly increases the number of harmful germs in the mouth. The germs are swallowed with food and saliva, and the poisons they generate are absorbed and serve still further to lower the vitality.

Certain experiments made by dentists in Cleveland, Ohio, have given some very encouraging results. A number of school children from schools in the poorer section of the city and suffering from defective teeth, had their mouths placed in good condition, with the result that a remarkable gain in weight, general health, and scholastic standing ensued.

There can be no doubt but that a small amount of attention to the teeth in childhood is of inestimable benefit and far outweighs the most expensive and skilled treatment in later years, when it is too late. The teeth are such important factors in a sound mental and physical development that they are among the most important points covered by medical school inspection.

COMMUNICABLE DISEASES.

Vaccination.-Vaccination against smallpox is the most efficient safeguard ever contributed to preventive medicine against what was one of the worst diseases. Were everyone properly protected by vaccination, smallpox would cease to exist. Any system of mediical inspection of schools therefore should supervise vaccination in school children, nor would children be allowed to attend school unless successfully vaccinated or shown to be one of those occasional individuals who are naturally immune both to smallpox and to vaccination.

Infectious diseases of childhood. These are important not only because the ensuing mortality is greater than is popularly supposed, but because they may predispose to other diseases, such as tuberculosis, and several of them (e. g., measles, scarlet fever, diphtheria, etc.) may result in permanent disabilities. Moreover, the schoolroom is a place favorable to their spread. The necessity, therefore. is obvious for their detection in the school and the exclusion of children attacked until all danger of transmitting the disease to others is past. It follows from the foregoing that teachers should be familiar with the symptoms of the onset of these diseases.

Tuberculosis. The importance of tuberculosis as a cause of death is well known to all. Some 5 to 15 per cent of all school children suffer from active tuberculosis. Such children, when undetected, not but only may serve as a source of infection to their schoolmates, their continued presence in the environment ordinarily pertaining to schoolrooms may rob them of the chance of recovery they would otherwise have, for childhood is the period of life showing the greatest susceptibility to tuberculosis, as it is also the period holding out the greatest hope for recovery under intelligent treatment.

Intestinal parasites.-The investigations of recent years have shown the great importance of the presence of intestinal parasites in school children. Hookworm, which infects a large number of children in the southern States, is well known for the depraved condition of the health, anemia, stunted growth, mental apathy, and backwardness which it produces. Hookworm infection is undoubtedly the greatest single foe to advances in material prosperity in those States in which it is prevalent. It is not, however, a matter of general knowledge that other intestinal parasites, such as the whipworm (Trichocephalus dispar), the dwarf tapeworm, or even the ordinary roundworm, are capable of producing a high grade of anemia and otherwise interfering with the proper physical and mental development.

Intestinal parasites, as a rule, can be readily expelled by simple treatment. Their continued presence in the alimentary tract is so apt to be followed by unfortunate results that the examination of school children for intestinal parasites is indicated as a routine measure in districts where they are prevalent and constitutes an important part of medical school inspection in such regions. It should not be forgotten that children infected with intestinal parasites, even if the infection is so light as not to cause general symptoms, are, nevertheless, constantly passing the eggs in their excreta, and hence may serve as disseminators of the infection. This is particularly true in those sections where the insanitary privy is the rule rather than the exception.

Chronic communicable diseases.-In this category are included certain skin diseases usually affecting the scalp, such as ringworm and favus, and trachoma, a chronic contagious disease of. the eyelids. Favus and ringworm are regarded as "loathsome contagious diseases, while trachoma is designated as a "dangerous contagious disease" by the Federal authorities when found in immigrants. The exclusion of immigrants so affected is mandatory by law. Trachoma is readily spread by the close personal contacts of the schoolroom and playground, and may result in permanent impairment of the vision or even in blindness.

An accurate diagnosis of the presence of trachoma can be made only by turning up the eyelids of the affected individuals. In the absence of such inspection, some of the unfortunate results of trachoma, such as ulceration of the cornea, inflammation of the cornea (keratitis), etc., are likely to be attributed to other causes.

The disease is chronic, and when well established very difficult to cure. Hence it is of great importance to include examination for this disease in any form of medical school inspection.

Vermin.-It is astonishing to find the large number of school children infected with vermin such as body and head lice. Besides indicating neglect and poor surroundings in the home, the presence

of vermin may give rise to distressing eczema of the scalp or body. It has also recently been shown that the body louse is an agent for the transmission of typhus fever.

Mental deficiency and nervous affections.-Besides protecting the bodies of school children the state of their minds and nervous systems requires supervision from the medical standpoint. A certain proportion of children, either by heredity or through causes operative in early years, are permanent mental defectives. Others are apparently backward, but the underlying cause, while concealed, may originate in some physical defect discoverable only after competent examination. Epilepsy, neurasthenia, hysteria, and other nervous affections are not at all uncommon among school children, and proper attention in childhood may have the effect of turning these sufferers into useful citizens, rather than chronic invalids and inmates of institutions.

We clearly see, therefore, the necessity for the careful examination of mentally abnormal and deficient school children, so that the exact grade of their mental or nervous defect may be determined and the underlying cause made clear. The natural outcome of such examinations would be the creation of special classes for abnormal children.

Having thus briefly indicated some of the more important and common defects from which school children suffer and which have more or less pernicious influence upon their development and future usefulness, let us now look into the legislation provided, so far, in this country for dealing with the situation.

Unfortunately, up to the present time, such legislation is by no means so universal or far-reaching as it ought to be.

Twenty States, as follows, have recognized the necessity for the medical inspection of schools and have made some legal provision for its conduct: California, Colorado, Connecticut, District of Columbia. Indiana, Louisiana, Maine, Massachusetts, Minnesota, New Jersey, New York, North Dakota, Ohio, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, and West Virginia.

In 9 of the States the law is permissive, while in 11 it is mandatory. Of these 20 States, Massachusetts was the first to make medical inspection of schools mandatory by law in 1906, the legislation in the other States being passed from 1909 to the present time.

A considerable diversity exists in the kind of medical supervision contemplated, varying from examination for contagious diseases only to complete physical examination of pupils, teachers, and employees for defects of all kinds.

Massachusetts has probably the best and most developed system of medical school inspection in this country. The Massachusetts law provides (1) for the detection of contagious diseases in schools; and

(2) for the annual examination of children, (a) by physicians for noncontagious physical defects, and (b) by teachers for defects of eyesight and hearing.

It is evident, however, when we study what has been done as yet in medical inspection of schools, that the work is not sufficiently comprehensive. Too little money is appropriated, as a rule, for the purpose, and all available forces are not being generally utilized to their full capacity.

Let us then discuss the groups of persons who should make up the medical school-inspection staff and the extent of their duties and responsibilities.

These agents for the medical school inspection of children are as follows: (1) The school physician, (2) the school nurse, and (3) the teacher.

The Teacher.

We will begin with the teacher because her importance as an agent in medical school inspection has been generally overlooked. Hitherto teachers have been chiefly regarded as agents of instruction and discipline. No concern has been felt with respect to the part they might play in regard to the supervision of the children's health. Yet the teacher's position is filled with potentialities for good in such supervision.

In the first place, no one is brought into such close association with the class members as the school-teacher, and none, by precept and example, can exert so lasting an influence upon their mental and physical evolution. The sphere of usefulness of teachers can therefore be greatly increased by a good working knowledge on their part of the laws of health, the prevention of disease, and the fundamentals of school hygiene, and by being familiar with the more ordinary manifestations of contagious disease.

The school-inspection laws of most States provides for tests of the sight and hearing of school children by teachers. These tests are easily learned and readily executed. Their purpose is to single out the pupils having defective sight and hearing, so that the true cause and extent of their defects can be ascertained by competent medical examination and the proper treatment prescribed.

The teacher should also be the person to keep a record of the heights and weights of the children in the class. Recent studies have shown the close relation of height and weight to progress in physical and mental development.

According to Prof. Bird T. Baldwin, of Swarthmore (who has not as yet published his observations), mental maturity depends upon height and weight, the tallest and heaviest children of the same age being mentally the most mature.