notation regarding the state of his nutrition. This position is strengthened by the comment of the Chief Medical Officer of London, 1910: "It is certain that malnutrition and physical defects are closely associated, and react upon each other, but it is difficult to determine their exact relation to each child, or to say in what degree malnutrition causes the other physical evils. Merely to increase the supply of food would, in many cases, not solve the complex problem of the individual child, although in many cases lack of food lies at the root of the mischief."

Interdependence of Conditions.-The extent to which malnutrition is causative of physical defects, or the degree to which physical defects are responsible for malnutrition has not been determined. Their interdependence appears to be certain, or their coincidental occurrence may be due in part to their mutual dependence upon a series of basic factors underlying the healthful functioning of the human body.

Solution of the Problem.-The solution of the problem of malnutrition is not at hand, nor will it be until medical inspectors give greater consideration to malnutrition. Considered as a unit defect, it possesses unusual significance in a constructive programme for the establishment of the preventive and correctional methods so necessary for the protection or the conservation of school children. Considered from the standpoint of education, malnutrition is undoubtedly a factor in retardation, elimination, and mediocre, or worse, school work. The powers

of attention, concentration, memory, and directive effort are undermined in children whose blood tissues are lacking in the elements necessary to normal function. There is more than a grain of truth in Bacon's statement: "The brain is in some sort in the custody of the stomach."

From the standpoint of prevention, the school environment with its poor air, overstrain, excitement, and attendant worry demands frequent inspection lest it serve to destroy appetite and impair digestion with a resultant deterioration in nutrition.

Special cases of malnutrition demand various treatments from the educational standpoint according to the underlying causal factors. Obviously, poverty in the home cannot be directly remedied by the school, but the institution of school lunches may serve to partially correct the disadvantage of the home environment. Special classes for anæmics and open-air classes for. children

physically impaired appear to be essential in order to prevent further malnutrition or to correct nutritional defects whenever noted. The correction of physical defects interfering with digestion or calling forth unnecessary expenditures of energy are prerequisite of any systematic endeavor to remedy malnutrition.

The social disabilities effecting undernourishment may be attacked through the institution of school nurses, home and school visitors, or through the direct utilization of the various social and philanthropic agencies seeking to improve the welfare of families in the community.

Determination of Malnutrition.-Beyond a doubt, the first step in the solution of the problem is the actual determination of malnutrition. The potentialities of educational measures are dependent upon the state of nutrition. Nutritional deficiencies cannot be overcome until a thorough investigation has been made along modern scientific lines in order that there may be reached a uniform conception of malnutrition itself, the basic causes operating to produce it, together with such essential reconstructive measures in our educational institutions as will enable them to cope successfully with all phases of the problem.

VI. CLINICAL STUDIES AND OBSERVATIONS IN THE MOUTH OF THE EXCEPTIONAL CHILD

By ARTHUR ZENTLER, D.D.S., New York City

Oral Hygiene.-The oral hygiene movement has made such gigantic strides in the last few years, all through the entire civilized world, that it must reach out to the problem of the atypical child.

If it is at all true that it plays an important rôle in the life of the "typical" child-and who will gainsay this to-day?— then it certainly must be true that oral hygiene is doubly important in the life and redemption of the "atypical" or otherwise handicapped child.

If the lack of proper mouth conditions in any given case is not the only reason preventing the child from rising from the atypical state into the typical, from the subnormal into the normal, it certainly is an impeding factor.

In order that this be clearly understood it behooves me to

give not only a brief definition of oral hygiene, which means health of the mouth, but to explain it in its broader meaning.

Meaning of Oral Hygiene.-Oral hygiene, aside from complete asepsis of the hard and soft structures of the mouth, implies the constant keeping of each tooth individually in such condition, and all teeth collectively in such relation to each other, as to preserve normal occlusion, which means that when the mouth is in a state of repose all the teeth should be in such contact as to afford to each other the greatest possible support—which contact will enable their occlusal surfaces to give the greatest possible service in the act of mastication.

Pictures Nos. 48, 49, and 50 represent the casts of the same mouth where the left side is in normal occlusion, showing the contact spoken of, while the right side is thrown into malocclusion, because of the extraction of only one tooth, thus showing lack of contact.

How Early Should Care of Mouth Begin?-The desire to obtain the ideal conditions of normal occlusion would lead one to the natural question of how early one must begin the care of the mouth. I believe I have answered this question in my essay read before the Section on Stomatology of the A. M. A. at its annual meeting of 1911, written with the purpose of pointing out that the care of the teeth of the child must begin in the mouth of the mother during pregnancy.

During infancy the foundation to well-developed jaw-bones should be breast-feeding as against bottle-feeding, the former stimulating growth through activity, while the latter does not possess this advantage. After weaning, it is essential that a diet requiring thorough mastication be observed. Mushy foods so generally used should be replaced by dry toast, not such softened by liquids; meat broths should be replaced by the actual meat given the child to chew on, of course care being taken that only the juice is swallowed, etc. This admonition as to eating such foods which need thorough mastication holds good from babyhood all through the rest of one's life.

Scrupulous cleanliness of the teeth must begin with the

1 "Oral Development in Progeny Influenced by the Buccal Tissues During Pregnancy."

emerging of the first tooth in the baby's mouth, and be continued throughout life.

Caries. If in spite of all care, caries make their appearance, the lost portion of a tooth must be so replaced that the original shape of the tooth is again obtained. Nothing short of this will answer the purpose of oral hygiene in its broadest sense. If any one or more teeth are lost they must be replaced, and this in such a manner as to afford to the adjoining and opposing teeth that contact of which I spoke in the beginning.

Wrong Alignment. If from prenatal or postnatal causes the jaw-bones have failed to develop normally, and thereby teeth emerge or shift into wrong alignment, the cause for lack of jaw development must be ascertained, removed if possible, and nature aided through artificial stimulation to properly develop the jaw-bones, i. e., if indications for future narrow dental arches are present appliances should be anchored on the teeth as early as their shape will allow it, for the purpose of expanding the jaw, etc.

Other Pathologic Manifestations.-Pathologic manifestations of less ordinary occurrence such as cleft palate, harelip, etc., must of course be attended to in earliest infancy.

If, however, for one or another reason, proper mouth conditions do not exist, the child so afflicted will show the evil sequelæ in a more or less marked degree. This will be in proportion to the seriousness of the defects, although even minor defects have their influence as well upon the physical as upon the mental status of the child.

The Mouth as a Cause of Retardation. It will, therefore, be easy to understand that even where the general clinical history points to negative findings, a thorough examination of the mouth may contribute to the discovering of the reason of a retarded mental development, as, for instance, in the following case:

The casts of the mouth of C. G., Case 77, 26 years old (Figs. 51 and 52), whose clinical history runs as follows: Male, only child, no hereditary traits reported, deficient animation at birth, some convulsions during teething, had diphtheria at 1, language developed slowly, walked and talked at 3, had measles at 9, tonsils removed at 10, is undersized and heavy, and mental development at present is like that of a child of 12 or 13.

When one considers that among all the evil effects resulting

from the abnormal condition found in the mouth of C. G., such as poor assimilation due to improper mastication, etc., improper oxygenation due to faulty respiration, the cause of the retarded mental development may readily be traced to a brain lacking a sufficient supply of well-oxygenated blood. Who may say that if C. G., who to-day clearly belongs to the defective class, due to pathologically retarded development, would have obtained, in early childhood, the needed care resulting in the establishment of proper mouth conditions, his mental development would not be a much simpler problem than it now is?

Whether in a condition as aggravated as his, and at an age as advanced as his, great beneficial results could be derived from remedying, to such an extent as would be possible, his oral defects, is not altogether certain. But from past experiences the attempt is warranted.

In another case, the one of D. T., Case 65, 18 years old (Figs. 53 and 54), male, there are perhaps prenatal causes working along with the postnatal causes. The one important factor always assisting normal jaw-bone development-I refer to breast-feeding-being reported positive in D. T.'s clinical history, the underdeveloped maxilla and mandible can be accounted for either as an inheritance, or as the result of prolonged existence of adenoids and enlarged tonsils. These were not removed until the age of 10, which means that mouth breathing was allowed to interfere with proper respiration during the period of jaw-bone growth.

Mouth Breathing.-Breathing through the mouth instead of through the nose changes the normal action of the muscles controlling the position of the lips, and changes the position of the tongue, which, when the mouth is in repose, in normal breathing, rests flat against the roof of the mouth, thereby contributing mechanically to a lateral development of the maxillary bones. When in breathing the mouth is kept open, instead of closed, as it should be, the upper lip is drawn upward, depressing the subnasal anterior portion of the maxillary bones, contributing to underdevelopment of these parts, which accounts for the original crowded condition of the upper anterior teeth of D. T.

The unfortunate remedy resorted to, in this case, in the desire to cope with this condition, namely, the extraction of the right and left upper cuspids, presumably for the purpose of