community, pellagra is unknown, and there is but a limited prevalence of tuberculosis and typhoid fever. These diseases, therefore, are eliminated as causative factors. On the other hand, our observations tend to show that the habitual diet of these children was largely responsible. For example, the breakfast of 40 per cent of them was composed almost exclusively of carbohydrates, and but 60 per cent of them had a mixt diet of carbohydrates and proteids. Furthermore, 57 per cent used coffee, only 15 per cent drank milk, and 1.16 per cent did not habitually eat breakfast. The need is plain, therefore, for the general establishment of domesticscience classes in the schools, and the teaching of food values and food preparation.

Furthermore, no suitable facilities for play were provided, and no systematic physical exercises were practist at any of the rural schools of the county. The beneficial influences of these on health and physical development are now matters of common experience. Their absence may account in part for the subnormal physical development of a number of these children.

Ranking in importance with measures intended to increase vital resistance thru maintenance of the normal physical development of a school child are those directed to the discovery and correction of physical defects. Physical defects among rural-school children are potentially of more serious consequences than those among children in cities. This is due to the limited medical facilities in most rural districts, and in part to poorly constructed and equipt school buildings. Many examples illustrative of this observation have come under our personal notice. Witness the case of a small child between six and seven years of age who, figuratively speaking, was standing, on the edge of a threatening volcano, so far as life was concerned, by reason of a neglected inflammation of the middle ear. The otoscope revealed in this case a slit in a very congested eardrum thru which pus was oozing in great quantity. Neglect of such a condition leads to deafness and not infrequently to death. The parents of this child were unaware of the danger. Many cases similar to this occur in rural schools and remain unrecognized thru the lack of medical supervision until too late to prevent destructive changes.

Our investigations in the rural districts have revealed an almost complete disregard of visual prophylaxis. The faulty illumination so frequently observed in rural schools is largely responsible for much of the impaired vision encountered. Recent measurement of the desk-illumination of an eight-room school on a cloudy day showed that the illumination of more than half of the desks in a number of the classrooms was less than onethird of that demanded by the minimum standard. The effect of such faulty illumination is to promote eyestrain and to increase nearsightedness. The illumination of these classrooms could have been doubled by the proper tinting of reflecting surfaces; but the school authorities were without

competent advice in this important detail of school-construction. The need for such advice is largely responsible for many of the undesirable features of rural-school life.

Furthermore, a number of rural-school children had never been refracted and were sorely in need of glasses. The rural-school child cannot step around the corner to an eye clinic and secure the free services of a specialist. These children are frequently found wearing glasses entirely unsuited to them, as was a girl with one eye hyperopic and the other myopic, who was wearing a farsighted lens in front of the nearsighted eye.

The rural-school child is greatly in need of instruction in the care of the teeth and in need of adequate dental service. This is shown by the fact that 49.3 per cent of the children had defective teeth, 21.1 per cent had two or more missing teeth, and only 16.9 per cent had dental attention. Furthermore, 14.4 per cent of these children never used a toothbrush, 58.2 per cent used one occasionally, and only 27.4 per cent used one daily.

We have collected data relative to the occurrence of communicable diseases among rural children while attending school. The compilation of this material has not yet been completed. Sufficient evidence has been adduced, however, to indicate that the school is a factor in the spread of these diseases in rural communities, owing largely to the fact that the children of individual families are rarely in intimate contact except in school. An undue prevalence of these affections is measurably responsible for an increase in the number of children with impairment of the organs of special

sense.

The field investigations of the Public Health Service show certain problems of rural schools which require special consideration. For example: What is the remedy for the conditions just enumerated? How can the physical efficiency be increast? How can hampering physical defects be avoided? How is the control of communicable diseases to be brought about? How is improvement in rural school-construction to be secured? The answer is: (1) by abolishing school districts and establishing a county unit of school administration; (2) by establishing an efficient system of health-supervision of school children; (3) by consolidating rural schools. Let us consider these three facts further.

1. Educators have long advocated the abolition of separate school districts for administrative purposes, and the substitution therefor of the county unit. By so doing uniform school facilities can be provided for the county as a whole, which would include courses of study, requirements of teachers, duration of school term, and the pro rata distribution of school funds. In the absence of such a system of administration, generalized health-supervision of school children is well-nigh impossible.

2. Measures for the health-supervision of school children are of prime importance for educational purposes and the protection of health.

Unfortunately, only a small part of the rural-school population of the country enjoys the benefits of such supervision.

a) The interest of rural communities in the matter of medical inspection can best be secured thru intensive school-surveys. The value of this procedure lies in the fact that, by calling attention to unsuspected physical defects in their children and school conditions requiring attention, the necessity for some form of health-supervision is brought home to parents. We have had practical experience of the educational value of such investigations thru reports of an increast number of children seeking relief following surveys of this character.

b) The medical inspection of schools in rural districts is accompanied by a serious handicap, owing to the impossibility, under existing conditions, of securing the services of a person properly qualified for this position.

c) The restricted financial resources of most rural communities preclude the offering of a salary commensurate with the attainments of a desirable school-inspector. This difficulty can be overcome, in great measure, by combining the duties of the school physician with those of the district, county, or local health officer, with a salary equivalent to the combined salaries of the two positions. The trend of recent practice is to place the health-supervision of school children under the direction of the health authorities. Indeed such is the case in a number of our largest cities, namely, Baltimore, Boston, Buffalo, Chicago, Cincinnati, Detroit, New York, Philadelphia, and Pittsburgh. By so doing it becomes possible for these communities to secure the full-time services of a trained sanitarian for health work and school-inspection.

3. The possibilities of rural-school consolidation for the protection of the health of the children is an important consideration in the adoption of this measure. The sanitary requirements of school-constructions can more readily be secured in the larger buildings of this type and the child thereby placed in a more healthful school environment.

Lastly, no system of health-supervision will be effective without the cooperation of the parents. This can be secured thru the employment of tactful school nurses to do follow-up work. The practical application of the principles of sanitation by an efficient nurse in time of sickness will do much toward educating parents regarding measures for safeguarding the health of their children. In addition, the cooperation of social workers and the formation of civic leagues and of home- and school-improvement associations among rural-school children lead toward a better understanding of good citizenship and of the obligations of the individual to the community which, in time, should bring about improved social conditions and an increast efficiency of the individual.

COOPERATION IN HEALTH ADMINISTRATION

WILLARD S. SMALL, PRINCIPAL, EASTERN HIGH SCHOOL, WASHINGTON, D.C. Within the last year the United States Bureau of Education has collected a large body of information with regard to health-teaching agencies in the country. The number and variety of such agencies are truly amazing. They are both official and voluntary, commercial and philanthropic, single in their aim to promote health-and merely incidental to the main purpose of the institution to which they are auxiliary. A few illustrative examples will suffice: department of health, state, county, and local; departments of education, state, county, and local; insurance companies; industrial corporations; department stores; labor organizations; fraternal organizations; anti-tuberculosis associations; safety-first associations; medical societies; social-hygiene organizations; Youngs Mens' Christian Associations; charities organizations; boys' and girls' clubs; schools, colleges, and universities; bureaus of the federal government; and many others. Needless to say there is overlapping, duplication, and waste motion.

Beginnings have been made in cooperation and coordination. Mostly however, these attempts at cooperation have been voluntary or quasiofficial, and consequently of doubtful permanency. A typical example of cooperation of the quasi-official sort is the Minnesota Public Health Association organized in March 1914. It was an independent organization finanst by voluntary contributions. It served as a coordination center for investigation and propaganda and had recognized relations with the State Board of Health, the State Department of Education, the State Federation of Womens' Clubs, and other voluntary organizations. The salary of the executive secretary was paid in part by the State Board of Health for his services as publicity agent for the board. In the first year of its existence it performed valuable service in school-health work, both in the way of investigation and in the dissemination of information.

In the second year of its existence, however, its efficiency was greatly reduced on account of lack of funds and the breaking of the quasi-official relations with the State Board of Health. This illustrates aptly the tenuous nature of all such coordinations.

Quite generally the supporting agency for such cooperation is the public school. By reason of its universality and its specific organization, it naturally serves as a means of coordination. Too frequently the part played by the school is that of a complacent distributing agency for properly authenticated propaganda and for alien health-supervision. There is, however, a rapidly increasing tendency for the public school to become the effective coordinating agency-to organize cooperation. This, of course, is markedly the case in communities in which the health-supervision of the schools has been assumed by the educational authorities; but there are

cases of well-organized cooperation in cities in which health-supervision is still managed by the health department.

It should be recognized that the promotion of health is at bottom an educational problem the effective solution of which demands the most complete and sympathetic cooperation of the public-health and the publiceducation organizations. Volunteer organizations of all kinds will play important accessory rôles; but it is these governmental agencies upon which will rest the real responsibility. There has not been as complete cooperation of spirit and coordination of effort between health and school departments as there should be. Indeed, too often there has been mutual suspicion and misunderstanding. In the last few years there has been rather a markt tendency for the schools to take over the administration of phases of educational hygiene including "medical inspection." It is not at all certain that this tendency is permanent in character. As the supervision of the public health becomes better developt, it becomes evident that the control of health before school age is quite as important as the control of health during the school period. This phase of public-health work obviously must be administered by the health authorities. It is not at all improbable that "efficiency and economy" may require continuous administration of "child hygiene" by the health authorities, as is already the case in New York. At present the locus of administrative authority is largely a local question. In reality it is not important; the only matter of importance is that the highest possible efficiency be secured.

There is one modification, however, of administrative machinery that could easily be made, and, if made, would be a long step toward effective cooperation between school and health authorities. If the executive officer of every health board-state, county, local-were a member of the corresponding educational board, and vice versa, if every school superintendent— state, county, and local-were a member of the corresponding health board, there would be set up an effective legalized addition to the administrative machinery that could not fail to produce results in mutual understanding and unification of effort. It hardly need be said that a full-time health officer is necessary for the complete success of this plan.

There is one other opportunity for cooperation that is big with possibilities for the development and improvement of health work in the public schools. The federal bureaus that have to do with health and education should have the equipment and the resources to meet the growing demands that are being made upon them for information, advice, and guidance by local communities all over the United States. The Public Health Service should have the resources to make many such surveys as that described by Dr. Clark in his paper this morning. The Bureau of Education should have the resources to give adequate information and advice with regard to plans of administration whenever and under whatever conditions such advice and information are askt-and the requests are very numerous and