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EPOftt ',\ |in|Min|i jiMii|ii STATE f(i i HI I" 11 fi ( '''^IIIIIIHIIIIilliiiiillUinnil illl IHIillllH niliillililll 11 II I / Library OF THE University of NortH Carolina This book was presented by Ql ^\h-^ W^T XqN'^.VS >C">- This book must not be taken from the Library building. SEVENTEENTH BIENNIAL REPORT OF THE NORTH CAROLINA STATE BOARD OF HEALTH 1917-1918 I ' RALEIGH Edwards & Broughton Printing Co. State Printers 1919 TABLE OF CONTENTS PAGE Members of the State Board of Health , 3 Letter of Transmittal 5 Preface 6 Health Work in the State of North Carolina for the Biennial Period 1917-1918 7 What the Board of Health is doing with its money 12 Present Organization of the North Carolina State Board of Health 19 Work of the Executive Office 21 Bureau of Education 25 Bureau of County Health Work 27 Bureau of Medical Inspection of Schools 36 State Laboratory of Hygiene 39 Bureau of Epidemiology 41 Bureau of Vital Statistics 47 Bureau of Infant Hygiene 51 Bureau of Venereal Diseases 54 Recommendations of the North Carolina State Board of Health to the General Assembly of 1919 55 The First Recommendation 55 The Second Recommendation 59 The Third Recommendation 60 The Fourth Recommendation 63 General Financial Report 69 Financial Report, Laboratory of Hygiene 70 Fund Balance Sheet 71 Appropriations, Earnings, and Expenditures 72 Financial Report. Bureau of County Health Work 80 Disbursements by Counties 81 Members of the State Board of Health ^ i Elected by the North Carolina Medical Society: Thomas E. Anderson, M.D., Statesville. Term expires 1923. Charles O'H. Laughinghouse, M.D., Greenville. Term expires 1923. F. R. Harris, M.D., Henderson. Term expires 1919. Cyrus Thompson, M.D., Jacksonville. Term expires 1919. Appointed by the Governor: J. L. Ludlow, C.E., Winston-Salem. Term expires 1921. J. Howell Way, M.D., Waynesville. Term expires 1923. Richard H. Lewis, M.D., LL.D., Raleigh. Term expires 1919. Edward J. Wood, M.D., Wilmington. Term expires 1919. E. C. Register, M.D., Charlotte. Term expires 1923. LETTER OF TRANSMITTAL Raleigh, 'N. C, January 1, 1919. His Excellency, T, W. Bickett, Governor of North Carolina. My dear Sir :—Under authority of section 3, chapter 62, Public Laws of 1911, as amended by the General Assembly of 1913, I have the honor to submit the Biennial Report of the State Board of Health for the years 1917 and 1918. Very respectfully yours, W. S. Rankin, Secretary and Treasurer. PREFACE The same principles hare influenced the preparation of this biennial report as governed the j^reparation of our last report; therefore, the preface of the report of 1915-1916 is altogether pertinent to this one, and we trust we may be pardoned for the repetition : "It is our intention to smash precedent in the size and substance of biennial reports. The large size of the average biennial report appears to rest on the hope of impressing those to whom it is addressed (not the few who read it) vdih the size rather than with the contents of the re-port. The size alone of most of these reports precludes their being read by busy people; and it makes little difference whether the other class does or does not read them. There is a story of a young reporter who was directed by a large i^ew York paper to report a certain lynching of unusual public interest. The young reporter wired his paper to hold three columns for his story. The editor wired the reporter to confine himself to one column. The young reporter, in the atmosphere of the lynching, could see only the importance of the lynching, and wired back to the paper that it was impossible to restrict his story to a single column. The business manager telegraphed, 'Description whole creation covered in Genesis one. Read it.' "With this idea of brevity, and ^\dth the hope of reaching busy people, we have sought the avoidance (1) of matter that can be obtained easily from other publications, and (2) of matter consisting largely of details and statistics that is of little general interest and that can be more con-veniently supplied to those interested in the form of supplementary re-ports. For example, the State public health laws, the itemized statement of the bookkeeper, and the vital statistics of the State have been ex-cluded from the report. Any or all of this matter may be obtained in separate form by request of the State Board of Health. "The arrangement of this report is by fairly independent subdivisions, so that it is possible for one to read and understand any part of the re-port without reading the whole report." Health Work in the State of North Carolina for the Biennial Period 1917-1918 HISTORICAL DEVELOPMENT OF PtBLIC HEALTH WORK IN NORTH CAROLINA In the biennial report of 1915-1916, pages 10 to 15, inclusive, we attempted to epitomize by years the development of public health work in North Caro-lina. If it were not for the high cost of paper and printing at this time, we should repeat that part of our last report, adding the principal developments in the health work of the State for the years 1917 and 1918. Under the pres-ent circumstances, however, we shall restrict the record to the principal developments in the health work of the State for the last two years, referring the reader who may be interested in securing the complete record to the previous biennial report. • 1917. The General Assembly of North Carolina passed the following important health legislation: Chapter 263, entitled "An act to prevent and control the occurrence of certain infectious diseases in North Caro-lina"; chapter 244, entitled "An act to provide for the physical examination of the school children of the State at regular intervals"; chapter 276, entitled "An act for the cooperative and effective devel-opment of rural sanitation"; chapter 257. entitled "An act to pre-vent blindness in infancy, designating certain powers and duties and otherwise providing for the enforcement of this act"; chapter 66, entitled "An act to provide for the sanitary inspection and conduct of hotels and restaurants"; chapter 286, entitled "An act to regulate the treatment, handling, and work of prisoners." Following the enactment of this legislation, the administrative machinery, consisting of a bureau of epidemiology under the. direc-tion of Dr. A. ]\IcR. Crouch, a bureau for the medical inspection of schools under the direction of Dr. Geo. M. Cooper, and a bureau for county health work under the direction of Dr. B. E. Washburn, was established. Dr. Washburn, an officer of the International Health Board, was loaned to the State without cost, and the International Health Board, in addition to furnishing Dr. Washburn, appropriated $15,000 annually for rural sanitation in accordance with the pro-visions of chapter 276. The United States Public Health Service in February, 1917, de-tailed Dr. K. E. Miller to study county health work in different sec-tions of the country and to establish for demonstration purposes, in Edgecombe County, an efficient county department of health on an economic basis easily within the financial reach of the average county. The State Laboratory of Hygiene moved into its own building January 15, 1917. NOBTH CaROLIXA BoARD OF HeALTH The State was admitted to the registration area of the Union January. 1917, the Bureau of the Census having found after investi-gation that our birth registration was 96 per cent complete. The special campaign against typhoid fever, begun so satisfac-torily in 1915. was continued. Free vaccination of the people, how-ever, was interfered with by the difficulty in securing medical officers to do the vaccination, the preparedness program of the Government having caused many physicians and nurses to enter the Army and Navy; nevertheless, a total of 30,000 citizens of the State were vaccinated as a direct result of the Board's activities, and many thousands of others were vaccinated by the physicians of the State as a result of the educational work of the Board directed to im-press the public with the value of vaccination as a means of pre-vention for typhoid fever. In December, 1917, life extension work as developed by the Life Extension Institute of New York, which consisted briefly of the free physical examination of interested citizens for the purpose of advising them as to their physical condition and needed hy-gienic reform and medical treatment, was begun on a county basis. The funds necessary for this work were appropriated partly by the State and partly by the counties in which the life extension work was carried out. Dr. Amzi J. Ellington, who at the time was a resident physician in the New York City Hospital and who had during his residency in that institution studied the methods of the Life Extension Institute under Dr. Eugene Lyman Fisk. was put in charge of this work. Life extension work was carried out in Vance. Alamance, Lenoir, and Robeson counties, and resulted in the full physical examinations of 4,000 citizens. This work was very favorably received, and the outlook for its con-tinued development seemed excellent when, with the declaration of the war and the call for physicians to enter the military service of the country. Dr. Ellington felt compelled to enter the Army. For this reason, and for the further reason that it has been almost impossible to secure health officers during the past two years, the work was not resumed. The educational work of the State Board of Health consisted in the issuance of eight Bulletins, each monthly edition amounting to 45,000, and a daily newspaper health article. The Bureau continued its moving picture show exhibit and, in addition, prepared probably the best three-dimension educational exhibit in the United States. In 1917, the following exhibits were given: motion picture enter-tainments, 236; traveling public health exhibits, 32; special ex-hibits, 58; stereopticon entertainments, 3—^to a total of 95,000 peo-ple. Arrangements were made for the preparation of newspaper plate, which was sent to and extensively used by 202 papers having a total subscription list of 303,000. A large part of this newspaper material was prepared hy the well-known authority and publicist in matters of sanitary and hygienic education. Dr. W. A. Brady of Elmira, New York. Sevknteenth Biennial Repokt 9 The annual appropriation for the State Board of Health was $60,772.16. The annual appropriation for the State Laboratory of Hygiene was $12,500, and this, in addition to $9,087.22 in fees per-mitted under the laws of the State to be paid to the Laboratory of Hygiene for special work, provide the Laboratory with a total annual budget of $21,587.22. 1918. Much of the work this year was influenced by the war and had to do with preparedness. The State Health Officer visited Washington, at the request of the Council of National Defense and as chairman of a committee of State Health Officers, on a number of occasions for conferences with respect to preparedness measures, provisions for the control of venereal diseases, arrrangements for coordinating the control of infectious diseases in the civilian population with their control in cantonments, and to arrange, if possible, with the Public Health Service and the Surgeon General of the Army for preserving the personnel of State health departments during the war. The State Health Officer also made a visit to the States of South Carolina. Georgia. Alabama, and Florida for the Council of National Defense in order, if possible, to interest the Governor, the State Board of Health, and the State Council of Defense in venereal disease control. Considerable tinT.e w'as given to assisting Major John W. Long. Medical Aide to the Governor, in the work of organizing the Medical Advisory Boards and in interesting physicians in entering the medi-cal service of the Army and Navy, and, later in the year, in inducing the physicians of the State to become .members of the Volunteer Medical Service Corps. Partly as a result of these activities, the Surgeon General of the army assigned ]\Iajor Joseph J. Kinyoun to assist the State Board of Health in the control of communicable diseases, the Board being under no financial obligation for Major Kinyoun's assistance; and as a result of the successful termination of the activities of various interests looking to a more effective control of venereal diseases, the Kahn Chamberlain Bill passed Congress, and made available to the State of North Carolina, and without condition, $23,988.61 for venereal disease work. " The Laboratory during this year began the distribution of a high grade of diphtheria antitoxin. The Bureau for the Medical Inspection of Schools developed, and with a degree of success that we may say established, free dental clinics for the public schools of the State. This Bureau also de-veloped to a successful extent an arrangement in the form of ade-noid and tonsil clubs for the practical and economic treatment of public school children suffering from these defects. The Bureau of Epidemiology employed two third-year medical students, equipped them with motorcycles, and put them into the 10 XoRTH Carolina Board of Health field to investigate infringements of the quarantine law. Sufficient convictions were obtained to impress the medical profession with the determination of the State to enforce its health laws, and a fairly satisfactory compliance with the laws regarding the reporting of communicable diseases was brought about. The Bureau for Venereal Diseases, paid for by the Federal appro-priation, was established in September under the directorship of Dr. James A. Keiger, of Charlotte, X. C. Mr. Warren H. Booker, for the last seven years the efficient director of the Bureau of Engineering and Education, left in September for Red Cross work in France, the work of his Bureau being continued, with the exception of the engineering work, by Mr. Ronald B. Wil-son. As a result of Mr. Booker's leaving, certain funds became available, and a Bureau of Infant Hygiene, under the directorship of Mrs. Kate Brew Vaughn, was organized late in 1918. Perhaps the most outstanding feature of the health work during the year 1918 was the epidemic of influenza. The epidemic began early in October and caused in October alone 6,056 deaths; in No-vember 2,133 deaths; and in December, 1.497 deaths, a total during the last three months of 9,686 deaths. A fuller report of the work in handling this epidemic is found on pages 15 and 23 of this report. The annual appropriation for the. State Board of Health for 1918 was $73,210.38. The annual appropriation for the State Laboratory of Hygiene was $12,500. The Laboratory, during 1918, collected $8,532.48 in fees for special work, so that the total income of the Laboratory for this year was $21,032.48. In addition to the regular appropriation, as above given, the Laboratory of Hygiene has received, in accordance with the original act, fees for ex-amination of pathological specimens submitted by physicians; also a tax on all water companies of $64 annually for the examination of monthly samples of water, and, since 1907, a small amount for administering the Pasteur treatment to persons bitten by rabid animals. Receipts from these sources began to come in in 1905. The annual receipts from these sources for the various years have been as shown in the following table: 1905 $ 3,425.27 1906 3,425.27 1907 4,887.97 1908 4,887.97 1909 5.196.54 1910 5,196.54 1911 6.271.39 1912 6.271.39 1913 6,118.94 1914 6.118.94 1915 8.541.72 1916 8.541.72 1917 8,809.85 1918 8.809.85 Seventeenth Biennial Report 11 RE\^NUE BASIS STATE BOARD OF HEALTH SINCE ESTABLISHMENT. Year WHAT THE BOAKI) OF HEALTH IS HOIXi WITH ITS 3I0NEY The following was prepared for and is taken from the North Carolina Manual for the year 1919: We assume that the people of North Carolina are interested particularly in two things with respect to the work of the State Bo^d of Health: (1) What the Board spends; (2) wihat the Board gets for the expenditure. This statement, therefore, will deal, in as brief a manner as is consistent with clearness, with the debit and credit side of the State's account with public health. Just one additional introductory statement needs to be made—a statement in no sense intended as an apology, but as simple justice to the Board of Health. The work of the State Board of Health, during the last biennium. has been seriously interfered with by two things: (1) the war; (2) the epidemic of influenza. The war called for a mobilization of medical men and health officers. The State Board of Health lost a number of its officers to the military service of the country, and it was not only impossible to replace our losses, but impossible to secure health officers for extensions in the health work that would have been made but for the war. The epidemic of influenza necessitated the cessation of much public health work for the reason that public health forces were concentrated on the epidemic. EXPENSES OF THE STATE FOR PUBLIC HEALTH During the biennial period of 1917-1918, the average annual income of the State Board of Health, including the Laboratory but not the Sanatorium, has been $88,301.12. DIVIDENDS ox INVESTMENTS IN PUBLIC HEALTH Item 1.—The State Laboratory of Hygiene has examined annually for the last two years 8,652 microsopic specimens, which would have cost the peo-ple and the physicians of this State, if examined in other laboratories, a minimum of $1..50 per specimen, or a total of $12,978. This $12,978 is one dividend that is paid on the State's investment of $88,301.12 in he health of her people. Itevti 2.—The State Laboratory of Hygiene has examined annually for the last two years 2,100 samples of drinking water. These analyses, if made by other laboratories would have cost the State $5 apiece, or a total of $10,500 This $10,500 is a second dividend paid on the State's investment of $88,- 301.12 in the health of her people. Item 3.—The State Laboratory of Hygiene has treated annually for the last two years 336 citizens of North Carolina who had been bitten by rabid animals. It would have cost these citizens a minimum of $15,000 to have secured this treatment outside the State. This $15,000, then, may be re-garded as a third dividend paid on the State's investment of $88,301.12 in the health of her people. Item -'/.—The State Laboratory of Hygiene has distributed annually for the last two years 248,876 doses of typhoid vaccine. 7,896 doses of whooping cough vaccine, and 29,580 doses of smallpox vaccine, which vaccines, if pur-chased at the ordinary retail price, would have cost a minimum of $100,000. This $100,000 is, then, a fourth dividend paid on the State's investment of $88,301.12 in the health of her people. Seventeenth Biennial Report 13 Item J.—The State Laboratory of Hygiene has distributed annually for the last two years 2,412 doses, or 12,060,000 units, of diphtheria antitoxin. The antitoxin, distributed free of cost to the people in 1918, at the old retail price would have cost $12,060. The antitoxin distributed in 1917, at about one-fourth the previous retail price of antitoxin, saved our people an additional $9,000, making a total saving on diphtheria antitoxin of $21,000 for the last two j'ears. or an annual saving of at least $10,000. But this by no means represents the total amount saved under this item to the citizens of North Carolina. Commercial manufacturers of antitoxin, in order to sell their product at all in North Carolina in competition with the State's free anti-toxin, have had to cut their original price to one-third of what it was. The people are now paying only one-third of what they otherwise would have to pay for the antitoxin of private manufacturers. The arrangement of the State Board of Health for supplying antitoxin to the people of North Caro-lina saves our State not less than $20,000 a year. This $20,000 is, then, a fifth dividend paid on the State's investment of $88,301.12 in public health. Item 6.—The State Board of Health has interested the International Health Board and the United States Public Health Service in opportunities for suc-cessful public health work in North Carolina to the extent of obtaining from these agencies, during the past two years, a total appropriation of $43,- 720.96. In addition to this direct appropriation, we have secured from the above agencies the loan of health officials for work in North Carolina, with-out cost to the State, whose combined salaries during the time of their work in this State has amounted ta over $16,000. In short, we have been instru-mental in securing from outside sources, without cost to the State, during the last two years, $60,000 worth of health work. Item 7.—A silver nitrate solution has been supplied to all the physicians and midwives of the State, with instructions as to the law requiring the ap plication of this solution to the eyes of all new-born children for the pre-vention of gonorrheal ophthalmia, or blindness in the new-born. There occurs in North Carolina annually about 100 cases of gonorrheal ophthalmia, or blindness in the new-born—a form of blindness that is pre-vented in 98 per cent of the births, where it otherwise would occur, by the use of the silver nitrate solution; in other words, there are 12 V^ cases of this preventable blindness for every 10,000 births. The State Epidemiologist believes that he is conservative in assuming that in at least half of the births occurring in the State. 40,000 births, the law requiring the applica-tion of silver nitrate is complied with. If this estimate is correct and if the prophylactic is 98 per cent efl^cient in preventing blindness. 49 cases of blindness are prevented each year through this law. Let us assume, how-ever, that less than half of this amount of blindness is prevented—20 cases. It costs the State of North Carolina $185 a year per blind child to give it an education with the hope of making it self-supporting. It requires at least ten years at the Blind Institution for the child to receive this education. This would make a total cost to the State for educating the blind child, as an effort to make it self-supporting, ten times $185, or $1,850; for twenty blind children this would be $37,000. While estimates of the amount saved by this law will vary with the individual viewpoint, it will be admitted by all that this law is saving the State each year many thousands of dollars, and saving some of the State's citizens a loss that is incalculable. 14 ISToRTii Carolina Board of Health Item S.—The Board of Health was successful in securing the appointment of all the officers—State and county—concerned with quarantine work in North Cai'olina to the position of collaborating epidemiologist of the Fed-eral Government. While the Federal Government pays these officials only $1 per year in accordance with an Act of Congress, the position of an official in the Federal Government permits the State and county quarantine officers to use the franking privilege which saves to the State and the counties not less than $5,000 a year postage. Item 9.—Several years ago the State Board of Health was responsible for a change in the management of outbreaks of smallpox. The change effected was shifting the responsibility of protecting the unvaccinated (the only susceptibles) from the community to the unvaccinated individual. In mak-ing this change, the State Board of Health did away with a system of small-pox quarantine and isolation which, according to reports from counties for the year preceding the change in the method of control, was costing the State $66,000. Smallpox is one of the least significant factors in the State's death rate. As a result of the change in the method of control, there has been, apparently, no increase in either cases or deaths. It appears, therefore, that the Board of Health, through this policy of making the individual responsible for his susceptibility to smallpox instead of his .community, is saving the State annually something like $50,000. Item 10.—In 1914, for the first time in the history of the State, deaths from all causes were accurately recorded. In that year there were 839 deaths from typhoid fever; in 1915, 744; in 1916, 700; in 1917, 628, and in 1918. 502. There were saved, therefore, 839 less 628, or. 211 lives from typhoid fever during the year 1917. There were saved 839 less 502, or 337 lives during the year 1918, or. during the two years, there have been saved 548 lives from typhoid fever. The fatality from typhoid fever is 10 per cent; that is, 100 cases of the disease cause 10 deaths. A decrease of 548 deaths, therefore, was neces-sarily associated with the prevention of 5,480 cases of the disease. Taking the estimates of the value of the average life at the average age at death from typhoid fever, made by political economists of national reputation and based upon the life expectancy and earning capacity, the 548 lives saved were worth $4,000 each, a total of $2,192,000 of vital conservation. The prevention of 5,480 cases of typhoid fever associated with this saving of 548 lives also has a money equivalent. The average case of typhoid fever lasts six weeks. The cost of treating an average case of typhoid fever, esti-mating the amount paid physicians, druggists, and nurses, and losses of salary or per diem on account of sickness, may be conservatively estimated at $100 a case (usually estimated at $200 each case), which amounts to a total of $548,000 saved from sickness. In this item it appears, therefore, that through the work of typhoid pre-vention as organized, directed, and carried on by the Board, and through the Board's previous efforts there is a vital saving to the State of No.'th Carolina estimated at $2,740,000. . Itevi 11.—The State law which requires that all plans and specifications for waterworks and sewerage systems shall be submitted to and approved by the State Board of Health, before being accepted by the municipalities for which the plans and specifications are designed, safeguards our towns and cities against the work of cheap engineers and contractors. To illustrate: A Seventeenth Biennial Report 15 town in this State, before this law went into operation, let a contract for the installation of a public water supply. The water supply was found dan-gerous on account of its location and had to be moved. The location of the water supply, had it been passed upon by the State Board of Health, would never have been approved. To change the location of the supply cost the town somewhere between $10,000 and $1.5,000. Many such losses have been saved the municipalities of the State by this law which requires that all plans and specifications for water supplies and sewerage systems be examined and ap-proved by the engineers of the State Board of Health before being accepted by the towns and cities for which they are intended. Item 12.—The State Board of Health, in its direction of the management of the influenza epidemic, believes and claims that when the epidemic has passed and the records are available, comparisons with the other states will show that the influenza cases and deaths per thousand population in North Carolina compare favorably with the incidence of the disease elsewhere, and that in attaining these results the cost of handling the epidemic to this State was small, comparatively speaking. In the work of medical relief, sixty-four communities were served with seventy emergency doctors and sixty-one emergency nurses at a total cost to the State of $1,266.37. We claim now, leaving the verification of the claim to the future, that in this work we saved many thousands of dollars to the State of North Carolina. Item 13.—Over 160,000 school children have been given a preliminary physi-cal examination by school teachers in accordance with instructions and un-der the direction of the State Board of Health. About 48,700 of these school children have been given a second or complete physical examination by physicians and specially trained nurses in accordance with instructions and under the direction of the State Board of Health. It is oflficially recorded that 10,670 of these school children have been treated. As a result of the above examinations and treatments, thousands of other school children of which we have no record have received much needed and proper treatment. Item, 14.—During the first full year, 1918. of its existence, the Bureau of Epidemiology of the State Board of Health prescribed the method and super-vised the quarantine of 29,785 cases of communicable diseases. As a further precaution against the unnecessary spread of communicable diseases, the teachers, pupils, and patrons of 3,598 public schools were notified, through a well-developed system, of the existence of communicable diseases in the school community, of the dangers of the disease, its methods of spread, and the means for its control. In this way. many thousands of cases of con-tagions that would have occurred otherwise, causing many deaths, have been prevented. Item 1-).—Probably the most important, certainly the most fundamental, health law that any State may enact is a vital statistics law. The vital sta-tistics law of North Carolina requires the State to secure, and permanently preserve in a fire-proof vault, a complete record of the two principal events in the life of each citizen—the birth and the death of the citizen. The State holds that not one of its citizens is so humble that his coming and his going should not be taken official note of. An annual average of 77,000 births and 34.000 deaths are registered, card indexed and classified by race, sex, age, county, township, town or city, and by cause of death. For the individual, these records mean that each child may be enabled to keep track of its ancestors—father, mother, grandparents, great grand- 16 XoRTH Carolina Board of Health parents, collateral kin. Each individual will be enabled to prove his or her age in the courts, his or her right to suffrage, the right to marriage, the right to insurance, the right to enter various industries, the right to inheritance, etc. For the State, this law means that the number of deaths per thousand of the population occurring in North Carolina, or in any county or township, or town or city of the State, shall be known; it means that the number of births per thousand of the population in the State, in the counties, in any part or subdivision of the State, shall be known; that by comparing such figures with similar figures from the other states of the Union, the people of this State, the people of other states and of the world, may know, not guess, what health conditions in North Carolina are. Best of all. this law has shown and caused to be published on the au-thority of the United States Government the fact that the State of North Carolina is one of the healthiest in the Union. This is the meaning of our death rate of 13.0 per thousand of the population per year, and our birth rate of 31.9 per thousand of the population per year as compared with the average death rate of 13.9 and birth rate of 24.8 of the registration states of the Union for the same year—the last year for which the figures are available. Item 16.—A continuous and extensive educational campaign has been waged against unhygienic and insanitary conditions in the homes and com-munities of the State. This has been carried on in the following manner: The Health Bulletin has been mailed to an average of 48,000 people monthly; specially prepared leaflets, pamphlets and placards have been distributed upon request to an extent exceeding 30,000 monthly; daily articles have been supplied to the newspapers of the State for publication, these having been used in publications having a circulation in excess of 1,125,000; a total of 12,816 letters have been written; motion pictures featuring health subjects in an entertaining manner have been witnessed by approximately .58,298 peo-ple; approximately 19,971 people have witnessed illustrated health lectures; approximately 52,285- people have witnessed special health exhibits. The value of the results attained by these efforts is something that cannot be estimated in dollars and cents. The value of any educational movement is an intangible quantity. The Bible, the work of the ministers and the churches, the school system, the press, all are vital agencies upon which no exact value can be placed, but of such tremendous importance that no sane person would argue for the suppression of any. In like manner the educational work along health lines cannot be valued exactly. It has car-ried information and instruction to the people of the State, reaching di-rectly at least one-half of the population. "Line upon line, precept upon precept," the prevention of disease has been preached, and the deaths from preventable diseases have been materially reduced. Item n.—The State Board of Health, by its educational activities, has fostered, strengthened, and directed an interest on the part of the counties in local health work so that today North Carolina has sixteen counties, em-bracing a total population of 687,634, or 28V2 per cent of the population of the State, under whole-time county health officers. No State in the Union has developed its county health work to a like extent. Sevexteexth Biennial Report 17 Item IS.—In nine of the sixteen counties referred to in item 17, the State Board of Health has had direction of the county health work for a period of fourteen months, and in that time the amount of work accomp]is]ied is in-dicated in the following tabulation: 1. 969 public health meetings were held with a total attendance of 87.450. 2. 815 health articles were published in the county papers. 3. 7.364 homes constructed sanitary privies. 4. 20,834 people were examined for hookworm disease, and 3,928 were treated. 5. 479 schools were visited by health officers. 6. 38,969 school children were examined by the teachers working under the direction of the health officers. 7. 12.699 school children were examined by the health officers, these chil-dren being referred by the teachers. 8. 6.171 defective children were treated. 9. 1,528 adults were given physical examinations by the health officers. 10. 37.234 people were vaccinated against typhoid fever. 11. 6.450 people were vaccinated against smallpox. 12. 4.356 cases of infectious diseases were quarantined. Item 19.—The executive office of the State Board of Health rendered con-siderable assistance, possibly amounting altogether to two months full-timo service, to the Council of National Defense, the Surgeon General of the Army. and the Medical Aide to the Governor in the preparedness program of the country. Item 20.—To indicate the general business handled by the State Board of Health, the official correspondence, during the last two years, has amounted to a receipt of 92,550 letters and 104,120 replies. This is equivalent to a daily correspondence of 126 letters received, and 142 replies. This does not include the preparation and mailing of 110,704 multigraph letters. 18 XoRTH Carolina Board of Health ^ ^^> 5: X 'o ^ sj ^ ^5^ ^ o s •5; .$ ^§.^ i^Sv^ <\, ^ \ N ^ PRESENT ORGANIZATION OF THE NORTH CAROLINA STATE BOARD OF HEALTH The North Carolina State Board of Health consists of the Board proper and the executive staff. TJie Board of Health, as indicated diagramatically on page 18, consists of nine members, five of whom ai'e appointed by the Governor and four of whom are elected by the North Carolina State Medical Society. The organization of this body embodies two important administrative principles: (1) stability of organization and permanency of policies; (2) partnership of State and the medical profession in the conservation of human life. The stability of the organization of the Board of Health depends funda-mentally upon the Board's freedom from political tinkering. The divorce-ment of the State Board of Health from politics depends largely upon the manner of selecting the members of the Board. Sudden and marked changes in the personnel of the Board under the present plan of organization are impossible: First, because the members of the Board of Health are ap-pointed for terms of six years and their terms of service expire, not in the same year, but in different years. The appointment of new members of the Board is, therefore, gradual and not sudden. Second, the Board of Health is selected by two parties: one, the Governor, and the other, the State Medi-cal Society. It is far less likely that two parties naming a Board would be dominated by political considerations than where one party names the Board. This division of the appointive and elective power and this provision for the slow and gradual exercise of that power by two parties guarantee the State Board of Health against the sudden changes of personnel and policy asso-ciated with a purely political organization. The Board of Health is stable; its members come and go, but as an organized body it stays. This stability of organization is the responsible factor for the permanency of policies adopted by the Board. Political boards elected or appointed for two years or four years are naturally inclined to adopt two- and four-year policies, to attempt to make the best showing possible during the short term of their official life. Their administrative thoughts and plans are largely defined by the time limitations of their administration. This is not true of self-perpetuating bodies such as the Board of Health, that, as legally con-stituted, has no limit to its life. The second administrative principle embodied in the organization of the State Board of Health is the recognition by the State of the fundamental rela-tion of the medical profession to the work of prevention. The State recog-nizes (1) the debt of society to that profession by which nearly all of the experimentation and discovery on which disease prevention is based, with the exception of the work of Pasteur, was contributed; (2) the interest of organized medicine in the conservation of human life and the peculiar abil-ity of organized medicine to advise the State as to the methods of preven-tion; and (3) the necessity of securing trom the medical profession first information in regard to the occurrence of deaths and their causes, and the appearances of epidemics. The executive staff of the State Board of Health may be divided into the executive office and the various bureaus or special divisions. The Executive Office.—The executive officer of the State Board of Health should be a man with technical training and experience, and, therefore. 20 I^ORTH Carolina Board of Health should be selected on account of his technical rather than his political quali-fications. It is, therefore, right that the Secretary of the State Board of Health, or the executive officer, should be selected by a specially qualified committee, that is, the State Board of Health, and not elected in a general election, as would be the case if the office were a political one. The six-year term of office for which the Secretary is elected is. in accordance with the idea of permanency of policies. The work of the executive office is detailed elsewhere. The Bureaus or Special Divisions of the Executive Staff.-—The work of the State Board of Health is large and varied, and is, therefore, apportioned among eight bureaus. These bureaus are each directed by an officer with special talent and training. The different bureaus and their more important problems are fully and clearly indicated in the diagram on page 18. The Correlation of the Work, of the Board.—This is also clearly indicated in the diagram on page 18. The division of the executive sitaff into special bureaus has the advantage of giving individualism to the work of each bureau and thereby creating a laudable pride and a healthy rivalry among the various bureaus engaged in the general work of the Board. While each bureau is separate and independent of other bureaus, as indicated in the diagram, the work of the entire executive staff is coordinated—the work of the Board being given compactness by the relation of the bureaus to one another through the executive office of the Board. IVORK OF THE EXECUTIVE OFFICE Character of Work OBJECTIVES The objectives of the executive office are: To determine what should be the public health policies of the State; to secure the adoption of desirable health policies by the State Government, and to supervise and to assist in their execution. More fully and analytically stated, the objectives of the executive office are: (1) To determine what are the more important state health policies of the State of North Carolina, and in what order they should be developed. (2) To arrange for and, when possible, to secure, by appropriate educa-tional methods and legislative recommendations, the necessary measures and appropriations for the successful development of the more important State health policies. (3) To find and employ persons properly qualified by native endowments, training, and experience, to man and direct bureaus or divisions under the State Board of Health for the successful development of the more important plans of the Hoard. (4) To give such direction, supervision, and assistance to the bureaus or divisions entrusted with the execution of State health policies as they may need. (5) To deal with all matters of official interest that may come to the attention of the State Board of Health that are not referable to some bureau or division entrusted with carrying out some special public health work. (6) To receive, disburse, and account for the funds available for the work of the State Board of Health. METHODS The methods of work adopted depend entirely upon the objectives sought. Therefore, in discussing the methods of the work of the executive office, we shall discuss them in connection with each of the aforementioned objectives. Methods for Objective 1.—In determining the public health policies of the State, it is necessary (a) that the executive office secure information through special and regular reports on the vital statistics of the State, and in this way be fully cognizant at all times of the vital conditions of the State as shown by the State's birth rate, the State's general death rate, the State's special death rates for certain diseases, the death rates in the State by counties, by races, and by seasons; (6) that the executive office secure infor-mation, through public health literature, books, and periodicals, as to the more recent developments and discoveries in public health work; (c) that the executive off.ce. by keeping in touch through conferences with other State health officers and Federal health officers, be thoroughly conversant with the methods and accomplishments of other State departments of health, and that the executive office be alert to those larger interstate movements, especially those related to action by the central government, in order that whenever and wherever possible those larger movements may be influenced to the advantage of the State. For Objective 2.—To secure the necessary measures and appropriations for the development of the State health policies, the following methods are pur-sued: (a) The people of the State are informed, through bulletins, exhibits, 22 jSTorth Carolina Board of Health the press, and public addresses, as to vital conditions and as to necessary measures and appropriations for favorably influencing the vitality and phy-sical efl!iciency of North Carolina people. In this way the executive office seeks to develop a favorable public sentiment for the development of its more important public health policies; (6) The executive office seeks to find and to interest certain individuals qualified by heart and head and position, for influencing, introducing, and supporting needed legislation. For Objective 3.—To find and secure, with the available means, a personnel for the bureau, division, or agency of the Board that may be relied upon for carrying into successful execution some special and important public health policy, calls for (1) an acquaintance with those who are in touch with men qualified for such positions, and (2) a judgment of men. This judgment of men by which an administrative oflScer selects his assistants is. of course, basic in the success or failure of an administration. Fo7- Ohjective '/.—In giving assistance to members of the executive staff charged with carrying out certain special health policies, the executive oflSce attempts to keep in touch with the work of each division or agency through regular monthly reports, special reports, and conferences from time to time. Consideration for the right amount of assistance—not too much and not too little—is regarded as important. Too much supervision tends to smother individually, to stifle the pride of accomplishment, to break down the self-confidence of an agency; while, on the other hand, too little supervision not infrequently results in a useless expenditure of funds. For Objective 5.—In taking care of the general business of the Board which is not referable to special bureaus, the executive oflice uses much of its time in correspondence or in conferences. Perhaps 60 per cent of the time of the executive office is spent in this way. The total correspondence of the execu-tive office is shown on this page. In addition to this correspondence, from 12 to 20 per cent of the time of the executive officer is consumed in official con-ferences with callers. This would leave about 25 or 30 per cent of the time of the executive office to be devoted to the other objectives. For Objective 6.—The bookkeeping of the executive office is entrusted to a thoroughly reliable, careful, and bonded clerk, whose system of account-ing has been devised by an expert accountant and whose work is audited at regular intervals. ROUTIXE WORK Letters received 6.971 Magazines and bulletins received and reviewed (1918) ^ . . 711 Letters written : Individual 7. .537 ^Tultigraph 22.099 Total 29,546 Articles written: Newspaper (words) ; 750 Bulletin (words) 20. .300 Official publication (words) 41,150 Other publication (words) 33,825 Forms and placards prepared 14 Addresses delivered : Number 23 Total audience 1,900 Inspections: State institutions (1917) ^ Countv institutions (1917) 16 Hotels (1917) 4 Epidemics: Conferences with local authorities (1917) 14 Supervision of (1917) 1 Jail reports received and examined (1918) 284 Convict camp reports received and examined (1918) 191 Seventeenth Biennial Eeport 23 Telegrams received o05 Telegrams sent 810 Vouchers issued 3,813 Receipts issued 411 Financial reports prepared 93 Days out of office on official business 165 Percentage of work not embraced in above statement 30 Important items not included in above statement: Conferences, Medical De-fense Work, Legislation, Influenza Work. M0>THLY AVERAGE Letters received 290 Magazines and bulletins received and reviev/ed 59 Letters written: Individual 314 IMultigraph 917 Total 1.231 Articles written: Newspaper (words) ' 31 Bulletin (words) 845 Official publication (words) 1,714 Other publication (words) 1.409 Forms and placards prepared 1 Addresses delivered : Number 1 Total audience , 79 Inspections: State institutions County institutions 1 Hotels Epidemics : Conferences with local authorities 1 Super\ision of Jail reports received and examined 23 Convict camp reports received and examined 15 Telegrams received 21 Telegrams sent 33 Vouchers issued 158 Receipts issued 17 Financial reports prepared 3 Days out of office on official business 6 Percentage of work not embraced in above statement 22 RESULTS OBTAINED Result 1.—The executive office planned, established, and gave much time to the successful development of the work of five new bureaus. The executive office, therefore, shares the credit of the work accomplished by these bureaus. The bureaus established during the last two years are: (a) A Bureau of Epidemiology (complete report of work on pages 41 to 46, inclusive), which concerns itself with enforcing the State laws that prescribe methods of quar-antine for the prevention of communicable diseases; (6) A Bureau for Medical Inspection of School Children (complete report of work on pages 35 to 37, in-clusive), which concerns itself with arranging for and supervising the physi-cal examination of public school children, and providing and securing proper treatment for as large a number of the school children that are found to need medical treatment as is possible w'ith the means at the disposal of the Bureau; (c) A Bureau of Infant Hygiene (complete report of work on pages 51 to 53, inclusive), which concerns itself mainly with the great and un-necessary loss of life under five years of age—11,749 deaths out of a total of 34,000 deaths at all ages for the State each year, and more than one-third of the total deaths—with the aim of lessening this vital loss by special educa-tional measures and by demonstrating to the local governments of the State the value of public health nurses for educating and assistin.p: the mothers of 2-i XoRTH Carolina Board of Health the State in the care of their children; {(I) A Bureau of County Health Work (complete report of work on pages 26 to 34, inclusive), which concerns it-self with the proper development of model county health departments and with the supervision of nine such county health departments now in opera-tion; (e) A Bureau of Venereal Diseases (complete report of work on page 54), which concerns itself with the treatment and the rendering noninfectious of persons having venereal diseases, with suppressing prostitution, and with educating the public to the advantages of sex hygiene and the dangers of unchastity. Result 2.—The State Board of Health has interested the International Health Board and the United States Public Health Service in opportunities for successful public health work in North Carolina to the extent of obtaining from these agencies, during the past two years, a total appropriation of $43,720.96. In addition to this direct appropriation, we have secured from the above agencies the loan of health officials for work in North Carolina, without cost to the State, whose combined salaries during the time of their work in this State have amounted to over $16,000. In short, we have been instrumental in securing from outside sources, without cost to the State, during the last two years. $60,000 worth of health work. Result 3.—The executive office rendered considerable assistance to the Council of National Defense and to the office of the Surgeon General in the preparedness program of the country. This assistance consisted in making a number of trips to Washington for conferences, and at one time in making a ten-day trip for the Council of National Defense to the States of South Carolina, Georgia, Alabama and Florida for conferring with th-e Governors, the State Health Officers, and the Chairman of the State Councils of Defense of those States with respect to sanitary defense measures. We also gave much time and assistance to the Council of National Defense in the organi-zation of the Volunteer Medical Service Corps, the aim of which was the mobilization of the medical profession on the basis of a signed agreement by each physician who is a member of the corps, leaving to the Council of National Defense the disposition of his services during the war. Still fur-ther work on the preparedness program of the country was assistance ren-dered to Major J. W. Long. Medical Aide to the Governor, in the organiza-tion of the Medical Advisory Boards. Result .'f.—The executive office formulated, after conference with State officials, local agencies and authorities, the measures directed to the regu-lation of the influenza epidemic and to the medical relief work. In the work of medical relief, we were instrumental in serving sixty-four communities, having sent seventy emergency doctors and sixty-one nurses at a total ex-pense to the State of approximately $1,266.37. This report is being made be-fore the epidemic has subsided and before figures are available showing case rates and death rates in other states, and the cost of handling the epidemic to other states, but we feel safe in asserting now that when these figures are available, the case rates and death rates in this State will com-pare favorably with those in other states, and we believe that comparison of the cost of handling the epidemic will show a saving of many thousands of dollars to the State of North Carolina. Result .').—The executive office has handled an official correspondence dur-ing the last two years amounting to a receipt of 6,971 letters and 7,537 re-plies. This does not include the preparation and mailing of 22,009 multi-graph letters. WORK OF THE BUREAU OF EDUCATION Character of AVork OBJECTIVES The Bureau of Education is conducted for the following specific purposes: (a) To appoint out and endeavor to change those habits and customs which interfere with the highest physical and mental development of the individual and the State. (&) To prevent epidemics of communicable diseases by giving warning of their occurrence, and by giving information with regard to the methods of control and prevention. (c) To interest the people of the State in individual and community health work in order that home and community hygiene and sanitation may be im-proved, and health instead of disease made "catching." METHODS The methods of attaining these purposes are as follows: (1) The Health Bulletin has been published monthly, dealing informa-tively with subjects of hygiene and sanitation. It is mailed free upon re-quest to any citizen of the State. The average monthly circulation is 48,000 copies. (2) Special pamphlets and placards, dealing in a thorough manner with specific diseases and conditions, have been prepared. These are mailed upon request free to citizens of the State. The average number distributed monthly has exceeded 30,000. (3) A press service has been maintained through which daily articles, varying in length from two to five hundred words, have been sent to all the newspapers of the State. These consist of: articles having a news value but little value in the teaching of hygiene and sanitation; articles having both a news value and which teach hygiene and sanitation; articles which teach hygiene and sanitation, but with little or no new^s value. In addition specially prepared articles on hygiene and sanitation have been prepared in plate form for distribution to 102 weekly newspapers of the State. The newspapers of the State have cooperated most heartily by making extended use of this press service. (4) Stock lectures have been prepared, together with lantern slides to illustrate them, these being furnished to civic organizations interested in promoting community health. Lanterns, slides, and lectures have been so arranged as to be easily available, and have been largely utilized. (o) Traveling exhibits, covering many subjects of hygiene and sanitation, have been prepared which through models and charts give a graphic pre-sentation of the subject. These have been furnished to local organizations in the same manner as the illustrated lectures. In addition an elaborate exhibit has been prepared for the fairs of the State, the exhibit being given by a trained demonstrator. (6) Motion pictures, featuring health subjects in an entertaining manner, have been used by means of a special traveling motion picture outfit which began the service in March. 1916. Through this method a number of people have been reached who could not be reached through other methods. 26 XoKTH C'aholina Board of Health KOUTINE WORK The details of the work are indicated in the following summary: Newspapers and magazines received and reviewed 13,660 Letters and postals received 19.530 Letters written : Individual 6,701 Multigraph 6.115 Total 12,816 Articles written: Newspapers Health Bulletin Official Pamphlets Other publications Total words 419,723 Motion picture entertainments given 264 Total audience witnessing same, approximately 58,298 Addresses delivered 11 Total audience present, approximately 1,861 Stock lectures given 167 Total audience present, approximately 19,971 Traveling public health exhibits given 39 Number seeing exhibits, approximately 52,285 Special exhibits given 58 Monthly Health Bulletins mailed 696,500 Pamphlets, leaflets, and placards distributed 743,398 Articles prepared for newspaper plates (words) 23,100 Number plates sent to newspapers 920 EESULTS OBTAINED Through the means of personal correspondence, the monthly Health Bul-letin, special pamphlets and placards, addresses, lectures, special traveling exhibits, and the newspapers of the State approximately one half of the en-tire population of North Carolina has been reached directly with a message of health. The value of this is something that cannot be estimated in dollars and cents. The value of any educational movement is an intangible thing the worth of which we realize, but which we cannot reduce to terms of money. The Bible, the work of the ministers and the churches, the school system, the press, all these are educational agencies of tremendous importance. So vital are they, in fact, that no sane person would for a moment argue for the suppression of any one. Yet it is not possible to say what any one of these agencies is worth to North Carolina in sums of money. So it is with the educational health work conducted by this Bureau. It has carried information and instruction to the people of the State with re-gard to hygiene and sanitation. It has shown how communicable diseases may be avoided; how epidemics may be controlled and prevented. It has waged warfare against those insanitary conditions which produce typhoid fever and the allied diarrheal diseases. It has carried a message of hope to the tubercular and has been the instrument of saving many from untimely death by pointing out the way to restored health. "Line upon line, precept upon precept," the prevention of disease has been preached, and the deaths from preventable causes have been materially reduced in the State. REPORT OF THE BUREAU OF COUNTY HEALTH WORK (July 1, 1917, to November 30, 1918) Character of Work The Bureau of County Health Work of the North Carolina State Board of Health is the agency through which the State extends cooperation to the counties in organizing and maintaining permanent county health depart-ments. The Bureau was organized July 1, 1917, and is supported by funds provided by the General Assembly and by the International Health Board. OBJECTIVES The object of the work of the Bureau is to defnonstrate the best methods of performing County Health Work. The work of each county health department organized and conducted by the Bureau of County Health Work is to present the health problems of the county, together with the best means of solution, to the people in a definite and comprehensive manner, and by a plan designed to reach directly and educate each home. This plan comprises lectures and demonstrations, news-paper articles and letters, and home visits with the aim of having the people apply in their homes the latest discoveries of sanitation and personal hygiene. An attempt is made to have each home and school construct a sanitary closet; to have each person examined and, if necessary, treated for hookworm dis-ease; to quarantine all cases of contagious diseases and stop the spread of epidemics. The examination of school children with the treatment of all who are found defective; the examination of adults in life extension work; the vaccination against typhoid fever, smallpox and whooping-cough, are emphasized. The plan also arranges for cooperation with the towns of the county in providing inspection of hotels, restaurants, markets, and dairies, and in encouraging sewer connections and other improvements in sanitation. The county health department also has charge of the county home and jail and convict camp. METHODS The Bureau of County Health Work, in order to accomplish its objects, is cooperating with the following nine counties in a three-year plan of public health work: Davidson, Forsyth, Lenoir, Nash, Northampton, Pitt, Robeson, Rowan, and Wilson. The program of work in each county consists of definite units on the more important health problems rather than an attempt to coyer the entire field of county health activity in a short period of time. The more important units of work are concerned with the prevention of soil pollution and its attending diseases such as typhoid fever, infant diarrhea, the dysen-teries, and hookworm; life extension work which contemplates the early detection and prevention of the diseases of adult life; the medical inspection and treatment of school children; the quarantine of infectious diseases; the prevention of tuberculosis; and infant welfare work. During the first year of the health department, three units of work are undertaken: Quarantine, Soil Pollution, and the School Units. The Quaran-tine Unit is the enforcement of the State quarantine law, and aside from the educational work is largely clerical and can be done by the office assist-ants. This unit, of course, is continued throughout the entire three years. 28 North Carolina ]3<)ard of Health The School Unit is also a required unit and takes up the greater part of the second six months' work of the first year. The work of the School Unit has been to obtain a record of the physical condition of every school child in each county and to get as many of the defective children treated as possible. During the past eighteen months especial attention has been called to the dangers of denial defects and the importance of their treatment. In this work the Jsureau of Medical Inspection of Schools has cooperated and a full report of the dental work has been published by Dr. Geo. M. Cooper, the director of that Bureau. Briefly stated, the activity of the Soil Pollution Unit is, as far as is practicable, to have an official of the health department visit every rural home (white and colored) in the county and collect specimens and give treatment for hookworm disease. This official attempts to teach the people the importance of providing sanitary closets at their homes. As part of the educational campaign, the health oflncer gives lectures and demonstrations at the school houses, churches, and other convenient gathering places in each community where the unit is being conducted. Health literature is also dis-tributed, and an effort is made to educate the people along the lines of gen-eral disease prevention. Special efforts are also made to have the towns and villages of the county provide and enforce sanitary measures, and to have the larger towns establish full time sanitary departments. The Soil Pollution Unit continues intensively for six months, more or less, and is carried on by from three to five field assistants, who reside in the communities in which they are conducting the work. These assistants work, of course, under the direction of the health officer. After the intensive campaign the Soil Pollution Unit is continued by one assistant who devotes his entire time to visiting the various sections of the county, in order to keep before the people the necessity of rural sanitation, and in continuing work in com-munities which did not complete their sanitary work during the intensive campaign. This assistant also collects specimens and gives treatments for hookworm disease. An important phase of the Soil Pollution Unit is the collection of. statistics from each home and each family, these statistics being of great value to the future work of the health department. The Life Extension Unit begins in the second year of the health depart-ment. It consists of making thorough physical exarninations of adults in order to detect any danger signals which might later, if untreated, develop into serious handicaps to the individual. Before beginning this work the health officer spends ten days or two weeks at the State Sanatorium for Tuberculosis where he is given a post-graduate course in physical diagnosis. An intensive campaign of two months is then conducted by the health officer for educational work and to advertise the features of life extension work, especially emphasizing the value of periodic physical examinations. At the county seat and at branch oflJices at convenient places in the county, adults are examined after a routine plan which was inaugurated by the Life Extension Institute. After the intensive campaign the health officer set-3 aside certain hours, or perhaps a whole day, each week for the examination of applicants. In this way the unit is carried on through the second and third years of work. The medical officers of the State Tuberculosis Sana-torium act as a consulting board to the county health officers and have arranged to cooperate in examination of difficult cases. Seventeenth Biennial Report 29 Definite work is conducted against tuberculosis. This consists of lectures and demonstrations regarding the disease and in making physical examina-tions of persons who are suspected of having the disease. Each case of tuber-culosis in the county is regularly visited by some representative of the county health department in order to see that proper precautions are being taken to prevent the spread of the disease. It is planned to add the Infant Hygiene Unit at the beginning of the third year of each county health department. The purpose of the work will be to lower the death rate among babies and young children by educating the mothers as to the best means of caring for their children. The health officer will be assisted by a trained nurse and it is planned to secure the cooperation of the physicians and mothers. An important feature of the Infant Hygiene Unit will be the control of the practice of midwifery by requiring every mid-wife to register with the health department and obtain a license after demon-strating a knowledge of hygiene and obstetrics. In addition to the outlined units of health work the county may provide other units which may be found to be desirable or necessary; all such addi-tional units being conducted, of course, under the supervision of the county health department. In the same way, any community, town, or city in the county may arrange with the county and State boards of health to have its special work conducted by the county department. In each county the health officer has had medical supervision of the county home, jail, and chain-gangs. During the epidemic of influenza the county departments took the lead in organizing the local forces in combatting the disease. BUDGETS As has already been stated, each county health department is organized on a three-year plan and is under the joint control of the State and county boards of health. The State Board of Health and the International Health Board assist by suggesting the best methods of conducting the county de-partment and also financially by providing (each contributing an equal por-tion) 50 per cent of the budget of each county health department during the first year, 40 per cent the second year, and 25 per cent the third year. The budgets for the county health departments are as follows: Fiist Second Third Year. Year. Year. Health officer, salary $ 2.100 $ 2,100 $ 2,400 Traveling 600 600 750 Clerical assistant, salary 600 600 900 Fixtures and supplies 500 100 100 Contingent Fund 140 140 140 Soil Pollution Unit '. 2.430 900 900 Quarantine and disinfection 100 100 100 School Work Unit 500 500 500 Life Extension Unit 400 Infant Hygiene Unit • ... 100 $ 6,970 $ 5,440 $ 5,890 FORCE EMPLOYED The central office of the Bureau of County Health Work has a force of two—a medical director and a stenographer. The salary of the medical director is paid in full by the International Health Board, no part of it 30 North Carolina Board of Health being paid by the State Board of Health. Tlie salary of the stenographer is $70 per month. The State Board of Health provides the office, office equip-ment, supplies and printing, and the traveling expenses of the medical director. The duties of the State Director are to secul^e county appropriations, select county health officers, inaugurate and direct the work of each county depart-ment, pay regular visits to each county and report the progress of the work to the State Board of Health, collect and compile county reports, prepare literature for the county work, and have supervision of the financial pro-ceedings of the Bureau and of the cooperating counties. Each county department is directed by a health officer who is appointed by and is an official of the State Board of Health. The health officer is given an adequate corps of assistants to enable him to give as near as possible each unit of work to his entire county. An office assistant is provided for the en-tire three years of work. During the intensive soil pollution campaign from three to five assistants are provided for the field work. After the first six months, a field worker for follow-up work is employed for the remainder of the three years. In the medical inspection of school unit the health officer is assisted by a dentist and other specialists. The following is a list of the county health departments with the name of the health officer and the date on which the work began: County. Health Officer. Work Began. Nash Dr. G. W. Botts July 1, 1917* Davidson Dr. E. F. Long July 1, 1917 Wilson Dr. L. J. Smith July 15, 1917 Northampton Dr. F. 'M. Register August 1, 1917 Lenoir Dr. J. S. ^Mitchener August 15, 1917 Pitt Dr. C. P. Fryer December 1. 1917t Robeson Dr. W. A. McPhaul December 1, 1917 R owan Dr. A. J. Warren January 1, 1918 Forsyth Dr. A. C. Bulla January 1. 1918 RESULTS obtained 1. statistical.—The following statistics, when consiidered in connection with the outlined plan of work given above, will convey some idea of what has been accomplished during the seventeen months of work already com-pleted: the central office Number of letters received 2,471 Number of letters mailed 2.566 Number of mimeographed letters sent out 5,397 Number of forms prepared 54 Number of articles prepared 107 Number of packages of literature and supplies sent 464 Number of telegrams sent 91 Number of days spent out of office on official business 193 Number of addresses given 55 Number of visits to county health departments 167 *The work in Nash County "was suspended from August 15 to November 15, 1918. tThe work in Pitt County was suspended from January 1 to May 1, 1918. Seventeenth Biennial Keport 31 THE COUNTY DEPARTMENTS (An aggregate of 120 months work.) 1. Number of public meetings held 591 (Attendance, 53,807.) 2. Lectui'es at schools 378 (Attendance, 33,643.) 3. Number of letters sent out 29,173 4. Number of newspaper articles published 815 5. Number of sanitary closets built 7,364 6. Number of specimens examined for hookworm disease 20,834 7. Number of people treated for hookworm disease 3,928 8. Diseases quarantined and visited: Whooping cough 1.774 Visited 240 Measles 1,536 Visited 45 Diphtheria 263 Visited 28 Scarlet fever 105 Visited 59 Typhoid fever 530 Visited 121 Smallpox 135 Visited 61 Infantile Paralysis 5 Visited 1 Epidemic Meningitis ... 9 Visited 19 9. Number of schools visited 479 10. Number of children examined by teachers 38,969 11. Number of children examined by health officers 12.699 12. Number of children having defects remedied 6,171 13. Number of children having dental defects remedied 5,354 14. Number of physical examinations of adults* 1,528 15. Number of people vaccinated against ayphoid fever 37,234 16. Number of people vaccinated against smallpox 6.450 17. Number of people vaccinated against whooping-cough 56 18. In the towns of Wilson, Salisbury, Kinston, Lexington, and Thomas-ville the following special work was accomplished: a. Visits by health nurses 1,673 b. Hotels, cafes, and markets inspected 2,545 c. Dairies inspected . . . .' 138 d. Microscopical examinations of milk 61 e. Sewer connections 746 /. Sanitary privies (Wilson pail type) cleaned 54,321 AVERAGE M'ORK OF ONE DEPARTMENT FOR ONE MONTH These nine departments organized by the Bureau of County Health Work had been in operation for an aggregate of 120 months up to November 30, 1918. The following is the average work of one of the county departments for one month: 1. Eight public lectures with an attendance of 729 people. 2. Seven newspaper health articles published in the county papers. 3. Sixty-one rural homes constructed sanitary privies. 4. One hundred and seventy-one people examined for hookworm disease and 33 of these treated. *Life extension work (the physical examination of adults) is a unit of work taken up during the second year of each health department. The statistics given here are for only four county departments. 32 ISToRTH Caroi-ina Board of Health 5. Four schools visited by the health officer.* 6. Three hundred any twenty-five school children examined by the teachers working under the direction of the health officer.* 7. One hundred and six school children personally examined by the health officer.* 8. Fifty-one of the children found defective by the health officer were treated.* 9. Thirty-two adults given physical examinations by the health officer. 10. Three hundred and ten people vaccinated against typhoid fever. 11. Fifty-four people vaccinated against smallpox. 12. County quarantine work performed satisfactory and included the quar-antining, according to the State law, of 43 cases of infectious diseases.! 13. Medical attention was given the county dependents who were inmates of the county home, the jail, and the chain-gangs. DETAILED REPORT OF COUNTY DEPARTMENTS A. Davidson County (17 months work.) 1. Number of public meetings 193 (Attendance, 19,772.) 2. Number of newspaper articles published 61 3. Number of sanitary closets built 1,614 4. Number of people examined for hookworms 4,642 5. Number of people treated for hookworm disease. 411 6. Number of schools visited 27 7. Number of children examined by teachers 3,172 8. Number of children examined by health officers 1,680 9. Number of children having defects remedied 1,157 10. Number of children having dental defects remedied 986 11. Number of physical examinations of adults 147 12. Number vaccinated against typhoid fever 1,710 13. Number vaccinated against smallpox 1,196 B. Forsyth County (11 months work.) 1. Number of public meetings 70 (Attendance, 7,004.) 2. Number of newspaper articles published 119 3. Number of sanitary closets built 488 4. Number of people examined for hookworms 2,555 5. Number of people treated for hook worm disease 149 6. Number of schools visited 59 7. Number of children examined by teachers 1,354 8. Number of children examined by health officers 2,702 9. Number of children having defects remedied 744 10. Number of children having dental defects remedied 389 11. Number vaccinated against typhoid fever 758 12. Number vaccinated vaccinated against smallpox 105 *In considering the school work note should be taken of the fact that in North Carolina the rural schools are in session from only 4 to 6 months each year. Hence, the average school work of the health department during the months that school is in session would be from 3 to 2 times that shown in items 5, 6, 7, and 8. tWhen a case of infectious disease is reported to the health department the house in which the patient resides is placarded, the family is instructed as to the care of the patient to prevent the spread of the disease, the nearby school authorities are notified of the existence of the disease and the teachers are provided with literature regarding the disease, this literature being sent through the school to each home in the community. Seventeenth Biennial Report 33 C. Lenoir County (15 months work.) 1. Number of public meetings 174 (Attendance, 8,842.) 2. Number of newspaper articles published 151 3. Number of sanitary closets built 627 4. Number of people examined for hookworms 4,319 5. Number of people treated for hookworm disease 1,661 6. Number of schools visited 104 7. Number of children examined by teachers 3,290 8. Number of children examined by health officers 154 9. Number of children having defects remedied 394 10. Number of children having dental defects remedied 389 11. Number of physical examinations of adults 175 12. Number vaccinated against typhoid fever 9,178 13. Number vaccinated against smallpox 327 D. Kash County (14 months work.) 1. Number of public meetings 72 (Attendance, 8,150.) 2. Number of newspaper articles published 49 3. Number of sanitary closets built 747 4. Number of people examined for hookworms 1,587 5. Number of people treated for hookworm disease 193 6. Number of schools visited 78 7. Number of children examined by teachers 4,553 8. Number of children examined by health officers 449 9. Number of children having defects remedied 665 10. Number of children having dental defects remedied 665 11. Number vaccinated against typhoid fever 1,493 12. Number vaccinated against smallpox 172 E. Northampton County (15 months work.) 1. Number of public meetings 154 (Attendance, 18,515.) 2. Number of newspaper articles published 105 3. Number of sanitary closets built 1,187 4. Number of people examined for hookworms 2,545 5. Number of people treated for hookworm disease 975 6. Number of schools visited 119 7. Number of childi'en examined by teachers 4,104 8. Number of children examined by health officers 1,866 9. Number of children having defects remedied 571 10. Number of children having dental defects remedied 563 11. Number vaccinated against typhoid fever 11.170 12. Number vaccinated against smallpox 763 F. Pitt County (8 months work.) 1. Number of public meetings 37 (Attendance 3,767.) 2. Number of newspaper articles published 78 3. Number of sanitary closets built 146 4. Number of people examined for hookworms 628 5. Number of people treated for hookworm disease 145 6. Number of schools visited 20 7. Number of children examined by teachers 1.430 8. Number of children examined by health officers 818 3 34 !N^ORTH Carolina Board of Health 9. Number of children having defects remedied 145 10. Number vaccinated against typhoid fever 3,226 11. Number vaccinated against smallpox 881 G. Roheson County (12 months v^^ork.) 1. Number of public meetings 110 (Attendance, 10,786.) 2. Number of newspaper articles published 120 3. Number of sanitary closets built 956 4. Number of people examined for hookworms 62 5. Number of people treated for hookworm disease 150 6. Number of schools visited 56 7. Number of children examined by teachers 9,550 8. Number of children examined by health officer 2,127 9. Number of children having defects remedied 1,602 10. Number of children having dental defects remedied 1,421 11. Number of physical examinations of adults 999 12. Number vaccinated against typhoid fever 2,634 13. Number vaccinated against smallpox 583 H. Rowan County (11 months work.) 1. Number of public meetings 96 (Attendance, 8,246.) 2. Number of newspaper articles published 31 3. Number of sanitary closets built 1,499 4. Number of people examined for hookworms 1,848 5. Number of people treated for hookworm disease 115 6. Number of schools visited 44 7. Number of children examined by teachers 6,054 8. Number of children examined by health officers 1,221 9. Number of children having defects remedied 126 10. Number vaccinated against typhoid fever 4,664 11. Number vaccinated against smallpox 259 7, Wilson County (17 months work.) 1. Number of public meetings 56 (Attendance, 3,468.) 2. Number of newspaper articles published 101 3. Number of sanitary closets built 100 4. Number of people examined for hookworms 93 5. Number of people treated for hookworm disease 24 6. Number of schools visited 84 7. Number of children examined by teachers 5,462 8. Number of children examined by health officers 1,882 9. Number of children having defects remedied 852 10. Number of children having dental defects remedied 941 11. Number of physical examinations of adults 209 12. Number vaccinated against typhoid fever 2,401 13. Number vaccinated against smallpox 2,164 2. Reduction in Death Rate.—The nine county health departments which have been organized have been uniformly successful and have impressed the citizens of the counties with their usefulness. It has been demonstrated be-yond doubt that a county can lower its sick and death rates and that it is economical for a county to do this. At this point it is interesting to note, for example, the decrease in the number of cases and the number of deaths from typhoid fever as a result of the soil pollution work. Seventeenth Biennial Report 35 We have a record of the deaths from typhoid for the years 1914 to 1917, inclusive. Also we have a record of the deaths from this disease from January 1 to August 31, 1918—later statistics not being available. In the five county departments organized in 1917 and conducted for more than a year, the reduction in the number of deaths from typhoid is notable. And when it is considered that there are an average of 10 cases for each death from typhoid fever and that the average cost of each case is $400 we can make an estimate of the saving in money as well as suffering in each county. The statistics are as follows: Northampton County had 14 deaths from 1914-1917, or an average of Zy^ deaths each year. No deaths from typhoid occurred from January to August 31, 1918. Davidson County had 44 deaths from 1914-1917, an average of 11 cases for each year. No deaths had been reported to August 31, 1918. Nash County reported 42 deaths for the four years up to 1918, being an average of 10% deaths each year. To August 31, 1918, only 1 death had been reported from typhoid. Lenoir County's average number of deaths each year from typhoid was 10%, meaning that there were 43 deaths during the years 1914-1917. Only 2 deaths occurred to August 31, 1918. Wilson County had an average of 14^/4 deaths from typhoid or 57 deaths in the years 1914-1917. To the end of August, 1918, only 2 deaths are reported. In all nine of the counties there has been a marked decrease in the general death rate, and especially in the number of deaths from typhoid, infant bowel troubles, and the infectious diseases. The experience being gained in the organization and conduction of county health departments will no doubt prove of value to the State Board of Health in determining the best plan of dealing with county health problems. WOKK OF THE BUREAU OF MEDICAL IINSPEtTIO^V OF SCHOOLS Character of Work OBJECTIVES The object of the work of the Bureau of Medical Inspection of Schools is (1) to arouse the teachers of the elementary schools of North Carolina to the necessity of making the same efforts to teach the children things they should know for the development of their bodies and for the protection of their health, that they make for their intellectual advancement; (2) to edu-cate the children in public health matters; (3) to discover the children who have remediable defects, and to have them treated while curable and before the condition becomes chronic, and (4) to enlist the interest and to coordi-nate the efforts of county authorities, school, health and commissional, for the protection of the health of school children. METHODS In order to explain the methods of work in this department it is necessary to consider the methods in relation to the objectives. Method for Objective i.—Written instructions for teachers have been pre-pared covering every phase of medical inspection of school children. Cards for recording the exact history and results of the preliminary physical ex-amination of each child have been prepared. All this literature has been placed in the hands of the teachers, county by county, as the work progressed. Lectures by competent physicians and specially trained nurses and others have been made direct to teachers individually in small groups and in large institute gatherings. Competent officials have made examinations of chil-dren in the presence of teachers to demonstrate by example the need for the examination, the purpose, and how to do it. For Objective 2.—Health talks in simple language have been made to the children from the first grade up. Leaflets and pamphlets on health subjects, simply written, have been placed in their hands. For Objective 3.—The methods devised to discover the defective children are: (a) The teacher after consultation with the parents when necessary and after personal study of each child records on a prepared card the findings of such preliminary examination; (b) The cards are passed on to a com-petent physician, who, after careful study, selects the cards representing childi-en who are most in need of medical examination; (c) These children are then called to a physician's office and examined, or a physician or nurse, or both, visit the school and make the examination, giving advice to the parent and urging the administration of necessary treatment, either medi-cal, dental, surgical, or special; (d) Special arrangements are made for club operations and dental treatment which are fully described under Results Ob-tained of this department. For Objective .).—County superintendents of schools, county commissioners, county boards of education, and county boards of health are visited and in-dividually and officially besought to make adequate provision for the en-forcement of this law, in spirit as well as letter. Seventeenth Biennial Report 37 routine work Biennial period ending December 31, 1918. Letters received " 3,152 Letters written: Individual 4.665 Multigraph 5,960 Total 10,625 Reports prepared 24 Articles written: Bulletin 20 (words) 11,845 Other publications, 28 (words) 25,836 Pamphlets prepared 5 Days spent out of office on official business 197 Pieces of literature distributed 482,956 Addresses delivered : Number 432 Total attendance 41,532 MONTHLY AVERAGE Letters received 131 Letters written : Individual 194 Multigraph 248 Total 442 Reports prepared 1 Articles written : Bulletin 1 Other publications 1 Pamphlets prepared 1 Days spent out of office on official business 8 Pieces of literature distributed 20,123 Addresses delivered : Number 18 Total attendance 1,730 • force employed Director of Bureau, three part-time physicians, six part-time dentists, three part-time nurses, one stenographer and clerk. budget Amount received from Executive Department $7,500.00 Amount received from Special State Funds 2.024.97 Amount received from counties 56.06 results obtained Some of the tangible results of the work of this department may be enum-erated as follows: 1. More than 7,000 defective children have been treated in the public clinics established by the State Board of Health working in conjunction with the authorities of a few counties. A total of 10,670 children have been treated. The condition of these children was found through the system of medical inspection. 2. A preliminary physical examination of about 160,000 school children was made by some three thousand teachers. Several thousand of these children have been treated as a direct result of that examination, and of which no records have been obtained. 3. About one hundred cases of trachoma, a dangerous eye disease, was discovered in four counties; and most of the cases treated satisfactorily. 4. Ten thousand eight hundred and ninety-two school children were ex-amined by specially trained registered nurses. 38 XoRTH Carolixa Board of Health 5. Thirty-eight thousand seven hundred and eighteen school children were examined by physicians. These examinations were carefully made, and many hundreds of cases of serious conditions were found. For example, two children in one county were found to be in the active stages of tuber-culosis. Both were in school with other children. Both of them were sent to the State Sanatorium where they were able to regain their health. 6. Free traveling dental service was provided for the rural schools in nine counties, the first of the kind for strictly rural school children at public expense in the United States. Two hundred and twenty-seven different dis-pensaries were held and 6.678 small school children given free dental treat-ment. Such in brief are some of the specific results of the activities of the Bureau of Medical Inspection of Schools. >VORK OF THE STATE LABOKATORY OF HIGIEAE Character of Work The work of a public health laboratory is properly limited to those fields of usefulness which are strictly practical. Where other agencies exist the necessary work of health education and propaganda should be left to them. With these ideals in view, the State Laboratory of Hygiene ha,s always ad-dressed its efforts to some definite practical piece of work. When it has been necessary, on account of limited funds, to choose between different lines of work, the choice has been for that work which promised the widest help to the greatest number of the State's inhabitants. Specifically this work has been done under the following heads: 1. Analyses of water from public supplies and from commercial springs. 2. Examination of specimens for the purpose of diagnosis. 3. Pasteur treatment of persons infected with rabies. 4. Manufacture and distribution of vaccines and antitoxins. The average monthly work for the years 1917 and 1918 is as follows: Water 175 Sputum 132 Blood for typhoid 91 Blood for malaria 17 Throat swabs for diphtheria ' 59 Pus for gonorrhea 6 Brains for rabies 42 Intestinal parasites 119 Tissue for cancer 7 Urine 25 Blood for syphilis 245 (After February, 1918.) Blood for gonorrhea 4 (After February, 1918.) Miscellaneous 14 Pasteur patients (three weeks treatment each), average per month. 28 Typhoid vaccine distributed (average doses per month) 20,698 Whooping-cough vaccine (average doses per month) 658 Smallpox vaccine (average doses per month) 2,465 Diphtheria antitoxin (bought and distributed at cost in 1917, manu-factured and distributed pi^actically free in 1918) average units per month 1.005.000 Tetanus antitoxin (1918) average units per month 2,200 Also small amount tuberculin, material for Schick test and several other biological products. FORCE EMPLOYED The force employed consists of a director, one bookkeeper, four assistant bacteriologists, one chemist, one serologist, one manufacturing serologist, one laboratory assistant, one janitor and stableman, and one charwoman. In addi-tion, it is necessary to employ several extra assistants, usually medical stu-dents, during the busy summer months. 40 North Carolina Board of Health BUDGET The income for the two years July 1, 1916 to June 30, 1918, as reported to the Legislative Reference Librarian is as follows: Appropriation $26,250.00 Water tax 11.723.12 Diphtheria antitoxin 48.50 Pasteur treatments 1,054.14 Fees 1,955.17 $ 41,030.93 Less amount used for permanent Improvements 1.179.63 $ 39,851.30 At the beginning of the fiscal year December 1, 1916, there remained un-expended fi'om previous appropriation approximately $7,000. This balance was due to the fact that the completion of the new laboratory buildings had been delayed and the new antitoxin work could not be undertaken to best ad-vantage until the new buildings were occupied. In spite of the utmost economy a deficit of approximately $4,000 existed at the close of the year November 30, 1918. Two thousand dollars of this was covered by a loan from Dr. Rankin and the balance remained as an over-draft and as unpaid bills. On the annual income of approximately $20,000, the State Laboratory of Hygiene is able to demonstrate a many-fold return. The vaccines alone which were distributed free in 1918 would have cost the consumers $128,678.00 if it had been necessary for them to buy at retail prices. Diphtheria antitoxin is now available to rich and poor alike and a further saving in cost of $7,241.00 has been made. It is impossil)le to esti-mate the number of lives saved, nor the value to the medical profession and to the patients of the diagnostic work, but it is a matter of deiBonstration that the services of the laboratory have extended, during the one year 1918, to 144.000 different individuals, representing every county and almost every community in the State. The plans for the next two years call for the development of the existing lines of work and the ability to seize any new opportunity that may occur. For instance, it is hoped that out of the many different vaccines now used to combat the influenza epidemic some one will be demonstrated as efficient. If this is the case, the laboratory wants to be in position to make use of it at once. Taking into consideration only the deficit that now exists and the most conservative estimate of the needs of further development, it is necessary to have an annual appropriation of $25,000. Respectfully submitted. C. A. Shore, Director. WORK OF THE Bl KEAl OF EPIDEMIOLOGY Cliaracter of Work OBJECTIVES To prevent and control the occurrence of whooping cough, measles, diph-theria, scarlet fever, smallpox, typhoid fever, infantile paralysis, cerebro-spinal meningitis, and ophthalmia neonatorum (sore eyes in the new-born). METHODS Section 1—The County Unit 1. A quarantine officer for each county in the State has been secured and placed in charge of the quarantine work of the county, under the super-vision of the Bureau of Epidemiology. His duties are as follows: (a) To secure reports from parents and physicians of all cases of com-municable diseases. {h) To keep an accurate record in his office of all reports. (c) To transmit all reports daily to the Bureau of Epidemiology. id) To supply the parent, guardian, or householder, when the disease is reported, with rules and regulations governing that person, with a placard to be posted on the house, and with a pamphlet descriptive of the disease, its dangers, cause, mode of infection, and methods of control. (e) To inform the teachers in the community where the disease exists that the disease is present, and to supply them with rules and regulations governing the school while the disease is present, and with pamphlets de-scriptive of the disease, its dangers, cause, mode of infection, and methods of control, to be distributed through the children to the parents represented in the school. (/) To make the presence and locations of diseases known to the public by publishing monthly in the county paper the names and addresses of all cases reported during the month. This calls the attention of the public to any cases not reported. ((j) To investigate all cases of suspected contagions which have not been reported, to determine the nature of the disease. {h) To secure, at the beginning of each school in the county, a disease census* of the school children. This record is to be kept on file in his office for a reference guide to determine what action is necessary to protect the school from a disease when it occurs in the school community. (i) To enforce the laws, rules, and regulations governing the control of communicable diseases. (i) To make monthly reports to the Bureau of Epidemiology of all the work, educational, administrative, or otherwise, done during the month. The pay of a quarantine officer depends upon satisfactory work, as detei-- mined by the monthly report. Section 2—The State Unit 1. The daily reports of each of the communicable diseases are recorded by the Bureau of Epidemiology by the counties, townships, and municipalities in which they occur. These are permanent records of the Bureau, and they show the number, location, and increase or decrease in the number of cases of each disease from month to month and from year to year. The reports of cases are also temporarily recorded, geographically, on maps with colored *By disease census is meant a census of the school children showing the number immune to certain diseases by previous attacks. 42 XoRTH Cakolixa Board of Health tacks. A separate map of the State is used foi* each disease, and the tacks are inserted in the towns or townships where the cases exist. These maps show the number and distribution of cases, the rate of development, and the direction of travel of each disease. Epidemics in the developmental stage are detected by watching the daily reports and pin maps, and when one is discovered or anticipated a systematic campaign is instituted to stop it. Epidemics are handled in the following way: (a) The people in the community are notified by handbills of the presence of the disease and are given instructions how to prevent the development of further cases. (&) A history of each case is solicited so as to show the relation of the case to the usual sources of infection. (c) In epidemics of typhoid fever, diphtheria, or smallpox, arrangements are made for having the susceptible people of the community protected against the disease by vaccination. The people are notified of such arrange-ments and are encouraged to avail themselves of the opportunity. (d) An investigation of the sanitary and hygienic conditions in the im-mediate vicinity of each case is made. (e) The facts in the history of the cases and the findings of the sanitary and hygienic conditions are tabulated according to epidemiological methods, so that the exact sources of infection are determined. (/) Recommendations of the necessary measures for the control and pre-vention of the disease are made to the proper authorities. (g) When the nature of the disease is such that public gatherings are per-missible, a public meeting is held to advise the public as to the modes of in-fection, dangers, and measures necessary for the control of the disease, for it is through the cooperation of the public that diseases are controlled. (7i) State-wide publicity is given epidemics, to warn the people of the presence of the disease, to force the local authorities to take action to stop its spread, and to educate the people in disease prevention. (i) Twenty epidemics were investigated and assistance given in the sup-pression of the disease. The value of this work can not be estimated, but we feel assured that many cases of disease and many deaths have been pre-vented. Safe water was secured for one town; a sewerage system assured at another, and a safe water supply assured at another. Hundreds of people have been vaccinated. 2. Weekly telegraphic and monthly written reports of all cases of infectious and contagious diseases reported to the Bureau of Epidemiology are made to the Surgeon General, United States Public Health Service, Washington, D. C. These reports have been made since June, 1918. when the appointments of the State Epidemiologist as Collaborating Epidemiologist and of the county and city quarantine officers as Assistant Collaborating Epidemiologists were secured. 3. All deaths from the reportable diseases reported to the Bureau of Vital Statistics are checked against the reports of cases, to see if the cases which resulted in death were reported. If not, then proper action is taken against the person failing to report. 4. All report cards, blank forms, educational posters, placards and litera-ture on the reportable diseases, and all rules and regulations governing the control of the diseases, are prepared by the Secretary and the Epidemiologist of the State Board of Health, and distributed to the various quarantine offi-cers by the Bureau of Epidemiology. Seventy blank forms, pamphlets, rules, posters, placards, etc., have been prepared and distributed. 5. The one per cent (IVc) silver nitrate solution used as a prophylactic against sore eyes in the new-born is supplied to all physicians and midwives Seventeenth Biennial Report 43 of the State free of charge, with instructions as to its use, and blank re-quest cards are furnished for ordering more of the prophylactic when it is needed. 6. Investigations of counties are made from time to time by trained in-spectors, to determine: (a) If the county quarantine officer is doing his duty. His records are examined, and he is questioned as to his knowledge of quarantine work. Several cases recently reported are visited to see if proper literature has been supplied to the family and if quarantine was established. These in-vestigations brought trained inspectors in contact with fifty-five county quarantine officers, who were given personal instruction in quarantine work and support in furthering the quarantine measures. Through this intimate contact with the quarantine officers much interest in the work has been created among them, with good results. (b) If the physicians are reporting promptly all cases. The physicians who have reported but few cases recently are visited to ascertain if they have treated any cases which they have not reported. (c) Special efforts are made to learn of unreported cases. These are visited to ascertain the nature of the disease and why they were not re-ported. The person found responsible for neglecting to make the report is dealt with according to law. These investigations, together with the investigations of the deaths of unreported cases, have been responsible for seventy-seven indictments of physicians and others, with seventy-four con-victions. (d) The findings in the investigations of counties have been prepared, sub-mitted to the editors, and published in the county papers. These publications give the people an opportunity to know what is going on in the county in disease prevention, and often they inspire some conscientious person to in-form us of unreported cases which need to be dealt with. 7. Twenty-three public talks on the communicable diseases, their spread and control, have been given with an attendance of 1,638 people. RESULTS OBTAINED Result 1. In 1918, 29,787 cases of communicable diseases were reported to, and received the official attention of the Bureau. The households in which these diseases existed were quarantined, placarded, and instructed (a) as to the danger of the disease to the patient, and the methods for lessening its danger; (&) the danger of the disease to other members of the family, and the means for preventing their infection; (c) the danger of the disease to the community, and the measures by which the household might protect the community. As a further measure, 3,598 school populations, in which communicable diseases appeared, were notified of the occurrence of the dis-ease, and the teachers were furnished with popular pamphlets for distribu-tion, through the children of the school, to the homes in the community, notifying the community of the appearance of the disease, its danger, its method of infection, and the means for avoiding contracting it. The total number of homes thus warned and informed was approximately 65,000. That there would have been thousands of cases of contagious diseases in addi-tion to the number that actually occurred had not the foregoing method of prevention been carried out, is beyond a reasonable doubt. Result 2. The prevention of typhoid fever is an epidemiological proced-ure, and, therefore, the reduction in this disease, which has been associated wath a vigorous campaign against it, while extending over a period of five years antedating the establishment of the Bureau, should be accounted for 44 A'oKTH Cakolixa Board of Health under the work of this Bureau. The reductions in the deaths and cases from typhoid fever in North Carolina for the last five years (we have no record of cases and deaths prior to this period) are as follows; 1914. Deaths 839. Cases 8,390 1915. Deaths 744. Cases 7,440 1916. Deaths 700. Cases 7,000 . 1917. Deaths 628. Cases 6,280 1918. Deaths 502. Cases 5,020 It will be observed that there has been a decrease in this flve-year period of 337 deaths and 3,370 cases. Typhoid fever occurs among adults usually at the most active period of life, at a time when economists estimate life to be worth $4,000 per capita. This estimate applied to the 337 lives saved each year means a saving of $1,348,000 to the State of North Carolina. This is not all. To prevent 337 deaths from typhoid fever, it was necessary to prevent ten times as many cases, as the average fatality from typhoid is 10 per cent; therefore, in addition to 337 lives saved, there were 3,370 persons prevented from having a disease which lasts an average of six weeks and which costs, estimating the value of the time lost from sickness, the cost of nurses, the cost of drugs, and the amount paid physicians, about $200 per case. The prevention, then, of 3,370 cases at $200 each means an additional saving to the State of $674,000. Result 3. The Kureau of Epidemiology has supplied silver nitrate to all physicians and midwives of the State in order that they might comply with the law requiring that this remedy for the prevention of gonorrheal blindness in the new-born be applied at birth to the eyes of all babies. While the law is still new and as yet imperfectly complied with, it is a conservative estimate to assume that the prophylactic has been used in half of the births, that, is 40,000. The records of the Blind Institute indicate that before the passage of this law there had been a minimum of 12^^ cases of blindness from gonorrheal ophthalmia for every 10,000 births. It is known that this prophylactic solution applied to the eyes of the new-born will prevent at least 80 per cent of blind-ness in those that would otherwise become infected and lose their sight. On this estimate, the Bureau is entitled to claim the prevention of 48 cases of blindness; but in order that we may be too conservative rather than claim too much, let us assume that we prevented only 20 cases of blindness in North Carolina last year. Ten of the 20 blind will die before they reach an age when they become an expense to the State as well as to the parents. This leaves ten dependents, which cost the State to make them independent, self-supporting, $185 a year at the Blind Institute for ten years, or $1,850 for each case of blindness, or, for the ten, a total cost of $18,500. Result Jf. In 1918, the Bureau made 154 sanitary inspections of hotels, 59 inspections of jails, 34 inspections of convict camps, and 15 inspections of State institutions—a total of 262 inspections. These institutions were marked by a score-card method, and the results of the inspection pub-lished in the newspapers and the Bulletin with the result that there has been considerable sanitary improvement in the conduct of hotels, county and State institutions, greater comfort and greater safety to the traveling public and inmates of the institutions. Result ). The Bureau, through an arrangement with the Federal Gov-ernment, secured the appointment ' of all quarantine officers as Federal Seventeenth Biennial Report 45 officers without pay, except the nominal $1 per j'ear required by Congress. Through this arrangement, the quarantine work of the State and the coun-ties may be done without the use of postage, under the frank. The postage thus saved the State and the counties amounts to not less than $5,000 a year. Result 6. The Bureau secured, through certain cooperation rendered the United States Army, 30,000 doses of typhoid vaccine in the form of what is known as lipo-vaccine—a vaccine used in the Army and Navy with which one instead of three hypodermic injections produces an immunity. The value of the 30,000 doses, and the expense saved for administration^ two-thirds of the treatment being unnecessary, may be estimated at a saving of at least $5,000. OFFICE ROUTINE The following tabular estimate for the years 1917 and 1918, based upon seventeen monthly reports, shows the routine work of the Bureau: Letters received 2,792 Letters written : Individual 2,349 :\Iultigraphed 37,933 Total 40,282 Post cards received (replies to typhoid letters), 5 months 487 Packages of supplies sent out 4,590 Packages of silver nitrate sent out 11,400 Lectures prepared 3 Press articles prepared 8 Forms prepared (for records and reports, placards, pamphlets) 70 Cases of communicable diseases reported and recorded 36,662 Cases of ophthalmia neonatorum reported and recorded 15 Cases of influenza reported and recorded. 3 months (approximate) . . . .109,419 FIELD WORK Trips made 66 Quarantine officers visited 121 Counties investigated 55 Reports published 6 Epidemics investigated 20 Addresses delivered 24 Total audience 1,663 Prosecutions 77 Convictions 74 Inspections : Jails 59 Convict camps 34 Hotels 156 State institutions 16 Total 265 IXFLUEXZA RELIEF WORK Counties visited 11 Communities visited 19 Corps of relief workers organized 9 quarantine officers' REPORTS (16 months) Reports made 1.288 Homes visited 6,688 Schools notified of diseases 5.013 Public notices posted (smallpox) 1,922 School diseases censuses returned by teachers 9,873 Indictments 45 Publications 1,884 46 ISToRTH Carolina Board of Health AVERAGE MONTHLY ROUTINE WORK, 1917-1918 Letters received 164 Letters written : Individual 138 Multigraphed 2,231 Total 2.369 Postcards received (replies to typhoid letters) 97 Packages of supplies sent out 270 Packages of silver nitrate sent out 671 Lectures prepared 3/17 Press articles prepared 8/17 Forms prepared (for records and reports, placards, pamphlets) 4 Cases of communicable diseases reported and recorded 2,157 Cases of ophthalmia neonatorum reported and recorded 1 Cases of influenza reported and recorded (approximate) 36,473 FIELD WORK Trips made 4 Quarantine ofl^cers visited 7 Counties investigated 3 Reports published 6/17 Epidemics investigated 1 Addresses delivered 1 Total audience 98 Prosecutions 5 Convictions 4 Inspections : Jails 4 Convict camps 2 Hotels 9 State institutions 1 Total 16 QUARANTINE OFFICERS' REPORTS Reports made 81 Homes visited 418 Schools notified of diseases 313 Public notices posted (smallpox) 120 School disease censuses returned by teachers 617 Indictments 3 Publications 118 WORK OF THE BUREAU OF VITAL STATISTICS Character of Work OBJECTIVE The objective of the Bureau of Vital Statistics is to secure a permanent record of the more important facts concerning the birth and death of every citizen of the State of North Carolina, and from such records to prepare card indices and tabular classifications in such manner as to make readily available, on inquiry, the following information: 1. (a) The total number of births occurring annually in the State; (b) the birth rate of the State, that is, the number of births per thousand of the population; (c) the birth rates by races, white and colored; (d) the num-ber of illegitimate births; (e) the number of stillbirths; (/) all of the afore-going data as to births with respect to each county, town and city. These facts permit of comparisons of one part of the State with another, of the birth rate of the two races, and of the birth rate of this State with that of other states, and other countries. Such information is necessary in forming conclusions as to vital conditions in North Carolina and in the en-actment of suitable legislation for dealing with these conditions. 2. (a) The number of deaths occurring in the State of North Carolina annually; (b) the death rate, that is, the number of deaths per thousand of the population in North Carolina; (c) the number of deaths, by races and the death rates by races in North Carolina; (d) the number of deaths among in-fants and young children as compared with the births, and the total deaths as compared with the total births, with net gain in population; (e) the number of deaths from the more important causes of death; that is to say, the number of deaths from typhoid fever, from tuberculosis, diphtheria, in-fantile diarrheas, etc., amounting altogether to a classification of about forty separate causes of death; (/) all of the aforegoing data classified according to county, town and city. This information is absolutely necessary to under-stand vital conditions in the State; to know where health work is needed; against what causes of death health measures should be directed; and whether the work of health departments is associated with a decrease or no decrease in death rates. 3. Under 1 and 2. information necessary for the public welfare, and avail-able under the operation of the vital statistics law, has been briefly indi-cated. But the vital statistics law not only supplies information to legisla-tures. State and county commissioners, and other administrative bodies, which is necessary for framing conservation measures for human life, but it also records facts which may at any time become of great value to the individual. In matters of tracing ancestry, birth records are invaluable; also, in matters of proving age where the fact of age is in question, as for voting, as for the right to marry, as for the right to enter certain indus-tries, to enter school, or as to liability for military service, etc. METHODS The Bureau of Vital Statistics secures the birth and death certificates for the birth and deaths occurring in North Carolina through approximately fourteen hundred local registrars, appointed by the chairmen of the boards of county commissioners for the various townships and by the mayors for the various incorporated towns and cities of the State. The duties and powers of the local registrars are defined in chapter 109, section 22. Public Laws of 1913. The county pays the local registrars 2.5 cents for each birth and death certificate furnished by them to the office of the State Registrar at Raleigh. The vital statistics law makes it the duty of the doctors and 48 XoRTir rARoi,i]\rA Board of Health midwives in attendance on a birth to file a birth certificate with the local registrar of the district in which the birth occurs, and makes the undertaker, or person acting as undertaker, responsible for filing the death certificate. The birth and death certificates filed with the local registrars of the State are sent to the State Registrar on the fifth of the month succeeding the month in which the birth or death occurred. The certificates received in the office of the State Registrar are examined, and, if incorrect or incom-plete (as a large per cent of them are) effort is made to secure the infor-mation necessary to complete them. The certificates are then classified and tabulated according to county and registration districts, according to races, according to age at death, according to cause of death, according to death rates and birth rates, etc., in order to make readily available, upon request, the information mentioned under the heading of objective. ROUTINE WORK OF BtJREAtT The routine work of the Bureau of Vital Statistics is indicated in the fol-lowing table: WORK OF BUREAtr OF VITAL STATISTICS DURING YEARS 1917-1918 Item. wn. 1918. Letters received 18,273 15,992 Postals received 2,558 909 Undertaker's reports received 6,083 5,839 Local and deputy acceptance papers received 5,655 293 Provisional death certificates received 12 15 Supplemental reports received 2,642 2,354 Violation blanks received 235 179 Letters written: Individual 26,025 Multigraph 24.862 Total letters 50.887 Letters written: Individual 30,577 Multigraph 11,407 Total 41.984 Postal cards sent out 5,286 1,667 Acceptance papers sent out to registrars 1,755 231 Packages supplies sent out 4,658 7,957 Certificates received: Deaths 33,914 Births 77,063 Stillbirths 7.019 Total 117,996 Certificates received: Deaths 42.061 Births 75.764 Stillbirths 6.669 Total 124,494 Indexing: 1017. 1918. 1916. Births (last 9 months) Completed 1917. Births Completed 1917. Deaths Completed 1918. Births 66 2/3% 1918. Deaths 83 1/3% Miscellaneous tables made 29 44 Tables completed for Biennial Report (1916) Completed Tables completed for Biennial Report (1917) 4 Cards punched and proof read (1916) Completed Cards punched and proof-read (1917) Completed Index cards proof-read, assorted and filed 101,726 59.169 Index cards proof-read and assorted (1916) 52,708 Cards furnished (decedents from tuberculosis) 3,261 2,705 Number convictions secured 13 . 17 Seventeenth Biennial Keport 49 MONTHLY AVERAGE Letters received 1,428 Postals received 144 Undertakers' reports received 497 Local and deputy acceptance papers received 248 Provisional death certificates received 1 Supplemental reports received 208 Violation blanks received 17 Letters written : Individual 2,358 Multigraph 1,511 Total . 3,869 Postal cards sent out 290 Acceptance papers sent out 83 Packages supplies sent out 526 Certificates received (births, deaths, stillbirths) 10,104 Per cent of indexing of births for entire year completed each month. . . 10%* Per cent of indexing of deaths for entire year completed each month. . 8% Miscellaneous tables made 3 Index cards filed 6,704 Index cards proof-read and assorted 6,704 Cards furnished (decedents from tuberculosis) 249 Number convictions secured 1 Tables for 1916 (Annual Repoi-t) t Tables for 1917 (Annual Report) t Cards punched and proof-read for 1916 and 1917 t RESULTS OBTAINED Without going into unnecessary detail, it may be said that the objective of this Bureau, as aforestated, has been reached, and that all of the infor-mation, vi^ith its vital bearing upon the public health needs of the State and with the public health accomplishments of the State, is readily and com-pletely available. As a mere indication of the practical value of the work of this Bureau, we may point out the fact that the birth rate of North Carolina is four in excess of the highest birth rate of any other State in the Union to wit, Michi-gan, with a birth rate of 28.4, and that the death rate in North Carolina, not-withstanding the high birth rate, giving us an exceptionally large age group of tender years with high fatalities, is exceptionally low, the lowest of any of the old States of the Union, the lowest of any State on the Atlantic or Gulf Coast. To be brief, the vital records of the State show that North Carolina is one of the healthiest States in the Union. Another sample bit of information of great value is the relative birth rates and death rates of the two races, the white birth rate being 32.2 and the colored birth rate being 31.1, 1.1 less than the white birth rate, while on the other hand the white death rate is 11.2 and the colored death rate is 17.0. Here we see that the white race in North Carolina is making a net gain of 34,511 citizens a year while the colored race is making a net gain of only 10,775 citizens per year. Another sample of information obtained through the Bureau of Vital Sta-tistics is the record of the State in the decrease of typhoid fever as indicated *During years 1917 and 1918 percentage of births indexed for 1916, 75 per cent, 1917, 100 per cent, 1918. 66 2-3 per cent, making a monthly average of 10 per cent, timpossible to estimate amount of work completed per month. 50 iSToRTH Caroli^'a Board of Health in the following table of deaths and cases of this disease during the last five years, that is, the five years for which we have had a vital statistics law with a record of deaths: 1914. Deaths 839. Cases 8,390* 1915. Deaths 744. Cases 7.440 1916. Deaths 700. Cases 7,000 1917. Deaths 628. Cases 6,280 1918. Deaths 502. Cases 5,020 *Estimatecl on known average fatality of 10 cases per 1 death. WORK OF THE BUREAU OF INFANT HYGIENE Character of Work OBJECTIVE The objective of this Bureau is to take official cognizance of, and to direct remedial measures of established value to, the appalling death rate in North Carolina within the first five-year period of life. When we realize that more than one-third of all deaths that occur in this State are in the first five-year age group, or, to be exact, that 11,749 out of a total of 34,005 deaths for last year were under five years of age, we must see the absolute necessity for some positive action rather than a policy of indifference or inactivity in this large vital field. Of the 11,749 deaths, 7.825 are under two years of age and are due to three principal causes: 3,153 are stillbirths, due, in a large percentage of the cases, to an abnormal and unnecessary interruption of pregnancy; 2,04G occur in the first month of life from causes usually grouped under the general term as congenital debility many cases coming within this group being of a pre-ventable nature; 2,626 result from diarrheal diseases of infants within the first two years of life, and 90 per cent of these are either being raised on artificial food, or have been weaned and, in their second year, are being adjusted to a diet consisting largely of cow's milk. Of course, the weaning of a child at about the termination of its first year of life is right, but in the transition from the milk of the mother to the milk of the cow and other articles of diet, intelligence in infant feeding counts for much. A large per cent of the deaths of infants within the first five-year period of life, and more especially within the first two years, is due to two main causes: (1) carelessness, and (2) lack of essential information as to the hygiene of pregnancy and infancy. Prenatal hygiene, or the hygiene of pregnancy, when understood, even when superficially considered, will have, as it has had elsewhere, far-reaching influence in preventing the premature interruption of pregnancy from many causes that are avoidable, and thus will be reduced the large number of stillbirths and waste of life occurring annually in this State; moreover, this same knowledge regarding precau-tions to be taken by pregnant women will have much to do with decreasing the number of deaths occurring within the first month of life usually cer-tified to as being due to congenital weakness. An extensive and intensive educational campaign directed to impressing mothers with the value of breast feeding as against artificial feading, and with the necessity of a certain amount of essential information regarding the preparation of artificial food for infants, will be in North Carolina as it has been in other places coinci-dent with the decrease in the number of deaths of infants under two years of age from diarrheal diseases. METHODS The methods of the Bureau of Infant Hygiene may be conveniently di-vided into two classes: (1) those with the State as the unit; (2) those with the county as the unit. The methods with the State as the unit consist of securing the names and addresses of (a) as many pregnant women as possible; (h) of securing the names and addresses of the mothers of as many artificially fed infants within the first year of life as possible, and (c) the names and addresses of 52 I^ORTH Carolina Board of Health mothers with infants in the second year of life who are suffering from diges-tive disturbances. The methods for obtaining these names and addresses consist of appeals made to nurses, doctors, women's clubs, philanthropic or-ganizations, and county health officers, for cooperation and for furnishing the addresses of mothers—prospective and real—and of invitations extended generally through the State Board of Health Bulletin and the press of the State to any mother or pregnant woman who may be interested to the extent of permitting this Bureau to render any service to her within its power. With the addresses of possibly interested cases of pregnancy, and of mothers, this Bureau, by a carefully prepared series of letters (a correspondence course) and by educational pamphlets, seeks to interest them, to create a close bond of real sympathy between itself and the women, and to assist them in every way possible in either the conduct of their pregnancy or care for their children, or both. The methods with the county as the unit will be carried out largely through the use of a nurse specially trained in a knowledge of the hygiene of pregnancy and of infancy. This nurse will be paid partly by county funds, partly by State funds, and the prospect is bright for securing a Federal fund to be used in defraying the cost of the nurse. The nurse will (a) organize in the county a number of mothers clubs, and will give a regular, well con-sidered and planned course of instruction to these clubs, endeavoring by this means to develop to the highest possible degree a general knowledge of the hygiene of pregnancy and infancy among the women of the county; (6) The nurse will get in touch with, and will instruct and supervise the work of the midwives of the county through a county ordinance prohibiting careless or incompetent midwives from attending a case of labor; (c) The nurse will encourage the pregnant women of the county, by the assistance she renders them, to consult with her, to allow her to advise them, and to help them. The nurse can be of considerable assistance to these women through the information she can give, through making examinations of urine and re-porting to their attending physician, and through making examinations of the pelvis or bony canal to detect, anticipate, prepare for, and avoid the unnecessary complications of labor; (d) The nurse can keep a tack-map of a county, the tacks of one color indicating the homes of babies that are being raised on the bottle, and tacks of another color indicating babies within their second summer suffering from digestive troubles. She can make frequent visits to the homes of these children, advising with the moth-ers and assisting them in taking care of the children. This is, briefly, the county method that will be carried out under the direction of the Bureau of Infant Hygiene. THE ROUTINE WORK OF THE BUREAU ~ Letters received 160 Magazines and bulletins received and reviewed 24 Letters written : Individual 102 Multigraph (6 f
Object Description
Description
Title | Biennial report of the North Carolina State Board of Health |
Other Title | Report of the North Carolina State Board of Health. |
Creator | North Carolina. State Board of Health. |
Date | 1917; 1918 |
Subjects |
North Carolina. State Board of Health--Statistics--Periodicals Public health--North Carolina--Statistics--Periodicals Public Health--North Carolina |
Place | North Carolina, United States |
Time Period | (1900-1929) North Carolina's industrial revolution and World War One |
Description | Report covers two calendar years (13th-18th); (19th) covers Dec. 1, 1920-June 30, 1922; thence each covers July 1-June 30 years.; Printer: 13th (1909/10)-18th (1919/20) by Edwards & Broughton; 19th (1921/22)-20th (1923/24) by Bynum; 21st (1925/26)-<44th (1970/72)> unnamed. |
Publisher | Raleigh :The Board,1911- |
Agency-Current | North Carolina Department of Health and Human Services |
Rights | State Document see http://digital.ncdcr.gov/u?/p249901coll22,63754 |
Physical Characteristics | v. ;24 cm. |
Collection | Health Sciences Library. University of North Carolina at Chapel Hill |
Type | text |
Language | English |
Format | Reports |
Digital Characteristics-A | 4,814 KB; 102 p. |
Series | Biennial report of the North Carolina State Board of Health |
Digital Collection |
Ensuring Democracy through Digital Access, a North Carolina LSTA-funded grant project North Carolina Digital State Documents Collection N.C. Public Health Collection |
Digital Format | application/pdf |
Related Items | Printer: 13th (1909/10)-18th (1919/20) by Edwards & Broughton; 19th (1921/22)-20th (1923/24) by Bynum; 21st (1925/26)-<44th (1970/72)> unnamed. |
Title Replaces | North Carolina. Board of Health../1 |
Audience | All |
Pres File Name-M | pubs_edp_biennialreportboardofhealth19171918.pdf |
Pres Local File Path-M | \Preservation_content\StatePubs\pubs_edp\images_master\ |
Full Text | EPOftt ',\ |in|Min|i jiMii|ii STATE f(i i HI I" 11 fi ( '''^IIIIIIHIIIIilliiiiillUinnil illl IHIillllH niliillililll 11 II I / Library OF THE University of NortH Carolina This book was presented by Ql ^\h-^ W^T XqN'^.VS >C">- This book must not be taken from the Library building. SEVENTEENTH BIENNIAL REPORT OF THE NORTH CAROLINA STATE BOARD OF HEALTH 1917-1918 I ' RALEIGH Edwards & Broughton Printing Co. State Printers 1919 TABLE OF CONTENTS PAGE Members of the State Board of Health , 3 Letter of Transmittal 5 Preface 6 Health Work in the State of North Carolina for the Biennial Period 1917-1918 7 What the Board of Health is doing with its money 12 Present Organization of the North Carolina State Board of Health 19 Work of the Executive Office 21 Bureau of Education 25 Bureau of County Health Work 27 Bureau of Medical Inspection of Schools 36 State Laboratory of Hygiene 39 Bureau of Epidemiology 41 Bureau of Vital Statistics 47 Bureau of Infant Hygiene 51 Bureau of Venereal Diseases 54 Recommendations of the North Carolina State Board of Health to the General Assembly of 1919 55 The First Recommendation 55 The Second Recommendation 59 The Third Recommendation 60 The Fourth Recommendation 63 General Financial Report 69 Financial Report, Laboratory of Hygiene 70 Fund Balance Sheet 71 Appropriations, Earnings, and Expenditures 72 Financial Report. Bureau of County Health Work 80 Disbursements by Counties 81 Members of the State Board of Health ^ i Elected by the North Carolina Medical Society: Thomas E. Anderson, M.D., Statesville. Term expires 1923. Charles O'H. Laughinghouse, M.D., Greenville. Term expires 1923. F. R. Harris, M.D., Henderson. Term expires 1919. Cyrus Thompson, M.D., Jacksonville. Term expires 1919. Appointed by the Governor: J. L. Ludlow, C.E., Winston-Salem. Term expires 1921. J. Howell Way, M.D., Waynesville. Term expires 1923. Richard H. Lewis, M.D., LL.D., Raleigh. Term expires 1919. Edward J. Wood, M.D., Wilmington. Term expires 1919. E. C. Register, M.D., Charlotte. Term expires 1923. LETTER OF TRANSMITTAL Raleigh, 'N. C, January 1, 1919. His Excellency, T, W. Bickett, Governor of North Carolina. My dear Sir :—Under authority of section 3, chapter 62, Public Laws of 1911, as amended by the General Assembly of 1913, I have the honor to submit the Biennial Report of the State Board of Health for the years 1917 and 1918. Very respectfully yours, W. S. Rankin, Secretary and Treasurer. PREFACE The same principles hare influenced the preparation of this biennial report as governed the j^reparation of our last report; therefore, the preface of the report of 1915-1916 is altogether pertinent to this one, and we trust we may be pardoned for the repetition : "It is our intention to smash precedent in the size and substance of biennial reports. The large size of the average biennial report appears to rest on the hope of impressing those to whom it is addressed (not the few who read it) vdih the size rather than with the contents of the re-port. The size alone of most of these reports precludes their being read by busy people; and it makes little difference whether the other class does or does not read them. There is a story of a young reporter who was directed by a large i^ew York paper to report a certain lynching of unusual public interest. The young reporter wired his paper to hold three columns for his story. The editor wired the reporter to confine himself to one column. The young reporter, in the atmosphere of the lynching, could see only the importance of the lynching, and wired back to the paper that it was impossible to restrict his story to a single column. The business manager telegraphed, 'Description whole creation covered in Genesis one. Read it.' "With this idea of brevity, and ^\dth the hope of reaching busy people, we have sought the avoidance (1) of matter that can be obtained easily from other publications, and (2) of matter consisting largely of details and statistics that is of little general interest and that can be more con-veniently supplied to those interested in the form of supplementary re-ports. For example, the State public health laws, the itemized statement of the bookkeeper, and the vital statistics of the State have been ex-cluded from the report. Any or all of this matter may be obtained in separate form by request of the State Board of Health. "The arrangement of this report is by fairly independent subdivisions, so that it is possible for one to read and understand any part of the re-port without reading the whole report." Health Work in the State of North Carolina for the Biennial Period 1917-1918 HISTORICAL DEVELOPMENT OF PtBLIC HEALTH WORK IN NORTH CAROLINA In the biennial report of 1915-1916, pages 10 to 15, inclusive, we attempted to epitomize by years the development of public health work in North Caro-lina. If it were not for the high cost of paper and printing at this time, we should repeat that part of our last report, adding the principal developments in the health work of the State for the years 1917 and 1918. Under the pres-ent circumstances, however, we shall restrict the record to the principal developments in the health work of the State for the last two years, referring the reader who may be interested in securing the complete record to the previous biennial report. • 1917. The General Assembly of North Carolina passed the following important health legislation: Chapter 263, entitled "An act to prevent and control the occurrence of certain infectious diseases in North Caro-lina"; chapter 244, entitled "An act to provide for the physical examination of the school children of the State at regular intervals"; chapter 276, entitled "An act for the cooperative and effective devel-opment of rural sanitation"; chapter 257. entitled "An act to pre-vent blindness in infancy, designating certain powers and duties and otherwise providing for the enforcement of this act"; chapter 66, entitled "An act to provide for the sanitary inspection and conduct of hotels and restaurants"; chapter 286, entitled "An act to regulate the treatment, handling, and work of prisoners." Following the enactment of this legislation, the administrative machinery, consisting of a bureau of epidemiology under the. direc-tion of Dr. A. ]\IcR. Crouch, a bureau for the medical inspection of schools under the direction of Dr. Geo. M. Cooper, and a bureau for county health work under the direction of Dr. B. E. Washburn, was established. Dr. Washburn, an officer of the International Health Board, was loaned to the State without cost, and the International Health Board, in addition to furnishing Dr. Washburn, appropriated $15,000 annually for rural sanitation in accordance with the pro-visions of chapter 276. The United States Public Health Service in February, 1917, de-tailed Dr. K. E. Miller to study county health work in different sec-tions of the country and to establish for demonstration purposes, in Edgecombe County, an efficient county department of health on an economic basis easily within the financial reach of the average county. The State Laboratory of Hygiene moved into its own building January 15, 1917. NOBTH CaROLIXA BoARD OF HeALTH The State was admitted to the registration area of the Union January. 1917, the Bureau of the Census having found after investi-gation that our birth registration was 96 per cent complete. The special campaign against typhoid fever, begun so satisfac-torily in 1915. was continued. Free vaccination of the people, how-ever, was interfered with by the difficulty in securing medical officers to do the vaccination, the preparedness program of the Government having caused many physicians and nurses to enter the Army and Navy; nevertheless, a total of 30,000 citizens of the State were vaccinated as a direct result of the Board's activities, and many thousands of others were vaccinated by the physicians of the State as a result of the educational work of the Board directed to im-press the public with the value of vaccination as a means of pre-vention for typhoid fever. In December, 1917, life extension work as developed by the Life Extension Institute of New York, which consisted briefly of the free physical examination of interested citizens for the purpose of advising them as to their physical condition and needed hy-gienic reform and medical treatment, was begun on a county basis. The funds necessary for this work were appropriated partly by the State and partly by the counties in which the life extension work was carried out. Dr. Amzi J. Ellington, who at the time was a resident physician in the New York City Hospital and who had during his residency in that institution studied the methods of the Life Extension Institute under Dr. Eugene Lyman Fisk. was put in charge of this work. Life extension work was carried out in Vance. Alamance, Lenoir, and Robeson counties, and resulted in the full physical examinations of 4,000 citizens. This work was very favorably received, and the outlook for its con-tinued development seemed excellent when, with the declaration of the war and the call for physicians to enter the military service of the country. Dr. Ellington felt compelled to enter the Army. For this reason, and for the further reason that it has been almost impossible to secure health officers during the past two years, the work was not resumed. The educational work of the State Board of Health consisted in the issuance of eight Bulletins, each monthly edition amounting to 45,000, and a daily newspaper health article. The Bureau continued its moving picture show exhibit and, in addition, prepared probably the best three-dimension educational exhibit in the United States. In 1917, the following exhibits were given: motion picture enter-tainments, 236; traveling public health exhibits, 32; special ex-hibits, 58; stereopticon entertainments, 3—^to a total of 95,000 peo-ple. Arrangements were made for the preparation of newspaper plate, which was sent to and extensively used by 202 papers having a total subscription list of 303,000. A large part of this newspaper material was prepared hy the well-known authority and publicist in matters of sanitary and hygienic education. Dr. W. A. Brady of Elmira, New York. Sevknteenth Biennial Repokt 9 The annual appropriation for the State Board of Health was $60,772.16. The annual appropriation for the State Laboratory of Hygiene was $12,500, and this, in addition to $9,087.22 in fees per-mitted under the laws of the State to be paid to the Laboratory of Hygiene for special work, provide the Laboratory with a total annual budget of $21,587.22. 1918. Much of the work this year was influenced by the war and had to do with preparedness. The State Health Officer visited Washington, at the request of the Council of National Defense and as chairman of a committee of State Health Officers, on a number of occasions for conferences with respect to preparedness measures, provisions for the control of venereal diseases, arrrangements for coordinating the control of infectious diseases in the civilian population with their control in cantonments, and to arrange, if possible, with the Public Health Service and the Surgeon General of the Army for preserving the personnel of State health departments during the war. The State Health Officer also made a visit to the States of South Carolina. Georgia. Alabama, and Florida for the Council of National Defense in order, if possible, to interest the Governor, the State Board of Health, and the State Council of Defense in venereal disease control. Considerable tinT.e w'as given to assisting Major John W. Long. Medical Aide to the Governor, in the work of organizing the Medical Advisory Boards and in interesting physicians in entering the medi-cal service of the Army and Navy, and, later in the year, in inducing the physicians of the State to become .members of the Volunteer Medical Service Corps. Partly as a result of these activities, the Surgeon General of the army assigned ]\Iajor Joseph J. Kinyoun to assist the State Board of Health in the control of communicable diseases, the Board being under no financial obligation for Major Kinyoun's assistance; and as a result of the successful termination of the activities of various interests looking to a more effective control of venereal diseases, the Kahn Chamberlain Bill passed Congress, and made available to the State of North Carolina, and without condition, $23,988.61 for venereal disease work. " The Laboratory during this year began the distribution of a high grade of diphtheria antitoxin. The Bureau for the Medical Inspection of Schools developed, and with a degree of success that we may say established, free dental clinics for the public schools of the State. This Bureau also de-veloped to a successful extent an arrangement in the form of ade-noid and tonsil clubs for the practical and economic treatment of public school children suffering from these defects. The Bureau of Epidemiology employed two third-year medical students, equipped them with motorcycles, and put them into the 10 XoRTH Carolina Board of Health field to investigate infringements of the quarantine law. Sufficient convictions were obtained to impress the medical profession with the determination of the State to enforce its health laws, and a fairly satisfactory compliance with the laws regarding the reporting of communicable diseases was brought about. The Bureau for Venereal Diseases, paid for by the Federal appro-priation, was established in September under the directorship of Dr. James A. Keiger, of Charlotte, X. C. Mr. Warren H. Booker, for the last seven years the efficient director of the Bureau of Engineering and Education, left in September for Red Cross work in France, the work of his Bureau being continued, with the exception of the engineering work, by Mr. Ronald B. Wil-son. As a result of Mr. Booker's leaving, certain funds became available, and a Bureau of Infant Hygiene, under the directorship of Mrs. Kate Brew Vaughn, was organized late in 1918. Perhaps the most outstanding feature of the health work during the year 1918 was the epidemic of influenza. The epidemic began early in October and caused in October alone 6,056 deaths; in No-vember 2,133 deaths; and in December, 1.497 deaths, a total during the last three months of 9,686 deaths. A fuller report of the work in handling this epidemic is found on pages 15 and 23 of this report. The annual appropriation for the. State Board of Health for 1918 was $73,210.38. The annual appropriation for the State Laboratory of Hygiene was $12,500. The Laboratory, during 1918, collected $8,532.48 in fees for special work, so that the total income of the Laboratory for this year was $21,032.48. In addition to the regular appropriation, as above given, the Laboratory of Hygiene has received, in accordance with the original act, fees for ex-amination of pathological specimens submitted by physicians; also a tax on all water companies of $64 annually for the examination of monthly samples of water, and, since 1907, a small amount for administering the Pasteur treatment to persons bitten by rabid animals. Receipts from these sources began to come in in 1905. The annual receipts from these sources for the various years have been as shown in the following table: 1905 $ 3,425.27 1906 3,425.27 1907 4,887.97 1908 4,887.97 1909 5.196.54 1910 5,196.54 1911 6.271.39 1912 6.271.39 1913 6,118.94 1914 6.118.94 1915 8.541.72 1916 8.541.72 1917 8,809.85 1918 8.809.85 Seventeenth Biennial Report 11 RE\^NUE BASIS STATE BOARD OF HEALTH SINCE ESTABLISHMENT. Year WHAT THE BOAKI) OF HEALTH IS HOIXi WITH ITS 3I0NEY The following was prepared for and is taken from the North Carolina Manual for the year 1919: We assume that the people of North Carolina are interested particularly in two things with respect to the work of the State Bo^d of Health: (1) What the Board spends; (2) wihat the Board gets for the expenditure. This statement, therefore, will deal, in as brief a manner as is consistent with clearness, with the debit and credit side of the State's account with public health. Just one additional introductory statement needs to be made—a statement in no sense intended as an apology, but as simple justice to the Board of Health. The work of the State Board of Health, during the last biennium. has been seriously interfered with by two things: (1) the war; (2) the epidemic of influenza. The war called for a mobilization of medical men and health officers. The State Board of Health lost a number of its officers to the military service of the country, and it was not only impossible to replace our losses, but impossible to secure health officers for extensions in the health work that would have been made but for the war. The epidemic of influenza necessitated the cessation of much public health work for the reason that public health forces were concentrated on the epidemic. EXPENSES OF THE STATE FOR PUBLIC HEALTH During the biennial period of 1917-1918, the average annual income of the State Board of Health, including the Laboratory but not the Sanatorium, has been $88,301.12. DIVIDENDS ox INVESTMENTS IN PUBLIC HEALTH Item 1.—The State Laboratory of Hygiene has examined annually for the last two years 8,652 microsopic specimens, which would have cost the peo-ple and the physicians of this State, if examined in other laboratories, a minimum of $1..50 per specimen, or a total of $12,978. This $12,978 is one dividend that is paid on the State's investment of $88,301.12 in he health of her people. Itevti 2.—The State Laboratory of Hygiene has examined annually for the last two years 2,100 samples of drinking water. These analyses, if made by other laboratories would have cost the State $5 apiece, or a total of $10,500 This $10,500 is a second dividend paid on the State's investment of $88,- 301.12 in the health of her people. Item 3.—The State Laboratory of Hygiene has treated annually for the last two years 336 citizens of North Carolina who had been bitten by rabid animals. It would have cost these citizens a minimum of $15,000 to have secured this treatment outside the State. This $15,000, then, may be re-garded as a third dividend paid on the State's investment of $88,301.12 in the health of her people. Item -'/.—The State Laboratory of Hygiene has distributed annually for the last two years 248,876 doses of typhoid vaccine. 7,896 doses of whooping cough vaccine, and 29,580 doses of smallpox vaccine, which vaccines, if pur-chased at the ordinary retail price, would have cost a minimum of $100,000. This $100,000 is, then, a fourth dividend paid on the State's investment of $88,301.12 in the health of her people. Seventeenth Biennial Report 13 Item J.—The State Laboratory of Hygiene has distributed annually for the last two years 2,412 doses, or 12,060,000 units, of diphtheria antitoxin. The antitoxin, distributed free of cost to the people in 1918, at the old retail price would have cost $12,060. The antitoxin distributed in 1917, at about one-fourth the previous retail price of antitoxin, saved our people an additional $9,000, making a total saving on diphtheria antitoxin of $21,000 for the last two j'ears. or an annual saving of at least $10,000. But this by no means represents the total amount saved under this item to the citizens of North Carolina. Commercial manufacturers of antitoxin, in order to sell their product at all in North Carolina in competition with the State's free anti-toxin, have had to cut their original price to one-third of what it was. The people are now paying only one-third of what they otherwise would have to pay for the antitoxin of private manufacturers. The arrangement of the State Board of Health for supplying antitoxin to the people of North Caro-lina saves our State not less than $20,000 a year. This $20,000 is, then, a fifth dividend paid on the State's investment of $88,301.12 in public health. Item 6.—The State Board of Health has interested the International Health Board and the United States Public Health Service in opportunities for suc-cessful public health work in North Carolina to the extent of obtaining from these agencies, during the past two years, a total appropriation of $43,- 720.96. In addition to this direct appropriation, we have secured from the above agencies the loan of health officials for work in North Carolina, with-out cost to the State, whose combined salaries during the time of their work in this State has amounted ta over $16,000. In short, we have been instru-mental in securing from outside sources, without cost to the State, during the last two years, $60,000 worth of health work. Item 7.—A silver nitrate solution has been supplied to all the physicians and midwives of the State, with instructions as to the law requiring the ap plication of this solution to the eyes of all new-born children for the pre-vention of gonorrheal ophthalmia, or blindness in the new-born. There occurs in North Carolina annually about 100 cases of gonorrheal ophthalmia, or blindness in the new-born—a form of blindness that is pre-vented in 98 per cent of the births, where it otherwise would occur, by the use of the silver nitrate solution; in other words, there are 12 V^ cases of this preventable blindness for every 10,000 births. The State Epidemiologist believes that he is conservative in assuming that in at least half of the births occurring in the State. 40,000 births, the law requiring the applica-tion of silver nitrate is complied with. If this estimate is correct and if the prophylactic is 98 per cent efl^cient in preventing blindness. 49 cases of blindness are prevented each year through this law. Let us assume, how-ever, that less than half of this amount of blindness is prevented—20 cases. It costs the State of North Carolina $185 a year per blind child to give it an education with the hope of making it self-supporting. It requires at least ten years at the Blind Institution for the child to receive this education. This would make a total cost to the State for educating the blind child, as an effort to make it self-supporting, ten times $185, or $1,850; for twenty blind children this would be $37,000. While estimates of the amount saved by this law will vary with the individual viewpoint, it will be admitted by all that this law is saving the State each year many thousands of dollars, and saving some of the State's citizens a loss that is incalculable. 14 ISToRTii Carolina Board of Health Item S.—The Board of Health was successful in securing the appointment of all the officers—State and county—concerned with quarantine work in North Cai'olina to the position of collaborating epidemiologist of the Fed-eral Government. While the Federal Government pays these officials only $1 per year in accordance with an Act of Congress, the position of an official in the Federal Government permits the State and county quarantine officers to use the franking privilege which saves to the State and the counties not less than $5,000 a year postage. Item 9.—Several years ago the State Board of Health was responsible for a change in the management of outbreaks of smallpox. The change effected was shifting the responsibility of protecting the unvaccinated (the only susceptibles) from the community to the unvaccinated individual. In mak-ing this change, the State Board of Health did away with a system of small-pox quarantine and isolation which, according to reports from counties for the year preceding the change in the method of control, was costing the State $66,000. Smallpox is one of the least significant factors in the State's death rate. As a result of the change in the method of control, there has been, apparently, no increase in either cases or deaths. It appears, therefore, that the Board of Health, through this policy of making the individual responsible for his susceptibility to smallpox instead of his .community, is saving the State annually something like $50,000. Item 10.—In 1914, for the first time in the history of the State, deaths from all causes were accurately recorded. In that year there were 839 deaths from typhoid fever; in 1915, 744; in 1916, 700; in 1917, 628, and in 1918. 502. There were saved, therefore, 839 less 628, or. 211 lives from typhoid fever during the year 1917. There were saved 839 less 502, or 337 lives during the year 1918, or. during the two years, there have been saved 548 lives from typhoid fever. The fatality from typhoid fever is 10 per cent; that is, 100 cases of the disease cause 10 deaths. A decrease of 548 deaths, therefore, was neces-sarily associated with the prevention of 5,480 cases of the disease. Taking the estimates of the value of the average life at the average age at death from typhoid fever, made by political economists of national reputation and based upon the life expectancy and earning capacity, the 548 lives saved were worth $4,000 each, a total of $2,192,000 of vital conservation. The prevention of 5,480 cases of typhoid fever associated with this saving of 548 lives also has a money equivalent. The average case of typhoid fever lasts six weeks. The cost of treating an average case of typhoid fever, esti-mating the amount paid physicians, druggists, and nurses, and losses of salary or per diem on account of sickness, may be conservatively estimated at $100 a case (usually estimated at $200 each case), which amounts to a total of $548,000 saved from sickness. In this item it appears, therefore, that through the work of typhoid pre-vention as organized, directed, and carried on by the Board, and through the Board's previous efforts there is a vital saving to the State of No.'th Carolina estimated at $2,740,000. . Itevi 11.—The State law which requires that all plans and specifications for waterworks and sewerage systems shall be submitted to and approved by the State Board of Health, before being accepted by the municipalities for which the plans and specifications are designed, safeguards our towns and cities against the work of cheap engineers and contractors. To illustrate: A Seventeenth Biennial Report 15 town in this State, before this law went into operation, let a contract for the installation of a public water supply. The water supply was found dan-gerous on account of its location and had to be moved. The location of the water supply, had it been passed upon by the State Board of Health, would never have been approved. To change the location of the supply cost the town somewhere between $10,000 and $1.5,000. Many such losses have been saved the municipalities of the State by this law which requires that all plans and specifications for water supplies and sewerage systems be examined and ap-proved by the engineers of the State Board of Health before being accepted by the towns and cities for which they are intended. Item 12.—The State Board of Health, in its direction of the management of the influenza epidemic, believes and claims that when the epidemic has passed and the records are available, comparisons with the other states will show that the influenza cases and deaths per thousand population in North Carolina compare favorably with the incidence of the disease elsewhere, and that in attaining these results the cost of handling the epidemic to this State was small, comparatively speaking. In the work of medical relief, sixty-four communities were served with seventy emergency doctors and sixty-one emergency nurses at a total cost to the State of $1,266.37. We claim now, leaving the verification of the claim to the future, that in this work we saved many thousands of dollars to the State of North Carolina. Item 13.—Over 160,000 school children have been given a preliminary physi-cal examination by school teachers in accordance with instructions and un-der the direction of the State Board of Health. About 48,700 of these school children have been given a second or complete physical examination by physicians and specially trained nurses in accordance with instructions and under the direction of the State Board of Health. It is oflficially recorded that 10,670 of these school children have been treated. As a result of the above examinations and treatments, thousands of other school children of which we have no record have received much needed and proper treatment. Item, 14.—During the first full year, 1918. of its existence, the Bureau of Epidemiology of the State Board of Health prescribed the method and super-vised the quarantine of 29,785 cases of communicable diseases. As a further precaution against the unnecessary spread of communicable diseases, the teachers, pupils, and patrons of 3,598 public schools were notified, through a well-developed system, of the existence of communicable diseases in the school community, of the dangers of the disease, its methods of spread, and the means for its control. In this way. many thousands of cases of con-tagions that would have occurred otherwise, causing many deaths, have been prevented. Item 1-).—Probably the most important, certainly the most fundamental, health law that any State may enact is a vital statistics law. The vital sta-tistics law of North Carolina requires the State to secure, and permanently preserve in a fire-proof vault, a complete record of the two principal events in the life of each citizen—the birth and the death of the citizen. The State holds that not one of its citizens is so humble that his coming and his going should not be taken official note of. An annual average of 77,000 births and 34.000 deaths are registered, card indexed and classified by race, sex, age, county, township, town or city, and by cause of death. For the individual, these records mean that each child may be enabled to keep track of its ancestors—father, mother, grandparents, great grand- 16 XoRTH Carolina Board of Health parents, collateral kin. Each individual will be enabled to prove his or her age in the courts, his or her right to suffrage, the right to marriage, the right to insurance, the right to enter various industries, the right to inheritance, etc. For the State, this law means that the number of deaths per thousand of the population occurring in North Carolina, or in any county or township, or town or city of the State, shall be known; it means that the number of births per thousand of the population in the State, in the counties, in any part or subdivision of the State, shall be known; that by comparing such figures with similar figures from the other states of the Union, the people of this State, the people of other states and of the world, may know, not guess, what health conditions in North Carolina are. Best of all. this law has shown and caused to be published on the au-thority of the United States Government the fact that the State of North Carolina is one of the healthiest in the Union. This is the meaning of our death rate of 13.0 per thousand of the population per year, and our birth rate of 31.9 per thousand of the population per year as compared with the average death rate of 13.9 and birth rate of 24.8 of the registration states of the Union for the same year—the last year for which the figures are available. Item 16.—A continuous and extensive educational campaign has been waged against unhygienic and insanitary conditions in the homes and com-munities of the State. This has been carried on in the following manner: The Health Bulletin has been mailed to an average of 48,000 people monthly; specially prepared leaflets, pamphlets and placards have been distributed upon request to an extent exceeding 30,000 monthly; daily articles have been supplied to the newspapers of the State for publication, these having been used in publications having a circulation in excess of 1,125,000; a total of 12,816 letters have been written; motion pictures featuring health subjects in an entertaining manner have been witnessed by approximately .58,298 peo-ple; approximately 19,971 people have witnessed illustrated health lectures; approximately 52,285- people have witnessed special health exhibits. The value of the results attained by these efforts is something that cannot be estimated in dollars and cents. The value of any educational movement is an intangible quantity. The Bible, the work of the ministers and the churches, the school system, the press, all are vital agencies upon which no exact value can be placed, but of such tremendous importance that no sane person would argue for the suppression of any. In like manner the educational work along health lines cannot be valued exactly. It has car-ried information and instruction to the people of the State, reaching di-rectly at least one-half of the population. "Line upon line, precept upon precept," the prevention of disease has been preached, and the deaths from preventable diseases have been materially reduced. Item n.—The State Board of Health, by its educational activities, has fostered, strengthened, and directed an interest on the part of the counties in local health work so that today North Carolina has sixteen counties, em-bracing a total population of 687,634, or 28V2 per cent of the population of the State, under whole-time county health officers. No State in the Union has developed its county health work to a like extent. Sevexteexth Biennial Report 17 Item IS.—In nine of the sixteen counties referred to in item 17, the State Board of Health has had direction of the county health work for a period of fourteen months, and in that time the amount of work accomp]is]ied is in-dicated in the following tabulation: 1. 969 public health meetings were held with a total attendance of 87.450. 2. 815 health articles were published in the county papers. 3. 7.364 homes constructed sanitary privies. 4. 20,834 people were examined for hookworm disease, and 3,928 were treated. 5. 479 schools were visited by health officers. 6. 38,969 school children were examined by the teachers working under the direction of the health officers. 7. 12.699 school children were examined by the health officers, these chil-dren being referred by the teachers. 8. 6.171 defective children were treated. 9. 1,528 adults were given physical examinations by the health officers. 10. 37.234 people were vaccinated against typhoid fever. 11. 6.450 people were vaccinated against smallpox. 12. 4.356 cases of infectious diseases were quarantined. Item 19.—The executive office of the State Board of Health rendered con-siderable assistance, possibly amounting altogether to two months full-timo service, to the Council of National Defense, the Surgeon General of the Army. and the Medical Aide to the Governor in the preparedness program of the country. Item 20.—To indicate the general business handled by the State Board of Health, the official correspondence, during the last two years, has amounted to a receipt of 92,550 letters and 104,120 replies. This is equivalent to a daily correspondence of 126 letters received, and 142 replies. This does not include the preparation and mailing of 110,704 multigraph letters. 18 XoRTH Carolina Board of Health ^ ^^> 5: X 'o ^ sj ^ ^5^ ^ o s •5; .$ ^§.^ i^Sv^ <\, ^ \ N ^ PRESENT ORGANIZATION OF THE NORTH CAROLINA STATE BOARD OF HEALTH The North Carolina State Board of Health consists of the Board proper and the executive staff. TJie Board of Health, as indicated diagramatically on page 18, consists of nine members, five of whom ai'e appointed by the Governor and four of whom are elected by the North Carolina State Medical Society. The organization of this body embodies two important administrative principles: (1) stability of organization and permanency of policies; (2) partnership of State and the medical profession in the conservation of human life. The stability of the organization of the Board of Health depends funda-mentally upon the Board's freedom from political tinkering. The divorce-ment of the State Board of Health from politics depends largely upon the manner of selecting the members of the Board. Sudden and marked changes in the personnel of the Board under the present plan of organization are impossible: First, because the members of the Board of Health are ap-pointed for terms of six years and their terms of service expire, not in the same year, but in different years. The appointment of new members of the Board is, therefore, gradual and not sudden. Second, the Board of Health is selected by two parties: one, the Governor, and the other, the State Medi-cal Society. It is far less likely that two parties naming a Board would be dominated by political considerations than where one party names the Board. This division of the appointive and elective power and this provision for the slow and gradual exercise of that power by two parties guarantee the State Board of Health against the sudden changes of personnel and policy asso-ciated with a purely political organization. The Board of Health is stable; its members come and go, but as an organized body it stays. This stability of organization is the responsible factor for the permanency of policies adopted by the Board. Political boards elected or appointed for two years or four years are naturally inclined to adopt two- and four-year policies, to attempt to make the best showing possible during the short term of their official life. Their administrative thoughts and plans are largely defined by the time limitations of their administration. This is not true of self-perpetuating bodies such as the Board of Health, that, as legally con-stituted, has no limit to its life. The second administrative principle embodied in the organization of the State Board of Health is the recognition by the State of the fundamental rela-tion of the medical profession to the work of prevention. The State recog-nizes (1) the debt of society to that profession by which nearly all of the experimentation and discovery on which disease prevention is based, with the exception of the work of Pasteur, was contributed; (2) the interest of organized medicine in the conservation of human life and the peculiar abil-ity of organized medicine to advise the State as to the methods of preven-tion; and (3) the necessity of securing trom the medical profession first information in regard to the occurrence of deaths and their causes, and the appearances of epidemics. The executive staff of the State Board of Health may be divided into the executive office and the various bureaus or special divisions. The Executive Office.—The executive officer of the State Board of Health should be a man with technical training and experience, and, therefore. 20 I^ORTH Carolina Board of Health should be selected on account of his technical rather than his political quali-fications. It is, therefore, right that the Secretary of the State Board of Health, or the executive officer, should be selected by a specially qualified committee, that is, the State Board of Health, and not elected in a general election, as would be the case if the office were a political one. The six-year term of office for which the Secretary is elected is. in accordance with the idea of permanency of policies. The work of the executive office is detailed elsewhere. The Bureaus or Special Divisions of the Executive Staff.-—The work of the State Board of Health is large and varied, and is, therefore, apportioned among eight bureaus. These bureaus are each directed by an officer with special talent and training. The different bureaus and their more important problems are fully and clearly indicated in the diagram on page 18. The Correlation of the Work, of the Board.—This is also clearly indicated in the diagram on page 18. The division of the executive sitaff into special bureaus has the advantage of giving individualism to the work of each bureau and thereby creating a laudable pride and a healthy rivalry among the various bureaus engaged in the general work of the Board. While each bureau is separate and independent of other bureaus, as indicated in the diagram, the work of the entire executive staff is coordinated—the work of the Board being given compactness by the relation of the bureaus to one another through the executive office of the Board. IVORK OF THE EXECUTIVE OFFICE Character of Work OBJECTIVES The objectives of the executive office are: To determine what should be the public health policies of the State; to secure the adoption of desirable health policies by the State Government, and to supervise and to assist in their execution. More fully and analytically stated, the objectives of the executive office are: (1) To determine what are the more important state health policies of the State of North Carolina, and in what order they should be developed. (2) To arrange for and, when possible, to secure, by appropriate educa-tional methods and legislative recommendations, the necessary measures and appropriations for the successful development of the more important State health policies. (3) To find and employ persons properly qualified by native endowments, training, and experience, to man and direct bureaus or divisions under the State Board of Health for the successful development of the more important plans of the Hoard. (4) To give such direction, supervision, and assistance to the bureaus or divisions entrusted with the execution of State health policies as they may need. (5) To deal with all matters of official interest that may come to the attention of the State Board of Health that are not referable to some bureau or division entrusted with carrying out some special public health work. (6) To receive, disburse, and account for the funds available for the work of the State Board of Health. METHODS The methods of work adopted depend entirely upon the objectives sought. Therefore, in discussing the methods of the work of the executive office, we shall discuss them in connection with each of the aforementioned objectives. Methods for Objective 1.—In determining the public health policies of the State, it is necessary (a) that the executive office secure information through special and regular reports on the vital statistics of the State, and in this way be fully cognizant at all times of the vital conditions of the State as shown by the State's birth rate, the State's general death rate, the State's special death rates for certain diseases, the death rates in the State by counties, by races, and by seasons; (6) that the executive office secure infor-mation, through public health literature, books, and periodicals, as to the more recent developments and discoveries in public health work; (c) that the executive off.ce. by keeping in touch through conferences with other State health officers and Federal health officers, be thoroughly conversant with the methods and accomplishments of other State departments of health, and that the executive office be alert to those larger interstate movements, especially those related to action by the central government, in order that whenever and wherever possible those larger movements may be influenced to the advantage of the State. For Objective 2.—To secure the necessary measures and appropriations for the development of the State health policies, the following methods are pur-sued: (a) The people of the State are informed, through bulletins, exhibits, 22 jSTorth Carolina Board of Health the press, and public addresses, as to vital conditions and as to necessary measures and appropriations for favorably influencing the vitality and phy-sical efl!iciency of North Carolina people. In this way the executive office seeks to develop a favorable public sentiment for the development of its more important public health policies; (6) The executive office seeks to find and to interest certain individuals qualified by heart and head and position, for influencing, introducing, and supporting needed legislation. For Objective 3.—To find and secure, with the available means, a personnel for the bureau, division, or agency of the Board that may be relied upon for carrying into successful execution some special and important public health policy, calls for (1) an acquaintance with those who are in touch with men qualified for such positions, and (2) a judgment of men. This judgment of men by which an administrative oflScer selects his assistants is. of course, basic in the success or failure of an administration. Fo7- Ohjective '/.—In giving assistance to members of the executive staff charged with carrying out certain special health policies, the executive oflSce attempts to keep in touch with the work of each division or agency through regular monthly reports, special reports, and conferences from time to time. Consideration for the right amount of assistance—not too much and not too little—is regarded as important. Too much supervision tends to smother individually, to stifle the pride of accomplishment, to break down the self-confidence of an agency; while, on the other hand, too little supervision not infrequently results in a useless expenditure of funds. For Objective 5.—In taking care of the general business of the Board which is not referable to special bureaus, the executive oflice uses much of its time in correspondence or in conferences. Perhaps 60 per cent of the time of the executive office is spent in this way. The total correspondence of the execu-tive office is shown on this page. In addition to this correspondence, from 12 to 20 per cent of the time of the executive officer is consumed in official con-ferences with callers. This would leave about 25 or 30 per cent of the time of the executive office to be devoted to the other objectives. For Objective 6.—The bookkeeping of the executive office is entrusted to a thoroughly reliable, careful, and bonded clerk, whose system of account-ing has been devised by an expert accountant and whose work is audited at regular intervals. ROUTIXE WORK Letters received 6.971 Magazines and bulletins received and reviewed (1918) ^ . . 711 Letters written : Individual 7. .537 ^Tultigraph 22.099 Total 29,546 Articles written: Newspaper (words) ; 750 Bulletin (words) 20. .300 Official publication (words) 41,150 Other publication (words) 33,825 Forms and placards prepared 14 Addresses delivered : Number 23 Total audience 1,900 Inspections: State institutions (1917) ^ Countv institutions (1917) 16 Hotels (1917) 4 Epidemics: Conferences with local authorities (1917) 14 Supervision of (1917) 1 Jail reports received and examined (1918) 284 Convict camp reports received and examined (1918) 191 Seventeenth Biennial Eeport 23 Telegrams received o05 Telegrams sent 810 Vouchers issued 3,813 Receipts issued 411 Financial reports prepared 93 Days out of office on official business 165 Percentage of work not embraced in above statement 30 Important items not included in above statement: Conferences, Medical De-fense Work, Legislation, Influenza Work. M0>THLY AVERAGE Letters received 290 Magazines and bulletins received and reviev/ed 59 Letters written: Individual 314 IMultigraph 917 Total 1.231 Articles written: Newspaper (words) ' 31 Bulletin (words) 845 Official publication (words) 1,714 Other publication (words) 1.409 Forms and placards prepared 1 Addresses delivered : Number 1 Total audience , 79 Inspections: State institutions County institutions 1 Hotels Epidemics : Conferences with local authorities 1 Super\ision of Jail reports received and examined 23 Convict camp reports received and examined 15 Telegrams received 21 Telegrams sent 33 Vouchers issued 158 Receipts issued 17 Financial reports prepared 3 Days out of office on official business 6 Percentage of work not embraced in above statement 22 RESULTS OBTAINED Result 1.—The executive office planned, established, and gave much time to the successful development of the work of five new bureaus. The executive office, therefore, shares the credit of the work accomplished by these bureaus. The bureaus established during the last two years are: (a) A Bureau of Epidemiology (complete report of work on pages 41 to 46, inclusive), which concerns itself with enforcing the State laws that prescribe methods of quar-antine for the prevention of communicable diseases; (6) A Bureau for Medical Inspection of School Children (complete report of work on pages 35 to 37, in-clusive), which concerns itself with arranging for and supervising the physi-cal examination of public school children, and providing and securing proper treatment for as large a number of the school children that are found to need medical treatment as is possible w'ith the means at the disposal of the Bureau; (c) A Bureau of Infant Hygiene (complete report of work on pages 51 to 53, inclusive), which concerns itself mainly with the great and un-necessary loss of life under five years of age—11,749 deaths out of a total of 34,000 deaths at all ages for the State each year, and more than one-third of the total deaths—with the aim of lessening this vital loss by special educa-tional measures and by demonstrating to the local governments of the State the value of public health nurses for educating and assistin.p: the mothers of 2-i XoRTH Carolina Board of Health the State in the care of their children; {(I) A Bureau of County Health Work (complete report of work on pages 26 to 34, inclusive), which concerns it-self with the proper development of model county health departments and with the supervision of nine such county health departments now in opera-tion; (e) A Bureau of Venereal Diseases (complete report of work on page 54), which concerns itself with the treatment and the rendering noninfectious of persons having venereal diseases, with suppressing prostitution, and with educating the public to the advantages of sex hygiene and the dangers of unchastity. Result 2.—The State Board of Health has interested the International Health Board and the United States Public Health Service in opportunities for successful public health work in North Carolina to the extent of obtaining from these agencies, during the past two years, a total appropriation of $43,720.96. In addition to this direct appropriation, we have secured from the above agencies the loan of health officials for work in North Carolina, without cost to the State, whose combined salaries during the time of their work in this State have amounted to over $16,000. In short, we have been instrumental in securing from outside sources, without cost to the State, during the last two years. $60,000 worth of health work. Result 3.—The executive office rendered considerable assistance to the Council of National Defense and to the office of the Surgeon General in the preparedness program of the country. This assistance consisted in making a number of trips to Washington for conferences, and at one time in making a ten-day trip for the Council of National Defense to the States of South Carolina, Georgia, Alabama and Florida for conferring with th-e Governors, the State Health Officers, and the Chairman of the State Councils of Defense of those States with respect to sanitary defense measures. We also gave much time and assistance to the Council of National Defense in the organi-zation of the Volunteer Medical Service Corps, the aim of which was the mobilization of the medical profession on the basis of a signed agreement by each physician who is a member of the corps, leaving to the Council of National Defense the disposition of his services during the war. Still fur-ther work on the preparedness program of the country was assistance ren-dered to Major J. W. Long. Medical Aide to the Governor, in the organiza-tion of the Medical Advisory Boards. Result .'f.—The executive office formulated, after conference with State officials, local agencies and authorities, the measures directed to the regu-lation of the influenza epidemic and to the medical relief work. In the work of medical relief, we were instrumental in serving sixty-four communities, having sent seventy emergency doctors and sixty-one nurses at a total ex-pense to the State of approximately $1,266.37. This report is being made be-fore the epidemic has subsided and before figures are available showing case rates and death rates in other states, and the cost of handling the epidemic to other states, but we feel safe in asserting now that when these figures are available, the case rates and death rates in this State will com-pare favorably with those in other states, and we believe that comparison of the cost of handling the epidemic will show a saving of many thousands of dollars to the State of North Carolina. Result .').—The executive office has handled an official correspondence dur-ing the last two years amounting to a receipt of 6,971 letters and 7,537 re-plies. This does not include the preparation and mailing of 22,009 multi-graph letters. WORK OF THE BUREAU OF EDUCATION Character of AVork OBJECTIVES The Bureau of Education is conducted for the following specific purposes: (a) To appoint out and endeavor to change those habits and customs which interfere with the highest physical and mental development of the individual and the State. (&) To prevent epidemics of communicable diseases by giving warning of their occurrence, and by giving information with regard to the methods of control and prevention. (c) To interest the people of the State in individual and community health work in order that home and community hygiene and sanitation may be im-proved, and health instead of disease made "catching." METHODS The methods of attaining these purposes are as follows: (1) The Health Bulletin has been published monthly, dealing informa-tively with subjects of hygiene and sanitation. It is mailed free upon re-quest to any citizen of the State. The average monthly circulation is 48,000 copies. (2) Special pamphlets and placards, dealing in a thorough manner with specific diseases and conditions, have been prepared. These are mailed upon request free to citizens of the State. The average number distributed monthly has exceeded 30,000. (3) A press service has been maintained through which daily articles, varying in length from two to five hundred words, have been sent to all the newspapers of the State. These consist of: articles having a news value but little value in the teaching of hygiene and sanitation; articles having both a news value and which teach hygiene and sanitation; articles which teach hygiene and sanitation, but with little or no new^s value. In addition specially prepared articles on hygiene and sanitation have been prepared in plate form for distribution to 102 weekly newspapers of the State. The newspapers of the State have cooperated most heartily by making extended use of this press service. (4) Stock lectures have been prepared, together with lantern slides to illustrate them, these being furnished to civic organizations interested in promoting community health. Lanterns, slides, and lectures have been so arranged as to be easily available, and have been largely utilized. (o) Traveling exhibits, covering many subjects of hygiene and sanitation, have been prepared which through models and charts give a graphic pre-sentation of the subject. These have been furnished to local organizations in the same manner as the illustrated lectures. In addition an elaborate exhibit has been prepared for the fairs of the State, the exhibit being given by a trained demonstrator. (6) Motion pictures, featuring health subjects in an entertaining manner, have been used by means of a special traveling motion picture outfit which began the service in March. 1916. Through this method a number of people have been reached who could not be reached through other methods. 26 XoKTH C'aholina Board of Health KOUTINE WORK The details of the work are indicated in the following summary: Newspapers and magazines received and reviewed 13,660 Letters and postals received 19.530 Letters written : Individual 6,701 Multigraph 6.115 Total 12,816 Articles written: Newspapers Health Bulletin Official Pamphlets Other publications Total words 419,723 Motion picture entertainments given 264 Total audience witnessing same, approximately 58,298 Addresses delivered 11 Total audience present, approximately 1,861 Stock lectures given 167 Total audience present, approximately 19,971 Traveling public health exhibits given 39 Number seeing exhibits, approximately 52,285 Special exhibits given 58 Monthly Health Bulletins mailed 696,500 Pamphlets, leaflets, and placards distributed 743,398 Articles prepared for newspaper plates (words) 23,100 Number plates sent to newspapers 920 EESULTS OBTAINED Through the means of personal correspondence, the monthly Health Bul-letin, special pamphlets and placards, addresses, lectures, special traveling exhibits, and the newspapers of the State approximately one half of the en-tire population of North Carolina has been reached directly with a message of health. The value of this is something that cannot be estimated in dollars and cents. The value of any educational movement is an intangible thing the worth of which we realize, but which we cannot reduce to terms of money. The Bible, the work of the ministers and the churches, the school system, the press, all these are educational agencies of tremendous importance. So vital are they, in fact, that no sane person would for a moment argue for the suppression of any one. Yet it is not possible to say what any one of these agencies is worth to North Carolina in sums of money. So it is with the educational health work conducted by this Bureau. It has carried information and instruction to the people of the State with re-gard to hygiene and sanitation. It has shown how communicable diseases may be avoided; how epidemics may be controlled and prevented. It has waged warfare against those insanitary conditions which produce typhoid fever and the allied diarrheal diseases. It has carried a message of hope to the tubercular and has been the instrument of saving many from untimely death by pointing out the way to restored health. "Line upon line, precept upon precept," the prevention of disease has been preached, and the deaths from preventable causes have been materially reduced in the State. REPORT OF THE BUREAU OF COUNTY HEALTH WORK (July 1, 1917, to November 30, 1918) Character of Work The Bureau of County Health Work of the North Carolina State Board of Health is the agency through which the State extends cooperation to the counties in organizing and maintaining permanent county health depart-ments. The Bureau was organized July 1, 1917, and is supported by funds provided by the General Assembly and by the International Health Board. OBJECTIVES The object of the work of the Bureau is to defnonstrate the best methods of performing County Health Work. The work of each county health department organized and conducted by the Bureau of County Health Work is to present the health problems of the county, together with the best means of solution, to the people in a definite and comprehensive manner, and by a plan designed to reach directly and educate each home. This plan comprises lectures and demonstrations, news-paper articles and letters, and home visits with the aim of having the people apply in their homes the latest discoveries of sanitation and personal hygiene. An attempt is made to have each home and school construct a sanitary closet; to have each person examined and, if necessary, treated for hookworm dis-ease; to quarantine all cases of contagious diseases and stop the spread of epidemics. The examination of school children with the treatment of all who are found defective; the examination of adults in life extension work; the vaccination against typhoid fever, smallpox and whooping-cough, are emphasized. The plan also arranges for cooperation with the towns of the county in providing inspection of hotels, restaurants, markets, and dairies, and in encouraging sewer connections and other improvements in sanitation. The county health department also has charge of the county home and jail and convict camp. METHODS The Bureau of County Health Work, in order to accomplish its objects, is cooperating with the following nine counties in a three-year plan of public health work: Davidson, Forsyth, Lenoir, Nash, Northampton, Pitt, Robeson, Rowan, and Wilson. The program of work in each county consists of definite units on the more important health problems rather than an attempt to coyer the entire field of county health activity in a short period of time. The more important units of work are concerned with the prevention of soil pollution and its attending diseases such as typhoid fever, infant diarrhea, the dysen-teries, and hookworm; life extension work which contemplates the early detection and prevention of the diseases of adult life; the medical inspection and treatment of school children; the quarantine of infectious diseases; the prevention of tuberculosis; and infant welfare work. During the first year of the health department, three units of work are undertaken: Quarantine, Soil Pollution, and the School Units. The Quaran-tine Unit is the enforcement of the State quarantine law, and aside from the educational work is largely clerical and can be done by the office assist-ants. This unit, of course, is continued throughout the entire three years. 28 North Carolina ]3<)ard of Health The School Unit is also a required unit and takes up the greater part of the second six months' work of the first year. The work of the School Unit has been to obtain a record of the physical condition of every school child in each county and to get as many of the defective children treated as possible. During the past eighteen months especial attention has been called to the dangers of denial defects and the importance of their treatment. In this work the Jsureau of Medical Inspection of Schools has cooperated and a full report of the dental work has been published by Dr. Geo. M. Cooper, the director of that Bureau. Briefly stated, the activity of the Soil Pollution Unit is, as far as is practicable, to have an official of the health department visit every rural home (white and colored) in the county and collect specimens and give treatment for hookworm disease. This official attempts to teach the people the importance of providing sanitary closets at their homes. As part of the educational campaign, the health oflncer gives lectures and demonstrations at the school houses, churches, and other convenient gathering places in each community where the unit is being conducted. Health literature is also dis-tributed, and an effort is made to educate the people along the lines of gen-eral disease prevention. Special efforts are also made to have the towns and villages of the county provide and enforce sanitary measures, and to have the larger towns establish full time sanitary departments. The Soil Pollution Unit continues intensively for six months, more or less, and is carried on by from three to five field assistants, who reside in the communities in which they are conducting the work. These assistants work, of course, under the direction of the health officer. After the intensive campaign the Soil Pollution Unit is continued by one assistant who devotes his entire time to visiting the various sections of the county, in order to keep before the people the necessity of rural sanitation, and in continuing work in com-munities which did not complete their sanitary work during the intensive campaign. This assistant also collects specimens and gives treatments for hookworm disease. An important phase of the Soil Pollution Unit is the collection of. statistics from each home and each family, these statistics being of great value to the future work of the health department. The Life Extension Unit begins in the second year of the health depart-ment. It consists of making thorough physical exarninations of adults in order to detect any danger signals which might later, if untreated, develop into serious handicaps to the individual. Before beginning this work the health officer spends ten days or two weeks at the State Sanatorium for Tuberculosis where he is given a post-graduate course in physical diagnosis. An intensive campaign of two months is then conducted by the health officer for educational work and to advertise the features of life extension work, especially emphasizing the value of periodic physical examinations. At the county seat and at branch oflJices at convenient places in the county, adults are examined after a routine plan which was inaugurated by the Life Extension Institute. After the intensive campaign the health officer set-3 aside certain hours, or perhaps a whole day, each week for the examination of applicants. In this way the unit is carried on through the second and third years of work. The medical officers of the State Tuberculosis Sana-torium act as a consulting board to the county health officers and have arranged to cooperate in examination of difficult cases. Seventeenth Biennial Report 29 Definite work is conducted against tuberculosis. This consists of lectures and demonstrations regarding the disease and in making physical examina-tions of persons who are suspected of having the disease. Each case of tuber-culosis in the county is regularly visited by some representative of the county health department in order to see that proper precautions are being taken to prevent the spread of the disease. It is planned to add the Infant Hygiene Unit at the beginning of the third year of each county health department. The purpose of the work will be to lower the death rate among babies and young children by educating the mothers as to the best means of caring for their children. The health officer will be assisted by a trained nurse and it is planned to secure the cooperation of the physicians and mothers. An important feature of the Infant Hygiene Unit will be the control of the practice of midwifery by requiring every mid-wife to register with the health department and obtain a license after demon-strating a knowledge of hygiene and obstetrics. In addition to the outlined units of health work the county may provide other units which may be found to be desirable or necessary; all such addi-tional units being conducted, of course, under the supervision of the county health department. In the same way, any community, town, or city in the county may arrange with the county and State boards of health to have its special work conducted by the county department. In each county the health officer has had medical supervision of the county home, jail, and chain-gangs. During the epidemic of influenza the county departments took the lead in organizing the local forces in combatting the disease. BUDGETS As has already been stated, each county health department is organized on a three-year plan and is under the joint control of the State and county boards of health. The State Board of Health and the International Health Board assist by suggesting the best methods of conducting the county de-partment and also financially by providing (each contributing an equal por-tion) 50 per cent of the budget of each county health department during the first year, 40 per cent the second year, and 25 per cent the third year. The budgets for the county health departments are as follows: Fiist Second Third Year. Year. Year. Health officer, salary $ 2.100 $ 2,100 $ 2,400 Traveling 600 600 750 Clerical assistant, salary 600 600 900 Fixtures and supplies 500 100 100 Contingent Fund 140 140 140 Soil Pollution Unit '. 2.430 900 900 Quarantine and disinfection 100 100 100 School Work Unit 500 500 500 Life Extension Unit 400 Infant Hygiene Unit • ... 100 $ 6,970 $ 5,440 $ 5,890 FORCE EMPLOYED The central office of the Bureau of County Health Work has a force of two—a medical director and a stenographer. The salary of the medical director is paid in full by the International Health Board, no part of it 30 North Carolina Board of Health being paid by the State Board of Health. Tlie salary of the stenographer is $70 per month. The State Board of Health provides the office, office equip-ment, supplies and printing, and the traveling expenses of the medical director. The duties of the State Director are to secul^e county appropriations, select county health officers, inaugurate and direct the work of each county depart-ment, pay regular visits to each county and report the progress of the work to the State Board of Health, collect and compile county reports, prepare literature for the county work, and have supervision of the financial pro-ceedings of the Bureau and of the cooperating counties. Each county department is directed by a health officer who is appointed by and is an official of the State Board of Health. The health officer is given an adequate corps of assistants to enable him to give as near as possible each unit of work to his entire county. An office assistant is provided for the en-tire three years of work. During the intensive soil pollution campaign from three to five assistants are provided for the field work. After the first six months, a field worker for follow-up work is employed for the remainder of the three years. In the medical inspection of school unit the health officer is assisted by a dentist and other specialists. The following is a list of the county health departments with the name of the health officer and the date on which the work began: County. Health Officer. Work Began. Nash Dr. G. W. Botts July 1, 1917* Davidson Dr. E. F. Long July 1, 1917 Wilson Dr. L. J. Smith July 15, 1917 Northampton Dr. F. 'M. Register August 1, 1917 Lenoir Dr. J. S. ^Mitchener August 15, 1917 Pitt Dr. C. P. Fryer December 1. 1917t Robeson Dr. W. A. McPhaul December 1, 1917 R owan Dr. A. J. Warren January 1, 1918 Forsyth Dr. A. C. Bulla January 1. 1918 RESULTS obtained 1. statistical.—The following statistics, when consiidered in connection with the outlined plan of work given above, will convey some idea of what has been accomplished during the seventeen months of work already com-pleted: the central office Number of letters received 2,471 Number of letters mailed 2.566 Number of mimeographed letters sent out 5,397 Number of forms prepared 54 Number of articles prepared 107 Number of packages of literature and supplies sent 464 Number of telegrams sent 91 Number of days spent out of office on official business 193 Number of addresses given 55 Number of visits to county health departments 167 *The work in Nash County "was suspended from August 15 to November 15, 1918. tThe work in Pitt County was suspended from January 1 to May 1, 1918. Seventeenth Biennial Keport 31 THE COUNTY DEPARTMENTS (An aggregate of 120 months work.) 1. Number of public meetings held 591 (Attendance, 53,807.) 2. Lectui'es at schools 378 (Attendance, 33,643.) 3. Number of letters sent out 29,173 4. Number of newspaper articles published 815 5. Number of sanitary closets built 7,364 6. Number of specimens examined for hookworm disease 20,834 7. Number of people treated for hookworm disease 3,928 8. Diseases quarantined and visited: Whooping cough 1.774 Visited 240 Measles 1,536 Visited 45 Diphtheria 263 Visited 28 Scarlet fever 105 Visited 59 Typhoid fever 530 Visited 121 Smallpox 135 Visited 61 Infantile Paralysis 5 Visited 1 Epidemic Meningitis ... 9 Visited 19 9. Number of schools visited 479 10. Number of children examined by teachers 38,969 11. Number of children examined by health officers 12.699 12. Number of children having defects remedied 6,171 13. Number of children having dental defects remedied 5,354 14. Number of physical examinations of adults* 1,528 15. Number of people vaccinated against ayphoid fever 37,234 16. Number of people vaccinated against smallpox 6.450 17. Number of people vaccinated against whooping-cough 56 18. In the towns of Wilson, Salisbury, Kinston, Lexington, and Thomas-ville the following special work was accomplished: a. Visits by health nurses 1,673 b. Hotels, cafes, and markets inspected 2,545 c. Dairies inspected . . . .' 138 d. Microscopical examinations of milk 61 e. Sewer connections 746 /. Sanitary privies (Wilson pail type) cleaned 54,321 AVERAGE M'ORK OF ONE DEPARTMENT FOR ONE MONTH These nine departments organized by the Bureau of County Health Work had been in operation for an aggregate of 120 months up to November 30, 1918. The following is the average work of one of the county departments for one month: 1. Eight public lectures with an attendance of 729 people. 2. Seven newspaper health articles published in the county papers. 3. Sixty-one rural homes constructed sanitary privies. 4. One hundred and seventy-one people examined for hookworm disease and 33 of these treated. *Life extension work (the physical examination of adults) is a unit of work taken up during the second year of each health department. The statistics given here are for only four county departments. 32 ISToRTH Caroi-ina Board of Health 5. Four schools visited by the health officer.* 6. Three hundred any twenty-five school children examined by the teachers working under the direction of the health officer.* 7. One hundred and six school children personally examined by the health officer.* 8. Fifty-one of the children found defective by the health officer were treated.* 9. Thirty-two adults given physical examinations by the health officer. 10. Three hundred and ten people vaccinated against typhoid fever. 11. Fifty-four people vaccinated against smallpox. 12. County quarantine work performed satisfactory and included the quar-antining, according to the State law, of 43 cases of infectious diseases.! 13. Medical attention was given the county dependents who were inmates of the county home, the jail, and the chain-gangs. DETAILED REPORT OF COUNTY DEPARTMENTS A. Davidson County (17 months work.) 1. Number of public meetings 193 (Attendance, 19,772.) 2. Number of newspaper articles published 61 3. Number of sanitary closets built 1,614 4. Number of people examined for hookworms 4,642 5. Number of people treated for hookworm disease. 411 6. Number of schools visited 27 7. Number of children examined by teachers 3,172 8. Number of children examined by health officers 1,680 9. Number of children having defects remedied 1,157 10. Number of children having dental defects remedied 986 11. Number of physical examinations of adults 147 12. Number vaccinated against typhoid fever 1,710 13. Number vaccinated against smallpox 1,196 B. Forsyth County (11 months work.) 1. Number of public meetings 70 (Attendance, 7,004.) 2. Number of newspaper articles published 119 3. Number of sanitary closets built 488 4. Number of people examined for hookworms 2,555 5. Number of people treated for hook worm disease 149 6. Number of schools visited 59 7. Number of children examined by teachers 1,354 8. Number of children examined by health officers 2,702 9. Number of children having defects remedied 744 10. Number of children having dental defects remedied 389 11. Number vaccinated against typhoid fever 758 12. Number vaccinated vaccinated against smallpox 105 *In considering the school work note should be taken of the fact that in North Carolina the rural schools are in session from only 4 to 6 months each year. Hence, the average school work of the health department during the months that school is in session would be from 3 to 2 times that shown in items 5, 6, 7, and 8. tWhen a case of infectious disease is reported to the health department the house in which the patient resides is placarded, the family is instructed as to the care of the patient to prevent the spread of the disease, the nearby school authorities are notified of the existence of the disease and the teachers are provided with literature regarding the disease, this literature being sent through the school to each home in the community. Seventeenth Biennial Report 33 C. Lenoir County (15 months work.) 1. Number of public meetings 174 (Attendance, 8,842.) 2. Number of newspaper articles published 151 3. Number of sanitary closets built 627 4. Number of people examined for hookworms 4,319 5. Number of people treated for hookworm disease 1,661 6. Number of schools visited 104 7. Number of children examined by teachers 3,290 8. Number of children examined by health officers 154 9. Number of children having defects remedied 394 10. Number of children having dental defects remedied 389 11. Number of physical examinations of adults 175 12. Number vaccinated against typhoid fever 9,178 13. Number vaccinated against smallpox 327 D. Kash County (14 months work.) 1. Number of public meetings 72 (Attendance, 8,150.) 2. Number of newspaper articles published 49 3. Number of sanitary closets built 747 4. Number of people examined for hookworms 1,587 5. Number of people treated for hookworm disease 193 6. Number of schools visited 78 7. Number of children examined by teachers 4,553 8. Number of children examined by health officers 449 9. Number of children having defects remedied 665 10. Number of children having dental defects remedied 665 11. Number vaccinated against typhoid fever 1,493 12. Number vaccinated against smallpox 172 E. Northampton County (15 months work.) 1. Number of public meetings 154 (Attendance, 18,515.) 2. Number of newspaper articles published 105 3. Number of sanitary closets built 1,187 4. Number of people examined for hookworms 2,545 5. Number of people treated for hookworm disease 975 6. Number of schools visited 119 7. Number of childi'en examined by teachers 4,104 8. Number of children examined by health officers 1,866 9. Number of children having defects remedied 571 10. Number of children having dental defects remedied 563 11. Number vaccinated against typhoid fever 11.170 12. Number vaccinated against smallpox 763 F. Pitt County (8 months work.) 1. Number of public meetings 37 (Attendance 3,767.) 2. Number of newspaper articles published 78 3. Number of sanitary closets built 146 4. Number of people examined for hookworms 628 5. Number of people treated for hookworm disease 145 6. Number of schools visited 20 7. Number of children examined by teachers 1.430 8. Number of children examined by health officers 818 3 34 !N^ORTH Carolina Board of Health 9. Number of children having defects remedied 145 10. Number vaccinated against typhoid fever 3,226 11. Number vaccinated against smallpox 881 G. Roheson County (12 months v^^ork.) 1. Number of public meetings 110 (Attendance, 10,786.) 2. Number of newspaper articles published 120 3. Number of sanitary closets built 956 4. Number of people examined for hookworms 62 5. Number of people treated for hookworm disease 150 6. Number of schools visited 56 7. Number of children examined by teachers 9,550 8. Number of children examined by health officer 2,127 9. Number of children having defects remedied 1,602 10. Number of children having dental defects remedied 1,421 11. Number of physical examinations of adults 999 12. Number vaccinated against typhoid fever 2,634 13. Number vaccinated against smallpox 583 H. Rowan County (11 months work.) 1. Number of public meetings 96 (Attendance, 8,246.) 2. Number of newspaper articles published 31 3. Number of sanitary closets built 1,499 4. Number of people examined for hookworms 1,848 5. Number of people treated for hookworm disease 115 6. Number of schools visited 44 7. Number of children examined by teachers 6,054 8. Number of children examined by health officers 1,221 9. Number of children having defects remedied 126 10. Number vaccinated against typhoid fever 4,664 11. Number vaccinated against smallpox 259 7, Wilson County (17 months work.) 1. Number of public meetings 56 (Attendance, 3,468.) 2. Number of newspaper articles published 101 3. Number of sanitary closets built 100 4. Number of people examined for hookworms 93 5. Number of people treated for hookworm disease 24 6. Number of schools visited 84 7. Number of children examined by teachers 5,462 8. Number of children examined by health officers 1,882 9. Number of children having defects remedied 852 10. Number of children having dental defects remedied 941 11. Number of physical examinations of adults 209 12. Number vaccinated against typhoid fever 2,401 13. Number vaccinated against smallpox 2,164 2. Reduction in Death Rate.—The nine county health departments which have been organized have been uniformly successful and have impressed the citizens of the counties with their usefulness. It has been demonstrated be-yond doubt that a county can lower its sick and death rates and that it is economical for a county to do this. At this point it is interesting to note, for example, the decrease in the number of cases and the number of deaths from typhoid fever as a result of the soil pollution work. Seventeenth Biennial Report 35 We have a record of the deaths from typhoid for the years 1914 to 1917, inclusive. Also we have a record of the deaths from this disease from January 1 to August 31, 1918—later statistics not being available. In the five county departments organized in 1917 and conducted for more than a year, the reduction in the number of deaths from typhoid is notable. And when it is considered that there are an average of 10 cases for each death from typhoid fever and that the average cost of each case is $400 we can make an estimate of the saving in money as well as suffering in each county. The statistics are as follows: Northampton County had 14 deaths from 1914-1917, or an average of Zy^ deaths each year. No deaths from typhoid occurred from January to August 31, 1918. Davidson County had 44 deaths from 1914-1917, an average of 11 cases for each year. No deaths had been reported to August 31, 1918. Nash County reported 42 deaths for the four years up to 1918, being an average of 10% deaths each year. To August 31, 1918, only 1 death had been reported from typhoid. Lenoir County's average number of deaths each year from typhoid was 10%, meaning that there were 43 deaths during the years 1914-1917. Only 2 deaths occurred to August 31, 1918. Wilson County had an average of 14^/4 deaths from typhoid or 57 deaths in the years 1914-1917. To the end of August, 1918, only 2 deaths are reported. In all nine of the counties there has been a marked decrease in the general death rate, and especially in the number of deaths from typhoid, infant bowel troubles, and the infectious diseases. The experience being gained in the organization and conduction of county health departments will no doubt prove of value to the State Board of Health in determining the best plan of dealing with county health problems. WOKK OF THE BUREAU OF MEDICAL IINSPEtTIO^V OF SCHOOLS Character of Work OBJECTIVES The object of the work of the Bureau of Medical Inspection of Schools is (1) to arouse the teachers of the elementary schools of North Carolina to the necessity of making the same efforts to teach the children things they should know for the development of their bodies and for the protection of their health, that they make for their intellectual advancement; (2) to edu-cate the children in public health matters; (3) to discover the children who have remediable defects, and to have them treated while curable and before the condition becomes chronic, and (4) to enlist the interest and to coordi-nate the efforts of county authorities, school, health and commissional, for the protection of the health of school children. METHODS In order to explain the methods of work in this department it is necessary to consider the methods in relation to the objectives. Method for Objective i.—Written instructions for teachers have been pre-pared covering every phase of medical inspection of school children. Cards for recording the exact history and results of the preliminary physical ex-amination of each child have been prepared. All this literature has been placed in the hands of the teachers, county by county, as the work progressed. Lectures by competent physicians and specially trained nurses and others have been made direct to teachers individually in small groups and in large institute gatherings. Competent officials have made examinations of chil-dren in the presence of teachers to demonstrate by example the need for the examination, the purpose, and how to do it. For Objective 2.—Health talks in simple language have been made to the children from the first grade up. Leaflets and pamphlets on health subjects, simply written, have been placed in their hands. For Objective 3.—The methods devised to discover the defective children are: (a) The teacher after consultation with the parents when necessary and after personal study of each child records on a prepared card the findings of such preliminary examination; (b) The cards are passed on to a com-petent physician, who, after careful study, selects the cards representing childi-en who are most in need of medical examination; (c) These children are then called to a physician's office and examined, or a physician or nurse, or both, visit the school and make the examination, giving advice to the parent and urging the administration of necessary treatment, either medi-cal, dental, surgical, or special; (d) Special arrangements are made for club operations and dental treatment which are fully described under Results Ob-tained of this department. For Objective .).—County superintendents of schools, county commissioners, county boards of education, and county boards of health are visited and in-dividually and officially besought to make adequate provision for the en-forcement of this law, in spirit as well as letter. Seventeenth Biennial Report 37 routine work Biennial period ending December 31, 1918. Letters received " 3,152 Letters written: Individual 4.665 Multigraph 5,960 Total 10,625 Reports prepared 24 Articles written: Bulletin 20 (words) 11,845 Other publications, 28 (words) 25,836 Pamphlets prepared 5 Days spent out of office on official business 197 Pieces of literature distributed 482,956 Addresses delivered : Number 432 Total attendance 41,532 MONTHLY AVERAGE Letters received 131 Letters written : Individual 194 Multigraph 248 Total 442 Reports prepared 1 Articles written : Bulletin 1 Other publications 1 Pamphlets prepared 1 Days spent out of office on official business 8 Pieces of literature distributed 20,123 Addresses delivered : Number 18 Total attendance 1,730 • force employed Director of Bureau, three part-time physicians, six part-time dentists, three part-time nurses, one stenographer and clerk. budget Amount received from Executive Department $7,500.00 Amount received from Special State Funds 2.024.97 Amount received from counties 56.06 results obtained Some of the tangible results of the work of this department may be enum-erated as follows: 1. More than 7,000 defective children have been treated in the public clinics established by the State Board of Health working in conjunction with the authorities of a few counties. A total of 10,670 children have been treated. The condition of these children was found through the system of medical inspection. 2. A preliminary physical examination of about 160,000 school children was made by some three thousand teachers. Several thousand of these children have been treated as a direct result of that examination, and of which no records have been obtained. 3. About one hundred cases of trachoma, a dangerous eye disease, was discovered in four counties; and most of the cases treated satisfactorily. 4. Ten thousand eight hundred and ninety-two school children were ex-amined by specially trained registered nurses. 38 XoRTH Carolixa Board of Health 5. Thirty-eight thousand seven hundred and eighteen school children were examined by physicians. These examinations were carefully made, and many hundreds of cases of serious conditions were found. For example, two children in one county were found to be in the active stages of tuber-culosis. Both were in school with other children. Both of them were sent to the State Sanatorium where they were able to regain their health. 6. Free traveling dental service was provided for the rural schools in nine counties, the first of the kind for strictly rural school children at public expense in the United States. Two hundred and twenty-seven different dis-pensaries were held and 6.678 small school children given free dental treat-ment. Such in brief are some of the specific results of the activities of the Bureau of Medical Inspection of Schools. >VORK OF THE STATE LABOKATORY OF HIGIEAE Character of Work The work of a public health laboratory is properly limited to those fields of usefulness which are strictly practical. Where other agencies exist the necessary work of health education and propaganda should be left to them. With these ideals in view, the State Laboratory of Hygiene ha,s always ad-dressed its efforts to some definite practical piece of work. When it has been necessary, on account of limited funds, to choose between different lines of work, the choice has been for that work which promised the widest help to the greatest number of the State's inhabitants. Specifically this work has been done under the following heads: 1. Analyses of water from public supplies and from commercial springs. 2. Examination of specimens for the purpose of diagnosis. 3. Pasteur treatment of persons infected with rabies. 4. Manufacture and distribution of vaccines and antitoxins. The average monthly work for the years 1917 and 1918 is as follows: Water 175 Sputum 132 Blood for typhoid 91 Blood for malaria 17 Throat swabs for diphtheria ' 59 Pus for gonorrhea 6 Brains for rabies 42 Intestinal parasites 119 Tissue for cancer 7 Urine 25 Blood for syphilis 245 (After February, 1918.) Blood for gonorrhea 4 (After February, 1918.) Miscellaneous 14 Pasteur patients (three weeks treatment each), average per month. 28 Typhoid vaccine distributed (average doses per month) 20,698 Whooping-cough vaccine (average doses per month) 658 Smallpox vaccine (average doses per month) 2,465 Diphtheria antitoxin (bought and distributed at cost in 1917, manu-factured and distributed pi^actically free in 1918) average units per month 1.005.000 Tetanus antitoxin (1918) average units per month 2,200 Also small amount tuberculin, material for Schick test and several other biological products. FORCE EMPLOYED The force employed consists of a director, one bookkeeper, four assistant bacteriologists, one chemist, one serologist, one manufacturing serologist, one laboratory assistant, one janitor and stableman, and one charwoman. In addi-tion, it is necessary to employ several extra assistants, usually medical stu-dents, during the busy summer months. 40 North Carolina Board of Health BUDGET The income for the two years July 1, 1916 to June 30, 1918, as reported to the Legislative Reference Librarian is as follows: Appropriation $26,250.00 Water tax 11.723.12 Diphtheria antitoxin 48.50 Pasteur treatments 1,054.14 Fees 1,955.17 $ 41,030.93 Less amount used for permanent Improvements 1.179.63 $ 39,851.30 At the beginning of the fiscal year December 1, 1916, there remained un-expended fi'om previous appropriation approximately $7,000. This balance was due to the fact that the completion of the new laboratory buildings had been delayed and the new antitoxin work could not be undertaken to best ad-vantage until the new buildings were occupied. In spite of the utmost economy a deficit of approximately $4,000 existed at the close of the year November 30, 1918. Two thousand dollars of this was covered by a loan from Dr. Rankin and the balance remained as an over-draft and as unpaid bills. On the annual income of approximately $20,000, the State Laboratory of Hygiene is able to demonstrate a many-fold return. The vaccines alone which were distributed free in 1918 would have cost the consumers $128,678.00 if it had been necessary for them to buy at retail prices. Diphtheria antitoxin is now available to rich and poor alike and a further saving in cost of $7,241.00 has been made. It is impossil)le to esti-mate the number of lives saved, nor the value to the medical profession and to the patients of the diagnostic work, but it is a matter of deiBonstration that the services of the laboratory have extended, during the one year 1918, to 144.000 different individuals, representing every county and almost every community in the State. The plans for the next two years call for the development of the existing lines of work and the ability to seize any new opportunity that may occur. For instance, it is hoped that out of the many different vaccines now used to combat the influenza epidemic some one will be demonstrated as efficient. If this is the case, the laboratory wants to be in position to make use of it at once. Taking into consideration only the deficit that now exists and the most conservative estimate of the needs of further development, it is necessary to have an annual appropriation of $25,000. Respectfully submitted. C. A. Shore, Director. WORK OF THE Bl KEAl OF EPIDEMIOLOGY Cliaracter of Work OBJECTIVES To prevent and control the occurrence of whooping cough, measles, diph-theria, scarlet fever, smallpox, typhoid fever, infantile paralysis, cerebro-spinal meningitis, and ophthalmia neonatorum (sore eyes in the new-born). METHODS Section 1—The County Unit 1. A quarantine officer for each county in the State has been secured and placed in charge of the quarantine work of the county, under the super-vision of the Bureau of Epidemiology. His duties are as follows: (a) To secure reports from parents and physicians of all cases of com-municable diseases. {h) To keep an accurate record in his office of all reports. (c) To transmit all reports daily to the Bureau of Epidemiology. id) To supply the parent, guardian, or householder, when the disease is reported, with rules and regulations governing that person, with a placard to be posted on the house, and with a pamphlet descriptive of the disease, its dangers, cause, mode of infection, and methods of control. (e) To inform the teachers in the community where the disease exists that the disease is present, and to supply them with rules and regulations governing the school while the disease is present, and with pamphlets de-scriptive of the disease, its dangers, cause, mode of infection, and methods of control, to be distributed through the children to the parents represented in the school. (/) To make the presence and locations of diseases known to the public by publishing monthly in the county paper the names and addresses of all cases reported during the month. This calls the attention of the public to any cases not reported. ((j) To investigate all cases of suspected contagions which have not been reported, to determine the nature of the disease. {h) To secure, at the beginning of each school in the county, a disease census* of the school children. This record is to be kept on file in his office for a reference guide to determine what action is necessary to protect the school from a disease when it occurs in the school community. (i) To enforce the laws, rules, and regulations governing the control of communicable diseases. (i) To make monthly reports to the Bureau of Epidemiology of all the work, educational, administrative, or otherwise, done during the month. The pay of a quarantine officer depends upon satisfactory work, as detei-- mined by the monthly report. Section 2—The State Unit 1. The daily reports of each of the communicable diseases are recorded by the Bureau of Epidemiology by the counties, townships, and municipalities in which they occur. These are permanent records of the Bureau, and they show the number, location, and increase or decrease in the number of cases of each disease from month to month and from year to year. The reports of cases are also temporarily recorded, geographically, on maps with colored *By disease census is meant a census of the school children showing the number immune to certain diseases by previous attacks. 42 XoRTH Cakolixa Board of Health tacks. A separate map of the State is used foi* each disease, and the tacks are inserted in the towns or townships where the cases exist. These maps show the number and distribution of cases, the rate of development, and the direction of travel of each disease. Epidemics in the developmental stage are detected by watching the daily reports and pin maps, and when one is discovered or anticipated a systematic campaign is instituted to stop it. Epidemics are handled in the following way: (a) The people in the community are notified by handbills of the presence of the disease and are given instructions how to prevent the development of further cases. (&) A history of each case is solicited so as to show the relation of the case to the usual sources of infection. (c) In epidemics of typhoid fever, diphtheria, or smallpox, arrangements are made for having the susceptible people of the community protected against the disease by vaccination. The people are notified of such arrange-ments and are encouraged to avail themselves of the opportunity. (d) An investigation of the sanitary and hygienic conditions in the im-mediate vicinity of each case is made. (e) The facts in the history of the cases and the findings of the sanitary and hygienic conditions are tabulated according to epidemiological methods, so that the exact sources of infection are determined. (/) Recommendations of the necessary measures for the control and pre-vention of the disease are made to the proper authorities. (g) When the nature of the disease is such that public gatherings are per-missible, a public meeting is held to advise the public as to the modes of in-fection, dangers, and measures necessary for the control of the disease, for it is through the cooperation of the public that diseases are controlled. (7i) State-wide publicity is given epidemics, to warn the people of the presence of the disease, to force the local authorities to take action to stop its spread, and to educate the people in disease prevention. (i) Twenty epidemics were investigated and assistance given in the sup-pression of the disease. The value of this work can not be estimated, but we feel assured that many cases of disease and many deaths have been pre-vented. Safe water was secured for one town; a sewerage system assured at another, and a safe water supply assured at another. Hundreds of people have been vaccinated. 2. Weekly telegraphic and monthly written reports of all cases of infectious and contagious diseases reported to the Bureau of Epidemiology are made to the Surgeon General, United States Public Health Service, Washington, D. C. These reports have been made since June, 1918. when the appointments of the State Epidemiologist as Collaborating Epidemiologist and of the county and city quarantine officers as Assistant Collaborating Epidemiologists were secured. 3. All deaths from the reportable diseases reported to the Bureau of Vital Statistics are checked against the reports of cases, to see if the cases which resulted in death were reported. If not, then proper action is taken against the person failing to report. 4. All report cards, blank forms, educational posters, placards and litera-ture on the reportable diseases, and all rules and regulations governing the control of the diseases, are prepared by the Secretary and the Epidemiologist of the State Board of Health, and distributed to the various quarantine offi-cers by the Bureau of Epidemiology. Seventy blank forms, pamphlets, rules, posters, placards, etc., have been prepared and distributed. 5. The one per cent (IVc) silver nitrate solution used as a prophylactic against sore eyes in the new-born is supplied to all physicians and midwives Seventeenth Biennial Report 43 of the State free of charge, with instructions as to its use, and blank re-quest cards are furnished for ordering more of the prophylactic when it is needed. 6. Investigations of counties are made from time to time by trained in-spectors, to determine: (a) If the county quarantine officer is doing his duty. His records are examined, and he is questioned as to his knowledge of quarantine work. Several cases recently reported are visited to see if proper literature has been supplied to the family and if quarantine was established. These in-vestigations brought trained inspectors in contact with fifty-five county quarantine officers, who were given personal instruction in quarantine work and support in furthering the quarantine measures. Through this intimate contact with the quarantine officers much interest in the work has been created among them, with good results. (b) If the physicians are reporting promptly all cases. The physicians who have reported but few cases recently are visited to ascertain if they have treated any cases which they have not reported. (c) Special efforts are made to learn of unreported cases. These are visited to ascertain the nature of the disease and why they were not re-ported. The person found responsible for neglecting to make the report is dealt with according to law. These investigations, together with the investigations of the deaths of unreported cases, have been responsible for seventy-seven indictments of physicians and others, with seventy-four con-victions. (d) The findings in the investigations of counties have been prepared, sub-mitted to the editors, and published in the county papers. These publications give the people an opportunity to know what is going on in the county in disease prevention, and often they inspire some conscientious person to in-form us of unreported cases which need to be dealt with. 7. Twenty-three public talks on the communicable diseases, their spread and control, have been given with an attendance of 1,638 people. RESULTS OBTAINED Result 1. In 1918, 29,787 cases of communicable diseases were reported to, and received the official attention of the Bureau. The households in which these diseases existed were quarantined, placarded, and instructed (a) as to the danger of the disease to the patient, and the methods for lessening its danger; (&) the danger of the disease to other members of the family, and the means for preventing their infection; (c) the danger of the disease to the community, and the measures by which the household might protect the community. As a further measure, 3,598 school populations, in which communicable diseases appeared, were notified of the occurrence of the dis-ease, and the teachers were furnished with popular pamphlets for distribu-tion, through the children of the school, to the homes in the community, notifying the community of the appearance of the disease, its danger, its method of infection, and the means for avoiding contracting it. The total number of homes thus warned and informed was approximately 65,000. That there would have been thousands of cases of contagious diseases in addi-tion to the number that actually occurred had not the foregoing method of prevention been carried out, is beyond a reasonable doubt. Result 2. The prevention of typhoid fever is an epidemiological proced-ure, and, therefore, the reduction in this disease, which has been associated wath a vigorous campaign against it, while extending over a period of five years antedating the establishment of the Bureau, should be accounted for 44 A'oKTH Cakolixa Board of Health under the work of this Bureau. The reductions in the deaths and cases from typhoid fever in North Carolina for the last five years (we have no record of cases and deaths prior to this period) are as follows; 1914. Deaths 839. Cases 8,390 1915. Deaths 744. Cases 7,440 1916. Deaths 700. Cases 7,000 . 1917. Deaths 628. Cases 6,280 1918. Deaths 502. Cases 5,020 It will be observed that there has been a decrease in this flve-year period of 337 deaths and 3,370 cases. Typhoid fever occurs among adults usually at the most active period of life, at a time when economists estimate life to be worth $4,000 per capita. This estimate applied to the 337 lives saved each year means a saving of $1,348,000 to the State of North Carolina. This is not all. To prevent 337 deaths from typhoid fever, it was necessary to prevent ten times as many cases, as the average fatality from typhoid is 10 per cent; therefore, in addition to 337 lives saved, there were 3,370 persons prevented from having a disease which lasts an average of six weeks and which costs, estimating the value of the time lost from sickness, the cost of nurses, the cost of drugs, and the amount paid physicians, about $200 per case. The prevention, then, of 3,370 cases at $200 each means an additional saving to the State of $674,000. Result 3. The Kureau of Epidemiology has supplied silver nitrate to all physicians and midwives of the State in order that they might comply with the law requiring that this remedy for the prevention of gonorrheal blindness in the new-born be applied at birth to the eyes of all babies. While the law is still new and as yet imperfectly complied with, it is a conservative estimate to assume that the prophylactic has been used in half of the births, that, is 40,000. The records of the Blind Institute indicate that before the passage of this law there had been a minimum of 12^^ cases of blindness from gonorrheal ophthalmia for every 10,000 births. It is known that this prophylactic solution applied to the eyes of the new-born will prevent at least 80 per cent of blind-ness in those that would otherwise become infected and lose their sight. On this estimate, the Bureau is entitled to claim the prevention of 48 cases of blindness; but in order that we may be too conservative rather than claim too much, let us assume that we prevented only 20 cases of blindness in North Carolina last year. Ten of the 20 blind will die before they reach an age when they become an expense to the State as well as to the parents. This leaves ten dependents, which cost the State to make them independent, self-supporting, $185 a year at the Blind Institute for ten years, or $1,850 for each case of blindness, or, for the ten, a total cost of $18,500. Result Jf. In 1918, the Bureau made 154 sanitary inspections of hotels, 59 inspections of jails, 34 inspections of convict camps, and 15 inspections of State institutions—a total of 262 inspections. These institutions were marked by a score-card method, and the results of the inspection pub-lished in the newspapers and the Bulletin with the result that there has been considerable sanitary improvement in the conduct of hotels, county and State institutions, greater comfort and greater safety to the traveling public and inmates of the institutions. Result ). The Bureau, through an arrangement with the Federal Gov-ernment, secured the appointment ' of all quarantine officers as Federal Seventeenth Biennial Report 45 officers without pay, except the nominal $1 per j'ear required by Congress. Through this arrangement, the quarantine work of the State and the coun-ties may be done without the use of postage, under the frank. The postage thus saved the State and the counties amounts to not less than $5,000 a year. Result 6. The Bureau secured, through certain cooperation rendered the United States Army, 30,000 doses of typhoid vaccine in the form of what is known as lipo-vaccine—a vaccine used in the Army and Navy with which one instead of three hypodermic injections produces an immunity. The value of the 30,000 doses, and the expense saved for administration^ two-thirds of the treatment being unnecessary, may be estimated at a saving of at least $5,000. OFFICE ROUTINE The following tabular estimate for the years 1917 and 1918, based upon seventeen monthly reports, shows the routine work of the Bureau: Letters received 2,792 Letters written : Individual 2,349 :\Iultigraphed 37,933 Total 40,282 Post cards received (replies to typhoid letters), 5 months 487 Packages of supplies sent out 4,590 Packages of silver nitrate sent out 11,400 Lectures prepared 3 Press articles prepared 8 Forms prepared (for records and reports, placards, pamphlets) 70 Cases of communicable diseases reported and recorded 36,662 Cases of ophthalmia neonatorum reported and recorded 15 Cases of influenza reported and recorded. 3 months (approximate) . . . .109,419 FIELD WORK Trips made 66 Quarantine officers visited 121 Counties investigated 55 Reports published 6 Epidemics investigated 20 Addresses delivered 24 Total audience 1,663 Prosecutions 77 Convictions 74 Inspections : Jails 59 Convict camps 34 Hotels 156 State institutions 16 Total 265 IXFLUEXZA RELIEF WORK Counties visited 11 Communities visited 19 Corps of relief workers organized 9 quarantine officers' REPORTS (16 months) Reports made 1.288 Homes visited 6,688 Schools notified of diseases 5.013 Public notices posted (smallpox) 1,922 School diseases censuses returned by teachers 9,873 Indictments 45 Publications 1,884 46 ISToRTH Carolina Board of Health AVERAGE MONTHLY ROUTINE WORK, 1917-1918 Letters received 164 Letters written : Individual 138 Multigraphed 2,231 Total 2.369 Postcards received (replies to typhoid letters) 97 Packages of supplies sent out 270 Packages of silver nitrate sent out 671 Lectures prepared 3/17 Press articles prepared 8/17 Forms prepared (for records and reports, placards, pamphlets) 4 Cases of communicable diseases reported and recorded 2,157 Cases of ophthalmia neonatorum reported and recorded 1 Cases of influenza reported and recorded (approximate) 36,473 FIELD WORK Trips made 4 Quarantine ofl^cers visited 7 Counties investigated 3 Reports published 6/17 Epidemics investigated 1 Addresses delivered 1 Total audience 98 Prosecutions 5 Convictions 4 Inspections : Jails 4 Convict camps 2 Hotels 9 State institutions 1 Total 16 QUARANTINE OFFICERS' REPORTS Reports made 81 Homes visited 418 Schools notified of diseases 313 Public notices posted (smallpox) 120 School disease censuses returned by teachers 617 Indictments 3 Publications 118 WORK OF THE BUREAU OF VITAL STATISTICS Character of Work OBJECTIVE The objective of the Bureau of Vital Statistics is to secure a permanent record of the more important facts concerning the birth and death of every citizen of the State of North Carolina, and from such records to prepare card indices and tabular classifications in such manner as to make readily available, on inquiry, the following information: 1. (a) The total number of births occurring annually in the State; (b) the birth rate of the State, that is, the number of births per thousand of the population; (c) the birth rates by races, white and colored; (d) the num-ber of illegitimate births; (e) the number of stillbirths; (/) all of the afore-going data as to births with respect to each county, town and city. These facts permit of comparisons of one part of the State with another, of the birth rate of the two races, and of the birth rate of this State with that of other states, and other countries. Such information is necessary in forming conclusions as to vital conditions in North Carolina and in the en-actment of suitable legislation for dealing with these conditions. 2. (a) The number of deaths occurring in the State of North Carolina annually; (b) the death rate, that is, the number of deaths per thousand of the population in North Carolina; (c) the number of deaths, by races and the death rates by races in North Carolina; (d) the number of deaths among in-fants and young children as compared with the births, and the total deaths as compared with the total births, with net gain in population; (e) the number of deaths from the more important causes of death; that is to say, the number of deaths from typhoid fever, from tuberculosis, diphtheria, in-fantile diarrheas, etc., amounting altogether to a classification of about forty separate causes of death; (/) all of the aforegoing data classified according to county, town and city. This information is absolutely necessary to under-stand vital conditions in the State; to know where health work is needed; against what causes of death health measures should be directed; and whether the work of health departments is associated with a decrease or no decrease in death rates. 3. Under 1 and 2. information necessary for the public welfare, and avail-able under the operation of the vital statistics law, has been briefly indi-cated. But the vital statistics law not only supplies information to legisla-tures. State and county commissioners, and other administrative bodies, which is necessary for framing conservation measures for human life, but it also records facts which may at any time become of great value to the individual. In matters of tracing ancestry, birth records are invaluable; also, in matters of proving age where the fact of age is in question, as for voting, as for the right to marry, as for the right to enter certain indus-tries, to enter school, or as to liability for military service, etc. METHODS The Bureau of Vital Statistics secures the birth and death certificates for the birth and deaths occurring in North Carolina through approximately fourteen hundred local registrars, appointed by the chairmen of the boards of county commissioners for the various townships and by the mayors for the various incorporated towns and cities of the State. The duties and powers of the local registrars are defined in chapter 109, section 22. Public Laws of 1913. The county pays the local registrars 2.5 cents for each birth and death certificate furnished by them to the office of the State Registrar at Raleigh. The vital statistics law makes it the duty of the doctors and 48 XoRTir rARoi,i]\rA Board of Health midwives in attendance on a birth to file a birth certificate with the local registrar of the district in which the birth occurs, and makes the undertaker, or person acting as undertaker, responsible for filing the death certificate. The birth and death certificates filed with the local registrars of the State are sent to the State Registrar on the fifth of the month succeeding the month in which the birth or death occurred. The certificates received in the office of the State Registrar are examined, and, if incorrect or incom-plete (as a large per cent of them are) effort is made to secure the infor-mation necessary to complete them. The certificates are then classified and tabulated according to county and registration districts, according to races, according to age at death, according to cause of death, according to death rates and birth rates, etc., in order to make readily available, upon request, the information mentioned under the heading of objective. ROUTINE WORK OF BtJREAtT The routine work of the Bureau of Vital Statistics is indicated in the fol-lowing table: WORK OF BUREAtr OF VITAL STATISTICS DURING YEARS 1917-1918 Item. wn. 1918. Letters received 18,273 15,992 Postals received 2,558 909 Undertaker's reports received 6,083 5,839 Local and deputy acceptance papers received 5,655 293 Provisional death certificates received 12 15 Supplemental reports received 2,642 2,354 Violation blanks received 235 179 Letters written: Individual 26,025 Multigraph 24.862 Total letters 50.887 Letters written: Individual 30,577 Multigraph 11,407 Total 41.984 Postal cards sent out 5,286 1,667 Acceptance papers sent out to registrars 1,755 231 Packages supplies sent out 4,658 7,957 Certificates received: Deaths 33,914 Births 77,063 Stillbirths 7.019 Total 117,996 Certificates received: Deaths 42.061 Births 75.764 Stillbirths 6.669 Total 124,494 Indexing: 1017. 1918. 1916. Births (last 9 months) Completed 1917. Births Completed 1917. Deaths Completed 1918. Births 66 2/3% 1918. Deaths 83 1/3% Miscellaneous tables made 29 44 Tables completed for Biennial Report (1916) Completed Tables completed for Biennial Report (1917) 4 Cards punched and proof read (1916) Completed Cards punched and proof-read (1917) Completed Index cards proof-read, assorted and filed 101,726 59.169 Index cards proof-read and assorted (1916) 52,708 Cards furnished (decedents from tuberculosis) 3,261 2,705 Number convictions secured 13 . 17 Seventeenth Biennial Keport 49 MONTHLY AVERAGE Letters received 1,428 Postals received 144 Undertakers' reports received 497 Local and deputy acceptance papers received 248 Provisional death certificates received 1 Supplemental reports received 208 Violation blanks received 17 Letters written : Individual 2,358 Multigraph 1,511 Total . 3,869 Postal cards sent out 290 Acceptance papers sent out 83 Packages supplies sent out 526 Certificates received (births, deaths, stillbirths) 10,104 Per cent of indexing of births for entire year completed each month. . . 10%* Per cent of indexing of deaths for entire year completed each month. . 8% Miscellaneous tables made 3 Index cards filed 6,704 Index cards proof-read and assorted 6,704 Cards furnished (decedents from tuberculosis) 249 Number convictions secured 1 Tables for 1916 (Annual Repoi-t) t Tables for 1917 (Annual Report) t Cards punched and proof-read for 1916 and 1917 t RESULTS OBTAINED Without going into unnecessary detail, it may be said that the objective of this Bureau, as aforestated, has been reached, and that all of the infor-mation, vi^ith its vital bearing upon the public health needs of the State and with the public health accomplishments of the State, is readily and com-pletely available. As a mere indication of the practical value of the work of this Bureau, we may point out the fact that the birth rate of North Carolina is four in excess of the highest birth rate of any other State in the Union to wit, Michi-gan, with a birth rate of 28.4, and that the death rate in North Carolina, not-withstanding the high birth rate, giving us an exceptionally large age group of tender years with high fatalities, is exceptionally low, the lowest of any of the old States of the Union, the lowest of any State on the Atlantic or Gulf Coast. To be brief, the vital records of the State show that North Carolina is one of the healthiest States in the Union. Another sample bit of information of great value is the relative birth rates and death rates of the two races, the white birth rate being 32.2 and the colored birth rate being 31.1, 1.1 less than the white birth rate, while on the other hand the white death rate is 11.2 and the colored death rate is 17.0. Here we see that the white race in North Carolina is making a net gain of 34,511 citizens a year while the colored race is making a net gain of only 10,775 citizens per year. Another sample of information obtained through the Bureau of Vital Sta-tistics is the record of the State in the decrease of typhoid fever as indicated *During years 1917 and 1918 percentage of births indexed for 1916, 75 per cent, 1917, 100 per cent, 1918. 66 2-3 per cent, making a monthly average of 10 per cent, timpossible to estimate amount of work completed per month. 50 iSToRTH Caroli^'a Board of Health in the following table of deaths and cases of this disease during the last five years, that is, the five years for which we have had a vital statistics law with a record of deaths: 1914. Deaths 839. Cases 8,390* 1915. Deaths 744. Cases 7.440 1916. Deaths 700. Cases 7,000 1917. Deaths 628. Cases 6,280 1918. Deaths 502. Cases 5,020 *Estimatecl on known average fatality of 10 cases per 1 death. WORK OF THE BUREAU OF INFANT HYGIENE Character of Work OBJECTIVE The objective of this Bureau is to take official cognizance of, and to direct remedial measures of established value to, the appalling death rate in North Carolina within the first five-year period of life. When we realize that more than one-third of all deaths that occur in this State are in the first five-year age group, or, to be exact, that 11,749 out of a total of 34,005 deaths for last year were under five years of age, we must see the absolute necessity for some positive action rather than a policy of indifference or inactivity in this large vital field. Of the 11,749 deaths, 7.825 are under two years of age and are due to three principal causes: 3,153 are stillbirths, due, in a large percentage of the cases, to an abnormal and unnecessary interruption of pregnancy; 2,04G occur in the first month of life from causes usually grouped under the general term as congenital debility many cases coming within this group being of a pre-ventable nature; 2,626 result from diarrheal diseases of infants within the first two years of life, and 90 per cent of these are either being raised on artificial food, or have been weaned and, in their second year, are being adjusted to a diet consisting largely of cow's milk. Of course, the weaning of a child at about the termination of its first year of life is right, but in the transition from the milk of the mother to the milk of the cow and other articles of diet, intelligence in infant feeding counts for much. A large per cent of the deaths of infants within the first five-year period of life, and more especially within the first two years, is due to two main causes: (1) carelessness, and (2) lack of essential information as to the hygiene of pregnancy and infancy. Prenatal hygiene, or the hygiene of pregnancy, when understood, even when superficially considered, will have, as it has had elsewhere, far-reaching influence in preventing the premature interruption of pregnancy from many causes that are avoidable, and thus will be reduced the large number of stillbirths and waste of life occurring annually in this State; moreover, this same knowledge regarding precau-tions to be taken by pregnant women will have much to do with decreasing the number of deaths occurring within the first month of life usually cer-tified to as being due to congenital weakness. An extensive and intensive educational campaign directed to impressing mothers with the value of breast feeding as against artificial feading, and with the necessity of a certain amount of essential information regarding the preparation of artificial food for infants, will be in North Carolina as it has been in other places coinci-dent with the decrease in the number of deaths of infants under two years of age from diarrheal diseases. METHODS The methods of the Bureau of Infant Hygiene may be conveniently di-vided into two classes: (1) those with the State as the unit; (2) those with the county as the unit. The methods with the State as the unit consist of securing the names and addresses of (a) as many pregnant women as possible; (h) of securing the names and addresses of the mothers of as many artificially fed infants within the first year of life as possible, and (c) the names and addresses of 52 I^ORTH Carolina Board of Health mothers with infants in the second year of life who are suffering from diges-tive disturbances. The methods for obtaining these names and addresses consist of appeals made to nurses, doctors, women's clubs, philanthropic or-ganizations, and county health officers, for cooperation and for furnishing the addresses of mothers—prospective and real—and of invitations extended generally through the State Board of Health Bulletin and the press of the State to any mother or pregnant woman who may be interested to the extent of permitting this Bureau to render any service to her within its power. With the addresses of possibly interested cases of pregnancy, and of mothers, this Bureau, by a carefully prepared series of letters (a correspondence course) and by educational pamphlets, seeks to interest them, to create a close bond of real sympathy between itself and the women, and to assist them in every way possible in either the conduct of their pregnancy or care for their children, or both. The methods with the county as the unit will be carried out largely through the use of a nurse specially trained in a knowledge of the hygiene of pregnancy and of infancy. This nurse will be paid partly by county funds, partly by State funds, and the prospect is bright for securing a Federal fund to be used in defraying the cost of the nurse. The nurse will (a) organize in the county a number of mothers clubs, and will give a regular, well con-sidered and planned course of instruction to these clubs, endeavoring by this means to develop to the highest possible degree a general knowledge of the hygiene of pregnancy and infancy among the women of the county; (6) The nurse will get in touch with, and will instruct and supervise the work of the midwives of the county through a county ordinance prohibiting careless or incompetent midwives from attending a case of labor; (c) The nurse will encourage the pregnant women of the county, by the assistance she renders them, to consult with her, to allow her to advise them, and to help them. The nurse can be of considerable assistance to these women through the information she can give, through making examinations of urine and re-porting to their attending physician, and through making examinations of the pelvis or bony canal to detect, anticipate, prepare for, and avoid the unnecessary complications of labor; (d) The nurse can keep a tack-map of a county, the tacks of one color indicating the homes of babies that are being raised on the bottle, and tacks of another color indicating babies within their second summer suffering from digestive troubles. She can make frequent visits to the homes of these children, advising with the moth-ers and assisting them in taking care of the children. This is, briefly, the county method that will be carried out under the direction of the Bureau of Infant Hygiene. THE ROUTINE WORK OF THE BUREAU ~ Letters received 160 Magazines and bulletins received and reviewed 24 Letters written : Individual 102 Multigraph (6 f |