Biennial report of the North Carolina State Board of Health

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TWENTY-FIRST BIENNIAL REPORT
OF THE
NORTH CAROLINA
STATE BOARD OF HEALTH
JULY 1, 1924 - JUNE 30, 1920
"7
Members of the State Board of Health
o
Elected by the North Carolina Medical Society
Cyrus Thompson, M.D.
Term expires 1931
D. A. Stanton, M.D.
Term expires 1931
W. S. Rankin, M.D.
Term expires 1929
Thomas E. Anderson, M.D.
Term expires 1929
Appointed by the Governor
Richard H. Lewis, M.D., LL.D.
Term expires 1931
E. J. Tucker, D.D.S.
Term expires 1931
James P. Stowe, Ph.G.
Terms expires 1927
J. Howell Way, M.D.
Term expires 1929
A. J. Crowell, M.D.
Term expires 1929
Letter of Transmittal
Raleigh, N. C, December 1, 1926.
His Excellency, A. W. McLean,
Governor of North Carolina.
My Dear Sir:—Under authority of chapter 118, Article 1, section 7050,
Consolidated Statutes of North Carolina, I have the honor to submit the
Biennial Report of the State Board of Health for the period July 1, 1924,
to June 30, 1926.
Very respectfully yours,
Chas. O'H. Laughinghouse,
Secretary and Treasurer.
Preface
Ten years ago the experiment was tried of including in
the Biennial Report only that information not easily obtain-able
from other sources, and of omitting information largely
of details and statistics of little general interest. The
experiment proved so satisfactory that the same principles
have since been followed. In the present report the arrange-ment
by fairly independent sub-divisions is continued, so
that it is possible to read and understand any part of the
report without reading the entire report. An annual report
, of the vital statistics records of the State is now being
issued.
Public Health Work in North Carolina
In the seventies Dr. Thomas Fanning Wood, of Wilmington, caught the
vision of the possibilities of public health work to North Carolina. How
fully he grasped the far-reaching consequences of his idea, how clearly he
saw the ever-growing hosts of lives saved as a result of his vision and in-spiration,
we shall never know. We do know that the vision never left
him, and that under its sway he worked, through the Medical Journal
which he edited and through the North Carolina State Medical Society,
until his influence reached the people of the State in their General As-sembly
of 1877, with the effect that on February 12, 1877, the North Caro-lina
State Board of Health was born. Ours was the twelfth State board of
health to be established.
Without treating the development of the newly-established board with
that thoroughness that could be termed history, we think it enough to set
down here in chronological order the principal events in the life and growth
of the North Carolina State Board of Health.
1877. Board created. Consisted in the beginning of entire State Medical
Society. Society acted through a committee. Annual appropri-ation,
$100.
1878. First educational pamphlet issued. Subject, "Timely Aid for the
Drowned and Suff"ocated." Annual appropriation, $100.
1879. The General Assembly reconstituted the Board of Health. Made it
to consist of nine members: six appointed by the Governor, three
elected by the State Medical Society. Term of office, five years.
Dr. Thomas F. Wood elected first Secretary of the Board, May 21.
Other legislative provisions: (1) Chemical examination of water,
and (2) organization of county boards of health, composed of all
regular practicing physicians and, in addition, the mayor of the
county town, the chairman of the board of county commissioners,
and the county surveyor. Four educational pamphlets issued.
Subjects: "Disinfection, Drainage, Drinking-water, and Disin-fectants;"
"Sanitary Engineering;" "Methods of Performing Post-mortem
Examinations;" "Limitation and Prevention of Diph-theria."
Annual appropriation, $200.
1881. General Assembly passed a law requiring registration of vital
statistics at annual tax listing; law ineffective. Annual appro-priation,
$200.
1885. General Assembly made county boards of health more efficient;
allowed printing privileges not to exceed $250 annually. Annual
appropriation, $2,000.
1886. Bulletin made its appearance in April. Pamphlet on "Care Eyes and
Ears," by Dr. Richard H. Lewis, printed and distributed. Subse-quent
Legislature provided for extra edition of 10,000 copies for
general distribution. Annual appropriation, $2,000.
1888. Yellow fever epidemic in Florida and refugees to Western North
Carolina demonstrated value of a Board of Health to cope with
situation. Annual appropriation, $2,000.
8 North Carolina Board of Health
1892. Dr. Thomas F. Wood, the Secretary of the Board, died August 22.
Dr. Richard H. Lewis elected Secretary to succeed Dr. Thomas F.
Wood, September 7. Annual appropriation, $2,000.
1893. Legislative provisions: (1) Laws improving the reporting of con-tagious
diseases, (2) the protection of school children from epi-demics,
(3) protecting the purity of public water supplies, and
(4) regulation of common carriers. Legislature provided that
Governor appoint five of the nine members of the Board of Health,
that the State Medical Society elect four, and that the term
of office of the members of the State Board of Health be reduced
from five to two years. The $250 printing limit was removed.
Pamphlet on quarantine and disinfection was prepared and re-printed
by many of the State papers. Annual appropriation,
$2,000.
1894. A number of public health conferences were arranged and held in
diff"erent towns of the State. Bulletin was increased from a
mailing list of 800 to 1,200. Annual appropriation, $2,000.
1895. Dr. Albert Anderson and Dr. W. T. Pate were elected bacteriologists
for the board. Annual appropriation, $2,000.
1896. Board passed a resolution requiring chemical and bacteriological
examinations of municipal water supplies. Dr. Venable of Chapel
Hill, undertook the chemical examination, and Drs. Anderson and
Pate the bacteriological examination. Board also directed Mr.
John C. Chase, the engineer member, to inspect all municipal water
plants in the State. Annual appropriation, $2,000.
1897. General Assembly enacted law requiring county superintendents of
health to be elected by county commissioners, and reduced term
of office to one year. Annual appropriation, $2,000.
1899. General Assembly improved the laws protecting public water sup-plies.
Smallpox prevailed extensively in the State. Dr. Henry F.
Long, and later, on Dr. Long's resignation, Dr. Joshua Tayloe
were employed to travel over the State, consulting with and
advising the local sanitary authorities as to proper means for
protecting the public. Annual appropriation, $2,000.
1900. State Board of Agriculture, on request of State Board of Health,
agreed to examine samples of v/ater from public water supplies
until Board of Health could provide its own examiner. Annual
appropriation, $2,000.
1901. State Board of Embalmers, with representatives of State Board of
Health, established. County health work placed in the hands of
county sanitary committees composed of county commissioners
and two physicians which commissioners elected to serve with
them. Term of office of county superintendent of health made
two years. Annual appropriation, $2,000.
1903. General Assembly enacted law permitting Board of Health to
charge $5 for each analysis of a public water supply, this fee to
be used in paying Department of Agriculture for services of
examiner. Dr. C. W. Stiles, U. S. P. H. S., before the State
Medical Society at Hot Springs, called attention to prevalence
of hookworm disease in the South. Dr. J. L. Nicholson and Dr.
W. S. Rankin, working under State Board of Health during fall
Twenty-first Biennial Reiport 9
of 1903 and spring of 1904, showed great prevalence of this
disease in North Carolina. Annual appropriation, $2,000.
1904. A stenographer was employed. One hundred and twenty thousand
pamphlets on tuberculosis were printed and distributed. There
was a renewal and an extension of cooperative work between the
Board of Health and the State press, a number of articles dealing
with hygienic and sanitary subjects being furnished the papers
and published in them. Annual appropriation, $2,000.
1905. General Assembly established State Laboratory of Hygiene; im-posed
water tax of $64 on all public water companies; voted $600
annually for support of Laboratory. Small appropriation made
it necessary for the Department of Agriculture to continue to
assist State Board of Health. Annual appropriation, $2,600.
1906. The North Carolina Association for the Study and Prevention of
Tuberculosis was organized. Annual appropriation, $2,600.
1907. Two thousand dollars appropriated for the State Laboratory of
Hygiene. Pasteur treatment provided. State Sanatorium for
treatment of tuberculosis founded: $15,000 appropriated for
permanent improvements and $5,000 for maintenance.. A law
requiring the separation of tuberculous prisoners from other
prisoners was enacted. Annual appropriation, $4,000.
1908. January 1, Dr. C. A. Shore became Director of State Laboratory
of Hygiene. Annual appropriation, $4,000.
1909. General Assembly provided for (1) whole-time State Health Officer;
(2) collection of vital statistics of towns having a population of
1,000 or over; (3) that all public water companies file plans and
specifications of their plants with the State Board of Health, and
that the State Board of Health pass necessary rules and regula-tions
for the care of public watersheds and plants and furnish
such rules and regulations and other advice to those having
charge of public water supplies; (5) that counties provide free
diphtheria antitoxin for county indigents, and (6) that the
maintenance appropriation for the Sanatorium be increased from
$5,000 to $7,500, and an additional $30,000 be granted for perma-nent
improvements. Dr. Richard H. Lewis resigned as Secretary
of the Board, and Dr. W. S. Rankin was elected as his successor,
beginning his official work July 1. Annual appropriation, $10,500.
1910. General effort to interest the people and State organizations in
public health work. Bulletin increased from 3,500 edition to
10,500 edition. Addresses on public health work delivered to
Conference of County Superintendents of Schools, State Federation
of Women's Clubs, State Press Association, and Sanitary Sunday
observed in April. Dr. John A. Ferrell elected, February, As-sistant
Secretary for Hookworm Eradication; began work under
State Board of Health and Rockefeller Sanitary Commission. First
effort in the eradication of hookworm disease was to interest
school teachers, in the disease and through their assistance ex-amine
and treat the children, and thereby reach the community.
Three bottled spring waters sold on the market examined, found
polluted, and public attention called to the pollution. Annual
appropriation, $10,500.
10 North Carolina Board of Health
1911. Legislature established county boards of health to take the place
of the county sanitary committees; county board of health com-posed
of chairman board of county commissioners, county superin-tendent
of schools, mayor of county town, and two physicians
selected by the three county officials to serve with them. Legis-lature
also abolished quarantine for smallpox and improved the
quarantine laws. One thousand dollars annually appropriated to
contract with antitoxin manufacturers for State supply of high-grade
diphtheria antitoxin, with result that price of antitoxin was
cut to one-fourth former price, saving the citizens of the State
over $30,000 annually. Bulletin increased from 11,500 copies to
20,000 copies each edition; closer cooperation with press of State
developed; regular weekly press articles prepared and sent to
papers; increase in numbers of popular pamphlets for distribution.
Hookworm work this year largely educational through the school
forces and investigative through county dispensaries; thousands
of children found infected and treated. Strong sentiment began
to make itself felt for better health work by counties, four
counties employing whole-time county health officers. Mainte-nance
appropriation for State Sanatorium increased to $12,500,
with $20,000 voted for permanent improvements. Annual appro-priation,
$22,500.
1912. Bulletin increased to 40,000 edition; number of popular pamphlets
dealing with different diseases increased; press work improved;
educational work of Board along all lines amplified. Secretary
of Board of Health called attention of conjoint meeting of State
Medical Society and State Board of Health to the relative im-portance
of health problems and the bearing of this subject upon
the proper apportionment of health funds; instrumental in pass-ing
a resolution to the effect that pellagra was an interstate prob-lem,
not a State problem, and requesting the Federal Government
to deal with pellagra as a Federal problem; resolution responsible,
to considerable extent, for successful effort on part of Hon. John
M. Faison's securing Congressional appropriation of $45,000 for
the study of pellagra by the Federal Government. Hookworm
work extended and county funds appropriated to supplement State
and Rockefeller Foundation for this work. Annual appropriation,
$22,500.
1913. General Assembly passed Model Vital Statistics Law with $10,000
appropriation for its enforcement. County superintendents of
health changed to either county physician or county health officer.
Educational efforts of Board continued and enlarged. Hookworm
work along same line as year before increased in amount. Dr.
John A. Ferrell resigned as Assistant Secretary to accept position
with the central office of the Rockefeller Sanitary Commission
in Washington, D. C. Dr. C. L. Pridgen succeeded Dr. Ferrell.
The movement for improved county health work had by this time
resulted in ten counties electing whole-time county health officers.
The State Sanatorium for Treatment of Tuberculosis turned over
by Extra Session of 1913 to the management of State Board of
Health. Annual appropriation, $40,500.
Twenty-first Biennial Report 11
1914. Preceding work of the Board continued. Board of Health took
over management of Sanatorium; started out under many diffi-culties
on account of the institution owing many debts and the
appropriation being limited. Hookworm work changed to com-munity
work directed to the installation of sanitary privies in all
homes. Laboratory began to produce and distribute free anti-typhoid
vaccine. Dr. C. L. Pridgen resigned as Director Hook-worm
Eradication, and Dr. W. P. Jacocks succeeded him. Annual
appropriation, $40,500.
1915. General Assembly makes State vital statistics law conform to
National model by requiring burial permits in rural communities;
enacts legislation permitting county commissioners and towns and
cities to appropriate money for support of tuberculous citizens in
State Sanatorium; provides $15,000 for purchase and building of
antitoxin plant; appropriates $60,000 for payment of Sanatorium
debts and new buildings and other improvements, and $25,000
annually for maintenance and $10,000 for extension anti-tubercu-losis
work. Educational work greatly extended: Bulletin now
47,000; traveling public health exhibit shown at fairs and other
assemblages; press work greatly developed through employment
of journalist for whole time; stock lectures with lantern slides
supplied public speakers in different parts of the State; com-munity
soil pollution work under Dr. W. P. Jacocks stops in May,
and Bureau of County Health Work with Dr. G. M. Cooper at
its head, succeeds, beginning work in June. Considerable amount
of work done for improvement of prison conditions. The unit
system of county health work gets a good start: over 52,000
people given three complete vaccinations against typhoid fever,
and medical inspection of schools put on in one county. Annual
appropriation, $50,500.
1916. North Carolina was admitted to the Registration Area for deaths.
To the educational agencies of the Board was added a self-supporting
moving picture health show. Many saw this show
during the year, and, seeing, believed in health work as never
before. Bulletin had to be discontinued temporarily for lack of
printing funds, but before discontinuance reached 51,000 edition.
Cooperation with University in developing a plan and putting on
a home post-graduate course in medicine, giving first course to
169 doctors. Put into operation an optional system of hotel
inspection, with grading and publishing scores. Continued unit
system of county health work, giving three anti-typhoid injections
to 48,000, making 100,000 immunized in summers of 1915 and
1916. Did complete medical inspection of five counties and with
inspection a large amount of educational work as to sanitary
and hygienic living. Secured effort by Federal Children's Bureau
to develop unit of child hygiene work, the Bureau using two
employees to work in Cumberland and Swain counties for about
eight months. Laboratory of Hygiene buys land and erects its
own building. Sanatorium making a decided impression on the
State. Annual appropriation, $55,500.
12 North Carolina Board op Health
1917. The General Assembly passed the following important health legis-lation:
Chapter 263, entitled "An act to prevent and control the
occurrence of certain infectious diseases in North Carolina;"
chapter 244, entitled "An act to provide for the physical ex-amination
of the school children of the State at regular inter-vals;"
chapter 276, entitled "An act for the cooperative and
effective development of rural sanitation;" chapter 257, entitled
"An act to prevent 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;" chap-ter
286, entitled "An act to regulate the treatment, handling and
work of prisoners."
Following the enactment of this legislation, administrative ma-chinery,
consisting of a Bureau of Epidemiology under the direc-tion
of Dr. A. McR. 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. Wash-burn,
was established. Dr. Washburn, an officer of the Inter-national
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 provisions 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
sections of the country and to establish for demonstration pur-poses,
in Edgecombe 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.
The State was admitted to the registration area of the Union
for births in January, 1917, the Bureau of the Census having
found after investigation that our birth registration was 96
per cent, complete.
The special campaign against typhoid fever begun so satis-factorily
in 1915, was continued. Free vaccination of the people,
however, was interferred with by the difficulty in securing medical
officers to do the work, the preparedness program of the Govern-ment
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 impressing the people with the value of vaccination as
a means of prevention 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 pur-pose
of advising them as to their physical condition and needed
hygienic reform and medical treatment, was begun on a county
basis. The funds necessary for this work were appropriated
Twenty-first Biennial Report 13
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 employed and placed in charge of the work. Life ex-tension
work was carried out in Vance, Alamance, Lenoir and
Robeson counties, and resulted in the full physical examination
of 4,000 citizens. This work was very favorably received, and
the outlook for its continued development seemed excellent when,
with the declaration of war and the call for physicians to enter
the military service of the country, Dr. Ellington enlisted in the
Medical Corps of 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 amount-ing
to 45,000, and a daily newspaper health article. The Bureau
continued its moving picture show exhibit and, in addition, pre-pared
probably the best three-dimension educational exhibit in
the United States. In 1917 the following exhibits were given:
motion picture entertainments, 236; traveling public health ex-hibits,
32; special exhibits, 58; stereopticon entertainments, 3
—
to a total of 95,000 people. Arrangements were made for the
preparation of newspaper plate, which was sent to- and extensively
used by 202 papers having a total circulation of 303,000. A large
part of this newspaper material was prepared by the well-known
authority and publicist in matters of sanitary and hygienic
education, Dr. W. A. Brady, of Elmira, New York.
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
permitted under the laws of the State to be paid to the Laboratory
for special work, provided 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 Washing-ton,
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, arrange-ments
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.
14 North Carolina Board of Health
Considerable time was 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 enter-ing
the medical 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 Major 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 anti-toxin.
The Bureau of 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. The Bureau also de-veloped
to a successful extent an arrangement in the form of
adenoid 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 field to investigate infringements of the quarantine law.
Sufficient convictions were obtained to impress the medical pro-fession
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 of Venereal Diseases, paid for by the Federal appro-priation,
was established in September under the directorship of
Dr. James A. Keiger, of Charlotte, N. 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. Wilson. As a result of Mr. Booker's leaving, cer-tain
funds became available, and a Bureau of Infant Hygiene,
under the directorship of Mrs. Kate Brew Vaughan, was organized
late in 1918.
Perhaps the most outstanding feature of the health work dur-ing
the year 1918 was the epidemic of influenza. The epidemic
began early in October and caused in October alone 6,056 deaths;
in November 2,133 deaths; and in December 1,497 deaths, a total
during the last three months of 9,686 deaths.
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 this year, collected $8,532.48
Twenty-first Biennial Report 15
in fees for special work, so that the total income of the Laboratory
for this year was $21,032.48.
1919. The General Assembly passed the following important health legis-lation:
Chapter 71, entitled "An act to prevent the spread of
disease from insanitary privies;" chapter 192, entitled "An act
to provide for the physical examination and treatment of the
school children of the State at regular intervals;" chapter 206,
entitled "An act for the prevention of venereal diseases;" chapter
213, entitled "An act to require the provision of adequate sanitary
equipment for public schools;" chapter 214, entitled "An act to
obtain reports of persons infected with venereal diseases;" chap-ter
215, entitled "An act for the repression of prostitution;" and
chapter 288, entitled "An act to amend chapter 671, Public-Local
Laws of 1913, relating to the injunction and abatement of certain
nuisances."
The Bureau of Engineering and Inspection was organized in
April. The engineering work of the Board had been suspended
with the resignation of Mr. Warren H. Booker in September, 1918,
Mr. Booker having gone to France to engage in tuberculosis work
under the direction of the Red Cross. Between September, 1918,
and April, 1919, the engineering problems coming before the
Board had been referred and very kindly and effectively taken
care of by Col. J. L. Ludlow of Winston-Salem. Mr. H. E. Miller,
an engineer and a graduate of the University of Michigan, was
placed in charge of the new bureau, and his brother. Dr. K. E.
Miller, of the United States Public Health Service, was detailed
by the Service to assist him in the organization of his work.
Mr. H. E. Miller and Dr. K. E. Miller spent the spring and sum-mer
and a part of the fall in studying various types of privies,
in preparing plans for the construction and maintenance of privies,
and in preparing the necessary notices and literature to inform
the people of the objects and requirements of the new privy law.
On May 1st Dr. A. J. Warren, health officer of Rowan County,
was appointed to and accepted the position of Assistant Secretary
of the Board.
On July 1st Mr. R. B. Wilson accepted the position of Director
of Public Health Education.
On August 1st Dr. A. McR. Crouch, Director of the Bureau of
Epidemiology, resigned to accept a position with the city of Wil-mington.
Dr. F. M. Register, whole-time health officer of
Northampton County, succeeded Dr. Crouch as director of the
bureau.
In September Dr. J. R. Gordon, Director of the Bureau of
Vital Statistics since 1914, resigned on account of impaired
health, and on October 1st the Bureau of Epidemiology and the
Bureau of Vital Statistics were combined and placed under the
direction of Dr. Register.
In September Mrs. Kate Brew Vaughan, Director of the Bureau
of Infant Hygiene, resigned. The bureau was reorganized under
an understanding with the American Red Cross and was enlarged
to include, in addition to infant hygiene, the problem of public
16 North Carolina Board of Health
health nursing, the name of the bureau being changed to that
of "Bureau of Public Health Nursing and Infant Hygiene."
Under the agreement with the Red Cross this bureau was to
have an available appropriation of $12,000 a year, half of which
was to be furnished by the American Red Cross and half by the
State Board of Health. The personnel of the bureau and its
plan of work, under the agreement, was made contingent upon
the approval of both participating agencies, the American Red
Cross and the State Board of Health. In December Miss Rose M.
Ehrenfeld took charge of the new bureau and began its organi-zation
and work.
On October 1st Dr. Jas. A. Keiger, Director of the Bureau of
Venereal Diseases, resigned and Dr. Millard Knowlton was
appointed to succeed him.
The typhoid campaign carried on during the summer through
previous years, was continued in the summer of 1919, using third-year
medical students, furnished either with automobile or motor-cycle
for getting about. Campaigns were carried out in the fol-lowing
counties: Bertie, Cabarrus, Chatham, Chowan, Columbus,
Craven, Hertford, Iredell, Johnston, Lincoln, Onslow, Pasquotank,
Perquimans, Randolph, Richmond, Rockingham, Stanly, Union,
Warren, Wayne. A total of 49,076 were given complete
vaccinations.
The educational work of the Board consisted of the publication
of a 48,000 monthly edition of the Bulletin, and the distribution
of about 350,000 pieces of public health literature.
The funds available during this fiscal year amounted to
$198,549.14, of which $102,301.98 was from State appropriations
and the remainder from outside sources.
The appropriation for the State Laboratory of Hygiene for this
year was $28,500; in addition to this, the Laboratory collected in
fees for special work, for anti-toxin, and in water taxes a total
of $14,344.02, making a total of $42,844.02 available for work
of Laboratory.
1920. During this year there was a Special Session of the General As-sembly,
lasting twenty days and held in the latter part of August.
This Special Session passed an act amending the vital statistics
law, making the fees for local registrars 50 cents instead of 25
cents for each certificate properly filed with the State Board of
Health.
On January 1st Dr. B. E. Washburn, who had had general
direction of the cooperative county health work and who had
rendered most acceptable service, was recalled by the International
Health Board and detailed to take charge of their interests in
Jamaica. Dr. K. E. Miller, of the United States Public Health
Service, who had been detailed in January, 1917, to organize a
model county health department in Edgecombe County and then,
in 1919, to assist his brother, Mr. H. E. Miller, in organizing the
work of the new Bureau of Engineering and Inspection, to which
was assigned the duty of enforcing the State-wide privy act,
Twenty-first Biennial Report 17
succeeded Dr. Washburn as Director of the Bureau of County
Health Work.
In January a cooperative effort with the United States Public
Health Service and the International Health Board to demonstrate
the possibilities and advantages of the eradication of malaria
from certain towns and cities in the eastern part of the State was
begun. The terms of cooperation were that the International
Health Board and the State Board of Health were to pay one-half
of the expenses of the local work and the town or city in which
the work was done the other half, the Public Health Service
furnishing, as its part, expert supervising personnel. The towns
and cities chosen for this work were Goldsboro, Farmville, and
Greenville, the budgets for each municipality being, respectively:
Goldsboro, $13,670.98; Farmville, $5,000; and Greenville, $9,000,
a total investment in this work of $27,670.98. Mr. A. W. Fuchs,
Associate Sanitary Engineer, was detailed by the Service to have
supervision of the work.
In February Dr. A. J. Warren, Assistant Secretary of the
State Board of Health, resigned his position in order to accept
the appointment of city health officer of Charlotte, N. C.
In the winter and spring of 1920, the North Carolina Land-owners
Association, under the progressive leadership of Mr. W. A.
McGirt, of Wilmington, undertook a very extensive educational
campaign against malaria, which was carried on through the
public schools of thirty-eight counties in Eastern North Carolina.
A series of county and State prizes for the best essay on malaria
by public school children were offered as an inducement to the
school children to interest and inform themselves, and, indirectly,
their parents, with regard to the importance of this disease. To
make possible this work by the school children 75,000 malaria
catechisms, prepared by Dr. H. R. Carter, of the United States
Public Health Service, were distributed through the public schools
of the eastern part of the State to the school children. Thousands
of essays were written, and it is reasonable to believe that the
campaign was one of the most successful public health educational
attempts yet undertaken.
In June it was found advisable to separate the Bureau of Epi-demiology
and the Bureau of Vital Statistics which had, on ac-count
of the scarcity of health officers, been placed under the
directorship of a single bureau chief. Dr. F. M. Register. Dr.
Register was appointed Director of the Bureau of Vital Statistics
and Dr. J. S. Mitchener was appointed Director of the Bureau
of Epidemiology.
In April the Interdepartmental Social Hygiene Board assigned
to the State Board of Health several workers for making a study
of vice conditions in North Carolina towns and cities and for
taking such steps as were found expedient for decreasing prosti-tution.
This group of workers was withdrawn in September, on
account of differences developing between them and Dr. Knowlton,
chief of the Bureau of Venereal Diseases, with the understanding
18 North Carolina Board of Health
that another group of workers would be assigned to this work
at a later date.
In June arrangements were made with the United States Public
Health Service and the American Social Hygiene Association for
the development of an elaborate educational unit on sex hygiene
and venereal diseases designed to reach rural meetings through
the use of picture films and a portable truck. An outfit con-sisting
of several lectures and a moving picture truck began work
in Cumberland County in August, and from its very beginning
met a most cordial reception and gave every promise of developing
into one of the most useful agencies for dealing with the venereal
disease problem.
During the year the anti-typhoid vaccination campaign was
continued in Alamance, Bladen, Columbus, Duplin, Franklin, Gas-ton,
Harnett, and Mecklenburg counties. Cooperative campaigns,
in which the counties furnished the working personnel, were also
carried on in Anson, Johnston and Rutherford counties. A total
of 29,435 citizens have been vaccinated against the disease, and
this does not include Columbus County, in which the work was
just beginning when this report was completed.
The educational work of the State Board of Health during this
year consisted of a 48,000 monthly edition of the State Board of
Health Bulletin and the distribution of approximately 350,000
pieces of public health literature.
The funds available during this fiscal year amounted to $342,-
284.33, of which $176,152.61 was State appropriation and the
remainder from outside sources.
The appropriation for the State Laboratory of Hygiene for this
year was $25,000; in addition to this, the Laboratory collected in
fees for special work, for antitoxin and in water taxes, a total
of $13,698.89, making a total of $38,698.89 available for the work
of the Laboratory. The above amount being insufficient, the
Special Session of the Legislature authorized a loan of $15,000
to enable the work of the Laboratory to be carried on, making a
total of $53,698.89 available for the work of the Laboratory
during this year.
1921. The Legislature meeting early in January of this year was asked
by the Board to amend the State law restricting the salary of
the executive off"icer of the Board to $3,000 annually, so as to
make the salary $5,000. Such an amendment was passed. A
further request from the Board was that legislation be enacted
removing the inspection tax of forty cents from privies coming
under the supervision of the Board of Health. Such an amend-ment
to the State-wide Privy Law was also enacted. A bill was
introduced in this session of the General Assembly under the
initiative of Hon. Emmet H. Bellamy requiring a physical ex-amination
of all applicants for marriage and making issuance of
license contingent upon the physical qualifications of the appli-cant.
The State Board of Health approved and supported Mr.
Bellamy's bill, realizing, as did the author of the bill, that the
proposed legislation was but a step in the right direction and was.
Twenty-first Biennial Report 19
therefore, rather loosely drawn and left many things to be de-sired.
The bill finally passed in amended form as chapter 129,
Public Laws of 1921.
The general health of the State for 1921, as indicated in the
vital statistical records for that year, published by the United
States Bureau of the Census, was good, and there was an im-provement
in reduced death rates for a number of diseases, as
well as a reduction in the general death rate over previous years.
Another general condition of State-wide importance with a
vital bearing on the work of the Board of Health which had to
be taken into account was a considerable amount of misunder-standing
between respective groups of the medical profession and
the Board of Health regarding matters of policy. Many physi-cians,
men in good standing professionally and men with high
civic ideals, seemed to feel that the Board of Health had no well-considered
and reasonable objectives in the field of public health
as it is related to that of private practice. This general condition
was responsible for the Board of Health seeking and availing
itself of opportunities to meet the profession, both in county,
district and State societies, and to discuss with the profession
what it conceived to be the proper relation between public health
activities and professional practice. This subject was presented
to and considered by the State Medical Society in its conjoint
meeting with the State Board of Health at Pinehurst in April,
1921. See transactions Medical Society of the State of North
Carolina, pages 472-506. As a result of these various conferences
between representative men engaged in public health work and
the profession, the general condition of misunderstanding and
some little friction had disappeared to a large extent by the latter
part of the year. Nevertheless, the results of contact between
those engaged in social medicine and private practice were such
as to encourage further conferences and efforts to bring about a
fuller recognition of mutual interests on the part of the public
and the profession, and the ultimate adoption of a program of
relations which would be to the mutual advantage of both parties.
Perhaps the most important change inaugurated in State
health administration during this year was the adoption of a
cost basis for standardizing and measuring the efficiency of public
health work in those counties in which the State participated
financially. This new principle is fully described in the State
Board of Health Bulletin for January, 1922, and a further dis-cussion
of cost basis for public health work is unnecessary here
except, perhaps, to say that it is apparently at least one of the
first attempts to introduce the cost system of industry into
government.
The Bureau of Venereal Diseases, in charge of Dr. Millard
Knowlton, established as a part of the war-time activities of the
Board in cooperation with the Bureau of Venereal Diseases of
the Federal Government, was combined with and made a part of
the work of the Bureau of Epidemiology, under the general direc-tion
of Dr. J. S. Mitchener.
20 North Carolina Board of Health
Funds available for the year included: State appropriation,
$275,000; miscellaneous receipts, $164,184.42; total, $439,184.42.
1922. In order to bring the records of this department into harmony with
those of other State departments, in accordance with the act of
the General Assembly of 1921, changing the fiscal year of the
State so as to begin on July 1st each year, this report ends with
June 30, 1922. It, therefoi'e, covers a period of nineteen months;
one full fiscal year from December 1, 1920, to November 30, 1921;
seven months from December 1, 1921, to June 30, 1922. Effective
February 1, the American Red Cross Society abrogated the agree-ment
existing since 1919 by which it jointly financed with the
Board of Health, the Bureau of Public Health Nursing and Infant
Hygiene. This bureau was reorganized April 1 as the Bureau
of Maternity and Infancy, for its maintenance the State receiving
$27,259.66 annually from the United States Government in ac-cordance
with the Sheppard-Towner Act for the promotion of
the welfare of mothers and infants. Dr. K. P. B. Bonner of More-head
City, was secured as the director of the reorganized Bureau,
with Miss Rose M. Ehrenfeld as supervisor of nursing and Mrs.
T. W. Bickett in charge of educational work.
The funds available during this period, and their distribution,
were seven-twelfths of the amounts set out under the tabulation
for 1921.
The appropriation for the State Laboratory of Hygiene for the
nineteen months between December 1, 1920, and June 30, 1922,
• was $87,083.33; in addition to this, the Laboratory collected in
fees for special work, for anti-toxin, and in water taxes, a total
of $30,872.51, making a total of $117,955.84 available for the work
of the Laboratory.
1922-23. In order to further develop local responsibility for the protection
and promotion of the public health, and to quicken local initiative,
a policy of decentralization was adopted by the Board. To carry
out this policy there were made several changes in the organi-zation
of the Board's executive staff. The Bureau of County
Health Work was discontinued. The Bureau of Epidemiology was
combined with the Bureau of Vital Statistics. Dr. G. M. Cooper,
director of the Bureau of Medical Inspection of Schools, was ap-pointed
Assistant Secretary, and Dr. J. S. Mitchener, director of
the Bureau of Epidemiology, was transferred to the Bureau of
Medical Inspection of Schools. Dr. K. E. Miller, who for four
years had been loaned to the Board by the United States Public
Health Service, and had directed the work of the Bureau of
County Health Work, was recalled for duty elsewhere. The State
was divided into four districts with Dr. E. F. Long, Dr. H. A.
Taylor, Dr. M. L. Ilsley, and Miss Rose M. Ehrenfeld as district
directors. This plan of organization became effective in the early
spring of 1923 and was continued through the calendar year.
Six vacancies in the membership of the Board occurred during
the year, four by expiration of term, and two by resignation.
The terms of Dr. J. Howell Way of Waynesville, and Dr. A. J.
Crowell of Charlotte, appointed by the Governor, expired, and
Twenty-first Biennial Report 21
they were respectively appointed to succeed themselves. The
terms of Dr. Charles O'H. Laughinghouse of Greenville, and Dr.
Thomas E. Anderson of Statesville, elected by the State Medical
Society, expired, and they vi^ere respectively reelected. Mr.
Charles E. Waddell of Asheville, appointed by the Governor in
1921, resigned and as his successor the Governor appointed Mr.
James P. Stowe of Charlotte. Dr. F. R. Harris resigned to be-come
health officer of Vance County, and to fill the unexpired
term the Board elected Dr. D. A. Stanton of High Point. Dr. J.
Howell Way was reelected president of the Board.
The General Assembly of 1923 made provision for the con-stantly
growing work of the Board, approving the budget as sub-mitted
and appropriating for the Board the sum of $425,000.
Legislation enacted included an act to provide for the sanitary
manufacture of bedding, to create an independent board of direc-tors
for the State Sanatorium, and to provide sanatorium facilities
for tuberculosis convicts.
The important new development during the year was the begin-ning
of malaria control work in certain counties of the coastal
plain area of the State. Through the courtesy of the International
Health Board a member of its field staff". Dr. H. A. Taylor, was
loaned to the Board for the purpose of making preliminary sur-veys,
and areas in Lenoir and Pamlico Counties were selected for
investigation. The results showed Pamlico County to be suitable
for the initial demonstration, and a unit for the investigation
and control of malaria was organized with Dr. Taylor as the
director, the budget being contributed forty per cent, by the
county, forty per cent, by the State, and twenty per cent, by the
International Health Board. The progress of the work, and the
results achieved, proved so satisfactory that in January, 1923, an
additional unit was organized in Beaufort County, and in May
Craven and Bladen counties were added to the list. Detailed re-sumes
of this work is given elsewhere in this report, but it should
be stated here that the success of the intensive malaria control
measures has been even greater than was anticipated. While
specializing on malaria control measures, the county units have
at the same time carried on a general program of public health
work. The International Health Board has continued its co-operative
aid in giving twenty per cent, of the unit budget, and
has continued the loan of Dr. Taylor, who has directed the work.
In June the resignation of Dr. J. S. Mitchener as director of
the Bureau of Medical Inspection of Schools was accepted, and
Dr. Roy C. Mitchell, who had been engaged in special educational
field work, was appointed to the vacancy.
1923-24. The Committee on Municipal Health Department Practice of the
American Public Health Association requested the Secretary of
the Board to become field director for the Committee in making
a study of municipal health practices in the United States for
the purpose of working out with and for the Committee a basis
or set of principles on and through which city health depart-ments
could be given classification or grading, and further for
22 North Carolina Board of Health
giving such additional time as might be needed in assisting such
departments in improving their organization and provision for
work. The request was brought before a special meeting of the
Executive Committee of the Board, and it directed the Secretary
to take advantage of the opportunity oifered to become acquainted
intimately and broadly with health administration in the cities of
the country, and at the same time continue to exercise general
supervision of, and executive control over, the work of the Board.
In January the Secretary established official headquarters in New
York City for the work of the Committee, and the general organ-ization
of the executive staff of the Board was continued with
the Assistant Secretary, Dr. G. M. Cooper, as administrative or
director. During the period of his absence the Secretary has
kept in close touch with the work of the Board through frequent
reports and a number of visits to the office for conferences with
members of the staff.
For the more efficient administration of the field activities of
the Board the four districts into which the State has been divided
the previous were consolidated into two, with Dr. E. F. Long and
Dr. H. A. Taylor as Deputy State Health Officers, as directors,
assisted respectively by Dr. C. N. Sisk, formerly health officer of
Forsyth County, and Dr. George Collins, formerly health officer
of Mecklenburg County.
At the annual meeting for the Board in April further steps
were taken towards making effective the policy of decentralization
adopted the previous year. This policy looks, in a broad way, to
the diminishing of State personnel and the use of funds so made
available for stimulating and paying county personnel, either
whole or part time, to do work which formerly had been in all
probability incorporated and carried on by full-time personnel
employed by the Board. It was directed by the Board that all
machinery and resources of the Bureau of Maternity and Infancy
and of the Bureau of Medical Inspection of schools be converted
into county machinery and resources, either full-time or part-time,
the transformation to be brought about gradually to become
effective not later than January 1, 1925.
During the year a plan for the more adequate sanitary control
of public milk supplies in the State was formulated. The de-velopment
of this important new undertaking was assigned to
the Bureau of Engineering and Inspection. Mr. Malcolm Lewis,
a graduate of Massachusetts Institute of Technology, and with
about seven years of experience in public health work, was secured
for this particular unit of work. As developed at the present
time this service has been largely an advisory one, the various
municipalities having at their command the aid of the Board
in improving local milk supply conditions.
The malaria control campaign in the coastal plain area was
enlarged by the addition of organized units in Columbus, Bruns-wick,
and Hyde counties, making a total of seven counties in the
State specializing on this plan of health work. The cooperative
aid of the International Health Board was continued.
Twenty-first Biennial Report 23
During the year Dr. Roy C. Mitchell, director of the Bureau
of Medical Inspection of Schools, resigned. The work of the
Bureau was continued under the supervision of the Assistant
Secretary. Dr. M. L. Ilsley and Miss Rose M. Ehrenfeld, both
district directors, resigned, and effective with the end of the fiscal
year Dr. K. P. B. Bonner, director of the Bureau of Maternity
and Infancy, resigned.
The appropriation by the General Assembly was $275,000 and
$300,000 respectively for the two years of the biennium. For the
Laboratory of Hygiene the appropriation was $75,000 annually.
The Present Biennium
During the period covered by this report the work of the Board was
directed by Dr. G. M. Cooper as Acting Secretary. For the first year of
the biennium the Secretary and State Health Officer, Dr. W. S. Rankin,
was serving as field director of the Committee on Municipal Health De-partment
Practices of the American Public Health Association. He was
consequently away from the office practically all of the time. In June,
1925, Dr. Rankin resigned to accept the directorship of the Hospital and
Orphanage Division of the Duke Foundation.
' The Acting Secretary during the biennium had the aid of the Executive
Committee of the Board in frequent meetings. The general plans and
policies of the Board were continued. These are set forth in detail under
the several divisions.
The appropriation to the Board was for 1924-5, $340,000 and for 1925-6,
$319,644. For the Laboratory of Higiene the appropriation was $70,000
annually.
24 North Carolina Board of Health
THE NORTH CAROLINA STATE BOARD OF HEALTH
Its Organization, Problems, Methods of Administration, and Principles
of Public Health Work
The North Carolina State Board of Health was created by an Act of the
General Assembly of 1877. The appropriation for the work of the Board
under the original Act was $100 annually. In the forty-seven years of
its existence the Board has from time to time had its powers enlarged and
its duties increased. For the fiscal year ending June 30, 1925, the appro-priation
for the work of the Board was $455,000, exclusive of that made
for permanent improvements and maintenance for the State Sanatorium
for the treatment of tuberculosis, and the educational work of that
institution.
The North Carolina State Board of Health consists of the Board proper,
composed of nine members, and the executive staff, which varies from
time to time.
Of the Board proper, five members are appointed by the Governor of
the State, and four are elected by the State Medical Society. The term
of office is six years, and the terms are so arranged that not more than
four vacancies will occur in any one year.
The organization of the Board embodies two important administrative
principles: First, stability of organization and permanency of policies;
second, the partnership of the 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 freedom of the Board from political changes brought
about by either party or factional changes in the State government. The
divorcement of the State Board of Health from politics depends largely
upon the manner of selecting the members of the Board. Sudden or marked
changes in the personnel of the Board under the present plan of organ-ization
are impossible. This is true, first, because the members of the
Board of Health are appointed for terms of six years and their terms of
service expire, not in the same years, but in different years. The appoint-ment
of new members of the Board, is therefore, gradual and not sudden.
" In the second place, the personnel of the Board of Health is selected by
two parties: one, the Governor, and the other, the State Medical 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
gradual exercise of that power by two parties guarantee the State Board
of Health against the sudden changes of personnel and policy associated
with a purely political organization. The State Board of Health is stable;
its individual members come and go, but as an organized body it has
continuity.
This stability and continuity of organization is the responsible factor
for the permanency of policies adopted by the Board. Political boards
elected or appointed for two or four years are naturally inclined to adopt
two- or 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 administra-
Twenty-first Biennial Report 25
tion. This is not true of self-perpetuating bodies such as the Board of
Health, that, as legally constituted, 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
relation of the medical profession to the work of disease prevention and
the conservation of human life. The State recognizes the debt of society
to that profession by which nearly all of the experimentation and dis-covery
on which disease prevention is based, with the exception of the
work of Pasteur, was contributed; the interest of organized medicine in
the conservation of human life and the peculiar ability of organized
medicine to advise the State as to the methods of disease prevention; and
the necessity of securing from the medical profession first information in
regard to the occurrence of deaths and their causes, and the appearance
of epidemics.
The executive staff of the Board consists of the executive officer and
the heads of various bureaus or special divisions organized for the more
efficient administration of policies and programs adopted by the Board.
The executive officer is the Secretary of the BoaM, and State Health
Officer. He is elected by the Board for a term of six years. The duties
of the office require that this official should be a man with technical train-ing
and experience, and, therefore, should be selected on account of his
technical rather than of his political qualifications. It is, therefore, right
that he should be selected by a specially qualified committee, that is, the
State Board of Health, and not be elected in a general election, as would
be the case if the office were a political one. The six-year term of office
is in accordance with the idea of permanency of policies. The law requires
that the Secretary, and State Health Officer, shall be a registered physician
in the State, and that he shall not engage in private practice, but devote
his time and energy to the work of the Board.
The work of the State Board of Health is large and varied, and is, there-fore,
apportioned among a number of bureaus, or special divisions, each
directed by an administrative head chosen for his special training and
ability. These bureaus in the present organization of the Board consist
of the following: The State Laboratory of Hygiene, to examine water
and diagnostic specimens, and to produce and distribute biological products,
vaccines, and sera; the Bureau of Vital Statistics, to secure, correct, tabu-late,
and publish information as to distribution and causes of deaths, and
as to distribution of births; to secure reports of communicable diseases
and epidemics, and direct measures for their control; the Bureau of Medical
Inspection of Schools, to develop public interest in the health of school
children as it is related to their education, and to stimulate more adequate
treatment for their most common defects; the Bureau of County Health
Work, to interest county authorities in providing efficient county health
departments, and to advise with, correlate, and assist such departments;
the Bureau of Maternity and Infancy, to develop a higher degree of public
intelligence regarding the importance and the care of the problems of
maternity and infancy; the Bureau of Engineering and Inspection, to
exercise supervision over the construction and maintenance of public water
supplies and sewerage, to inspect and enforce sanitary conditions of privies,
jails, public institutions, hotels, etc. The Bureau of Tuberculosis is now
administered as the Extension Division of the State Sanatorium for the
26 North Carolina Board of Health
treatment of tuberculosis, which is operated under the direction of a
special board of directors.
The correlation of the work of the several bureaus, to insure a harmoni-ous
and efficient administration of the work of the Board, is through the
supei'vision and direction of the executive officer of the Board. The
division of the executive staff 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 bureau directors.
While each bureau is separate and independent of other bureaus, 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 officer of the Board. The administrative heads of the several
bureaus, or directors, are selected by the executive officer of the Board,
their terms of service being dependent only upon their success or failure
in discharging their duties.
There are naturally many problems and duties which cannot be assigned
to any of the special bureaus, which by their nature must be under the
immediate direction of the executive officer. These may be briefly stated
as follows: (1) to assume primary responsibility for the enforcement of
the more important State health laws; (2) to consider and determine, with
the advice and consent of the Board, what should be the more important
public health policies of the State; (3) to secure the needed legislation
that will make possible the adoption of desirable health policies; (4) to
supervise and assist in the execution of established policies.
The enforcement of law rests, in a general way and broadly, upon the
judicial machinery of the State. On the other hand, it is not only the
privilege but the duty of any citizen to see that the violation of any law
is brought to the attention of the courts and dealt with. The more
thorough understanding of the purposes and the character of the public
health laws and the keener appreciation of their importance imposes in a
special way upon the executive officer of the State Board of Health the
duty of seeing that these particular laws are fully complied with.
The duty of considering and formulating for the action of the Board
what should be the more important public health policies of the State
rests largely with the executive officer of the Board on account of its
primary and general responsibility for the development of an effective
program of human conservation.
After the Board has considered and definitely decided upon a course of
action it becomes the duty of the executive officer to bring to the attention
of the people generally the need of the course of actio a approved by the
Board, and to so inform, interest, and appeal to the public, and reflexively
and directly to the General Assembly as to secure legislative approval
and provision for the public health policies which have been adopted by
the State Board of Health.
The efficiency of any agency is conditioned largely upon the personnel
who are employed in its activities. The responsibility of finding and
securing persons properly qualified by native endowments, training, and
experience to direct the special bureaus or divisions entrusted with carry-ing
out the established policies of the Board rests largely upon the
executive officer.
Twenty-first Biennial Report 27
As has been heretofore pointed out, the organization of the executive
work of the Board embraces a number of special bureaus which are held
responsible for some definite State health policy, and which are so organ-ized
as to be independent of each other. Naturally, these bureaus and
divisions in the character of their work are closely related and some means
of coordinating their activities is necessary. This means, the executive
officer supplies.
The majority of the calls by letter or person upon the Board for service
can be and are referred to the special bureaus of the Board concerned
directly with the sort of service called for in the letter or by the visitor.
However, there are a number of calls upon the Board for services that are
general in character, or not provided for by some special agency. These
services necessarily have to be supplied by the executive officer.
The interest and support of the people in public health is in proportion
to their understanding of the problem. To reach people, therefore, with
information as to what the public health needs of the State are and how
the Board purposes to meet the needs is, of all the Board's duties, the
most fundamental and the most important. Moreover, the educational
work of the Board is of a general character, dealing with the interests of
all the bureaus or special divisions and, therefore, belongs largely to the
executive officer whose interest is not particular but general with respect
to all health problems.
The duty of receiving, disbursing, and accounting for the public moneys
provided for the work of the Board is a duty that rests primarily upon
the executive officer because of his primary and general responsibility
for the interests of the Board.
The methods of work followed depend largely upon the character of
the duties which the executive officer seeks to discharge. For this reason
it is well in the discussion of methods to relate them to the special duties
of the executive officer as above set forth.
Investigations as to the violations of the more important health laws
of the State and the initiating of prosecutions where violations are found,
are carried out largely as a part of the special activities of the Bureaus
of Vital Statistics and Engineering and Inspection. These bureaus main-tain
a field force of inspectors, which vary in number but average about
twelve full-time officers. The responsibility falls upon the executive
officer to see that the bureaus fearlessly and without discrimination en-force
the important laws entrusted to their execution. The larger work
of the executive officer in law enforcement, however, concerns itself with
bringing to public attention the principal State health laws and the needs
of their careful observance, and in this way building up a public senti-ment
favorable to the observance of public health laws and sympathetic
with the judicial machinery in imposing penalties upon those who violate
them.
In determining the public health policies for the State it is necessary:
(a) that the executive officer secure information through special and
regular reports on the vital statistics of the State, and in this way to 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 State's death rates by counties, by
races, and by seasons; (b) that he secure information, through public
28 North Carolina Board of Health
health literature, books and periodicals, as to the more recent develop-ments
and discoveries in public health work; (c) that then by keeping in
touch through conferences with other State health officers and Federal
health officers, be thoroughly conversant with the methods and accomplish-ments
of other State departments of health, and that he be alert to those
larger interstate movements, especially those related to action by the
Federal government, in order that whenever and wherever possible these
larger movements may be influenced to the advantage of this State.
To secure the necessary measures and appropriations for the develop-ment
of the State health policies the people are informed, through bulle-tins,
the newspapers, exhibits, and public addresses, as to vital conditions
and as to necessary measures and appropriations for favorably influencing
the vitality and physical efficiency of North Carolina people. In this way
the effort is made to develop a favorable public sentiment for the develop-ment
of the more important public health policies. The executive officer
further seeks to find and interest certain individuals, qualified by heart
and head and position, for influencing, introducing, and supporting in the
General Assembly needed legislation.
To find and secure, with the available means, a personnel for the bureau,
division or agency of the Board that is to be relied upon for carrying into
successful execution some special and important public health policy calls
for an acquaintance with those who are in touch with men qualified for
such positions, and a judgment of men on the part of the executive officer.
This judgment of men by which an administrative officer selects his as-sistants
is, of course, basic in the success or failure of an administration.
In giving assistance to members of the executive staff charged with
carrying out certain public health policies the executive officer attempts
to keep in close touch with the work of each bureau or division 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 individuality; on the other hand, too little supervision not
infrequently results in a useless waste of time and funds.
The general work of the Board is a matter largely of correspondence
and conference. The correspondence is extensive both in volume and
variety, and personal callers at the office of the Board require a con-siderable
time devoted to conferences.
For reaching the people with information on health problems which
they need, and which is necessary to secure their interest in and their
support of the policies of the Board several means are in use. Primarily
there is The Health Bulletin, issued monthly throughout the year, con-sisting
of from sixteen to sixty-four pages. This is sent free to any
citizen requesting it, and the circulation monthly is now 58,000 copies.
In addition there are issued special pamphlets on the more important
health problems, information is disseminated through the newspapers by
means of specially written articles, and public addresses, often illustrated
with either stereopticon slides or motion pictures, are given.
The, bookkeeping for all the bureaus or divisions is done in the executive
office by means of a system approved by the State Auditor, and all pur-chases
are made through one purchasing agent.
Twenty-first Biennial Report 29
The State of North Carolina is composed of one hundred counties, of
separate and self-governing political entities. In the administration of
the public health policies of the State there are certain duties and re-sponsibilities
which are recognized as devolving upon the State, through
its established agency, the State Board of Health. There are certain
other duties and responsibilities which are recognized as devolving upon
the county, through its established agency, the County Board of Health.
In a democratic government such as North Carolina, where local self-government
by the people is firmly established as a basic principle, it is
necessary to keep in mind and regard scrupulously these distincCions.
The State is rightly held I'esponsible by all other States for the condition
of its death rate. In discharging this responsibility two main avenues
of service lie open.
First, the State should assume those public health activities that can
be carried on, practically speaking, only on a State-wide scale and through
State administrative machinery. Second, the State should make use of
its central position and federated authority to tactfully, progressively,
and persistently 'lead, but not drive, the counties to a clearer recognition
of their opportunities, privileges, duties, and responsibilities for local
health conditions.
Without entering into a discussion of the more important State-wide
public health activities they may be classified and listed as follows:
First, activities of common interest to all the counties and impracticable
of county handling, such as:
1. State supervision over communicable diseases, for the reason that
infection and contagion do not respect county boundaries.
2. The registration of births and deaths according to a standard system,
for the reason that birth rates and death rates as between counties to
have comparative value must be established by uniform practices.
3. The protection of the purity of streams from which public water
supplies are taken, for the reason that many streams flow through several
counties before reaching the one or the ones whose citizens make use of
such for domestic purposes.
Second, activities which for economic reasons, for rendering unnecessary
duplication and multiplication of officials, machinery, and equipment, be-long
properly to the State, such as:
1. The preparation, publication, and distribution of educational bulletins,
pamphlets, and leaflets needed in public health administration, for the
reason that the additional expense necessary for each county to prepare,
publish and distribute such material would be alike unnecessary and
extravagant.
2. Maintenance of common laboratory facilities by the State for the
same reason as that for maintaining central common equipment for the
preparation of educational equipment.
Third, activities concerned with disease factors of such exceptional im-portance
that the State cannot neglect them and at the same time carry
the responsibility for a State-wide reduction in death rates, such as:
1. A State policy for dealing with tuberculosis.
2. A State policy for dealing with venereal diseases.
3. A State policy for dealing with the factors of infant mortality.
4. A State policy for dealing with the common defects of school children.
30 North Carolina Board of Health
The county can be made to understand that, after the State has gone
its full length in dealing with public health conditions by general measures,
the county may do much more in a local and more intense manner for the
preservation and promotion of its own health conditions—just as the
intelligent individual, after both State and county have done all in their
power to protect his health, may still do much more for himself than both
governments combined. The State through its established agency co-operates
on a definite plan in aiding the individual county to assume and
efficiently discharge the purely local duties and responsibilities by both
personal service and financial help.
Through the forty-seven years of its existence the State Board of
Health has consistently developed in the scope of its service to the people,
and has in proportion grown in scope of organization and in amount of
money expended in its work. It began with no paid personnel and an
appropriation of $100. Today it has an executive officer with eight as-sistants
in charge of special phases of the work, and the necessary addi-tional
clerical personnel, having an annual appropriation of $455,000. The
outstanding achievements of the Board have been the marked reduction
in the general death rate, and the increased vitality of the people through
the practical eradication of smallpox, typhoid fever, hookworm disease,
and the winning fight being waged against malaria and tuberculosis. For
three consecutive years the State has had the highest birth rate in the
United States, and at the same time has maintained a death rate lower
than that of the country as a whole.
Twenty-first Biennial Re^'ort 31
STATE LABORATORY OF HYGIENE
The following is a Report of the Work of the State Laboratory of Hygiene
Covering the Period July 1, 1924—June 30, 1926
Specimens examined:
Malaria 807
Typhoid 2,749
Feces 3,197
Rabies 3,231
Gonococci 2,351
Diphtheria '. 10,683
Sputum 4,132
Cultures for Typhoid 1,701
Urine 634
Pathology 410
Miscellaneous .- 282
Blood Culture 27
Wassermann 78,433
Water 9,004
Total 117,641
Vaccines and .Antitoxins Made and Distributed
:
Diphtheria Antitoxin (Units) 280,050.000
Pasteur Treatments Supplied 3,582
Doses of Typhoid Vaccine Distributed 1,485,836
Doses of Toxin-Antitoxin Distributed 412,333
Doses of Smallpox Vaccine Distributed 448,261
Number of Schick Tests 162.300
Number of Schick Control Tests 127,750
Number of Ampules of Neo-Arsphenamine Distributed 255,583
Tetanus Antitoxin Distributed (Units) 16,404,000
Pertussis Vaccine Distributed (CC) 63,737
Syringes Scarlet Fever Antitoxin Distributed 129
Autogenous Vaccines 239
No attempt is made, nor can be made, to estimate the value of the preser-vation
of life and health which may have been accomplished by the work
just outlined, but some of the results can be given a definite and accurate
financial value. If there had been no State Laboratory of Hygiene in exist-ence,
this work would have cost the citizens of the State the following
amounts:
78,433 Wassermann tests @ $ 5.00 $ 392,165.00
9,004 Water examinations @ 5.00 45,020.00
30,204 Other examinations average @ 2.50 75,510.00
1,485,836 Doses of typhoid vaccine @ .50 742,918.00
63,737 Doses of pertussis vaccine @ .50 31,868.50
448,261 Doses of smallpox vaccine @ .15 67,239.65
412,333 Doses of toxin-antitoxin @ .50 206,166.50
3,582 pasteur antirabic treatments @ 25.00 89,550.00
32 North Carolina Board of Health
3,246 Schick tests @ $1.50 $ 4,869.00
2,555 Schick control tests @ 1.50 3,832.50
255,583 Ampules of neo-arsphenamine @ 1.00 255,583.00
Tetanus antitoxin:
9,572 1,500 unit packages @ $3.50 $ 33,502.00
417 5,000 unit packages @ 6.00 2,502.00
36,002.00
Scarlet fever antitoxin:
48 Therapeutic doses @ $6.00 $ 288.00
81 Prophylactic doses @ 3.00 243.00
531.00
Diphetheria antitoxin
:
4,901 1,000 unit packages @ $2.00 $ 9,802.00
503 3,000 unit packages @ 3.50 1,760.50
3,264 5,000 unit packages @ 5.00 16,320.00
25,732 10,000 unit packages @ 7.50 192,990.00
220,872.50
Total , $2,172,127.65
Receipts are as follows:
Appropriation $141,500.00
Water Tax 20,123.85
Sales Biological Products 38,311.10
Fees 2,893.32
$202,828.27
Twenty-first Biennial Report 33
REPORT FOR THE BUREAU OF VITAL STATISTICS AND
DIVISIONS OF EPIDEMIOLOGY AND '
VENEREAL DISEASES
Bureau of Vital Statistics
Since the biennial report of 1923-1924, there has been taken from the
Bureau of Vital Statistics, the distribution of silver nitrate, registration
of midwives, and the Bureau of Venereal Diseases.
While the Bureau of Vital Statistics and the Bureau of Epidemiology
have a separate function, the whole is classified more or less together,
especially as to number of letters sent out, and the general routine of office
work. Other than this, the activities of each division will be taken up
separately.
Practically all field work for the Bureau of Vital Statistics and Epidemi-ology
is done by the Director.
We will first take up the work of the registration of the births and deaths
occurring in North Carolina.
Character of Work
OBJECTIVES
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
number of illegitimate births; (e) the number of stillbirths attended by
midwives; (g) the number of white births attended by physicians; (h) the
number of white births attended by midwives; (i) the number of colored
births attended by physicians; (j) the number of colored births attended
by midwives; (k) all of the foregoing data as to births with respect to
each county 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 the other States and other countries. Such
information is necessary in forming conclusions as to vital conditions in
North Carolina and in the enactment 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;^ (c) the number of deaths, by races, and the death rates
by races in North Carolina; (d) the number of deaths among infants and
young children as compared with the births, and the total deaths as com-pared
with the total births, with net gain in population; (e) the total
number of deaths by months and year from each o.f the 209 causes appear-ing
in the International List of Causes of Death; (f) the number of deaths
according to age and to occupation; (g) the number of deaths according
to age and the causes of death; (h) the number of "seasonal" deaths
according to months; (i) all of the foregoing data classified according to
34 North Carolina Board of Health
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 one and two, information necessary for the public welfare and
available under the operation of the vital statistics law has been briefly
indicated. But the vital statistics law not only supplies information to
legislatures, 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 invalu-able;
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
industries, as to entering school, as to liability for military service, etc.
METHODS
The Bureau of Vital Statistics secures the birth and death certificates
for the births and deaths occurring in North Carolina through approxi-mately
fourteen hundred and fifty local registrars, appointed by the chair-man
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 Consolidated
Statutes, section 7113. The county pays the local registrars fifty 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 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 the filing
of the death certificate. The birth and death certificates filed with the
local registrars of the State are sent to the Bureau of Vital Statistics on
the fifth of the month succeeding the month in which the birth or death
occurred. The certificates received in the oflfice of the Bureau of Vital
Statistics are examined carefully, and if incorrect or incomplete (as a
large per cent of them are) effort is made to secure the information neces-sary
to complete them. Every parent of a legitimate child whose birth is
reported is sent a card advising them of the date of birth and whether or
not name appears on the certificate. This gives the parent an opportunity
to send in to the office the name of the child, in case it does not appear on
the certificate, or to make such change in name or date of birth necessary
to make certificate an accurate record of birth. The certificates are then
classified and tabulated according to county, townships 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 head-ing
of Objective.
ROUTINE WORK
The routine work in the registration of births and deaths is indicated in
the following table. This covers period from July 1, 1924, through June
30, 1926, inclusive.
Twenty-first Biennial Report 35
Letters and postals received 35,735
Casket dealers reports received 8,165
Supplementals received 3,630
Name cards received 14,865
Violation blanks received 114
Acceptance papers received - 2,909
Report cards received from local registrars 23 251
Letters written 25,484
Form letters sent 66,926
Postal cards sent 140,300
Packages of supplies sent 13,918
Indexing :
Cards made 264,790
Cards proofread 249,915
Cards assorted 232,882
Cards filed 245,332
Credit certificates sent local registrars '. 4,130
Certified copies made 5,506
Tables made 366
Cards punched and proofread 69,023
Transcripts made and proofread 194,423
Cards furnished Dr. McCain, giving information as to
deaths fi-om tuberculosis, monthly 5,321
Epidemiology forms made 432
Tabulation of births
Number certificates made in triplicate 5 800
Permanent index cards checked 7,285
Sheets written : 16,272
Certificates Received:
Births 172,996
Deaths 67,309
Stillbirths 16,678
*Total 256,983
Names checked on Undertakers reports with D. C 14,845
. Nitrate sent 4,786
RESULTS OBTAINED
Of course there is always a large per cent of routine work that is impos-sible
to put in a report of this kind, and 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 information with its vital bearing upon
the public health needs of the State and with the public health accomplish-ments
of the State is readily and completely available.
As a mere indication of the practicable value of the work of the reg'stra-tion
of births and deaths, we may point out the fact that the birth rate of
North Carolina is very high, the highest in the United States, and that the
death rate in North Carolina, notwithstanding the high birth rate, giving
^This total includes letters and postals received for our other divisions.
36 North Carolina Board op Health
us an exceptionally large age group of tender years with high fatalities,
is exceptionally low, one of 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.
DIVISION OF EPIDEMIOLOGY
Character of Work
OBJECTIVES
To prevent and control the occurrence of whooping cough, measles, diph-theria,
scarlet fever, infantile paralysis, cerebro-spinal meningitis, chicken-pox,
septic sore throat, German measles, smallpox, typhoid fever, trachoma,
syphlis, chancroid, gonorrhea, and ophthalmia neonatorum.
METHODS
Section 1—The County Unit
A quarantine oflficer for each county and city having a separate health
department in the State is appointed to be the Bureau's representative in
the local field. His duties are as follows:
(a) To secure reports from parents, teachers, and physicians of all com-municable
diseases.
(b) To keep an accurate record in his office of all reports.
(c) To transmit all reports daily to the Division.
(d) 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, apd 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, and with a pamphlet descriptive of the disease, its
dangers, cause, mode of spread, and methods of control, to be distributed
through the children to the parents represented in the school.
(f) To make the presence and locations of the disease known to the pub-lic
by publishing notices in the county paper when the disease appears and
advising means of prevention.
(g) To furnish householders forms to report diseases in their community
which have not been previously reported.
(h) To investigate all cases of suspected contagions which have not been
reported to determine the nature of the disease.
(i) To enforce the laws, rules and regulations governing the control of
communicable diseases.
(j) To make monthly reports to the Division of Epidemiology of all the
work, educational, administrative, or otherwise done during the month.
Compiled Monthly Report of County Quarantine Officers
July 1, 1924, to June 30, 1926
Cases reported by householder 9,028
Cases reported by nurses and health oflficers 14,192
Cases reported by physicians 39,277
Cases reported by teachers 2,156
Twenty-first Biennial Report 37
Total number of cases reported 64,919
Homes placarded 45,093
Articles published 372
Teachers certificates 3,744
Indictments 173
Section 2—The State Unit
To g-ive the reader a fair idea of the work done by this Division, we
have grouped the work under the following heads: (1) General office work
not included in office work mentioned in report previously; (2) special work
for the prevention of typhoid fever; (3) special work for the prevention of
diphtheria; (4) special work for the prevention of venereal diseases;
(5) special work for the prevention of sore eyes in the newborn.
I. Office Work
The daily reports of each of the communicable diseases are recorded by
the Bureau of Vital Statistics—Epidemiology Division—by the counties 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 year to year.
Weekly telegraphic and monthly written reports of all cases of infection
and contagious diseases reported are made to the Surgeon-General, United
States Public Health Service, Washington, D. C.
Charts are kept showing number of deaths and number of cases, by
months, from each of the communicable diseases.
Monthly reports of the quarantine officers are given a detailed examina-tion
by the Director, and where it is deemed necessary, letters are written
to the quarantine officer and the county commissioners of the non-perform-ance
of duty.
All repoi-t cards, blank forms, educational posters, placards and literature
on the reportable diseases, and all rules and regulations governing the con-trol
of the diseases, are prepared and distributed to the various quarantine
officers of the State by this Division.
Summary of Office Work
Circular letters 157,119
Oaths of office - 32
Bulletins sent 107,452
Packages of supplies sent 1,352
II. Special Work for Prevention of Typhoid
Campaigns for giving free treatment to prevent typhoid fever and diph-theria
are conducted in different counties of the State.
The Division of Epidemiology circularizes the county and furnishes ad-vertising
materials to the county for the mailing list made up from the tax
books—(The Division makes up mailing list from the records of births in
the county, filed with the Bureau of Vital Statistics.)
The Division of Epidemiology pays for all clerical help needed in the
counties to get out advertising, and pays for newspaper advertisements, etc.
Physicians who participate in these campaigns are paid 8^/^ cents a single
dose. Physicians make reports to the Division on forms supplied for the
38 North Carolina Board of Health
purpose. These are checked and certifications sent to the County Com-missioners.
Work for 1924 campaigns was completed in June, 1924, and included in
the twentieth biennial report.
In 1925, eighteen campaigns were conducted in the following counties:
No. Taking
County Three Doses
1. Avery 2,537
2. Beaufort - No Report*
3. Chowan - 494
4. Gates .- 1,593
5. Hertford - - 6,490
6. Hoke No Report*
7. Iredell 19,029
8. Lee 2,756
9. McDowell _ 3,652
10. Mitchell 1,219
11. Onslow 1,985
12. Pasquotank .....No report*
13. Scotland 4,189
14. Stokes 4,827
15. Union No report
16. Watauga 4,491
17. Yadkin 7,151
18. Yancey 7,833
Total : 74,460
In May and June, 1926, the following counties were circularized for cam-paigns
against typhoid fever: Alamance, Catawba, Chatham, Dare,
Forsyth, Lincoln, Martin,. Montgomery, Moore, Person, Randolph, Rocking-ham,
Wayne.
III. Special Work for the Prevention of Diphtheria
Toxin-antitoxin campaigns for the prevention of diphtheria were con-ducted
in 1924 and 1925, simultaneously with the typhoid campaigns.
Work for campaigns for 1924 was practically completed in 1925. The
counties and number taking complete treatments are listed in the follow-ing
tables. Children between six months and six years were advised to
take the treatment as in this age group seventy-five per cent of our deaths
from diphtheria occur and most of the children are susceptible to the disease.
No. Taking
County Three Doses
1. Avery 265
2. Beaufort No report*
3. Chowan 38
4. Gates 188
5. Hertford 488
*Whole time counties.
Twenty-first Biennial Report 39
No. Taking
County Three Doses
6. Hoke No report*
7. Iredell 1,758
8. Lee 723
9. McDowell 1,109
10. Mitchell 350
11. Onslow ...: 775
12. Pasquotank No. report*
13. Scotland 561
14. Stokes 1,291
15. Union No report*
16. Watauga 200
17. Yadkin 1,512
18. Yancey 1,002
Total 10,260
Thirteen counties, Alamance, Catawba, Chatham, Dare, Forsyth, Lincoln,
Martin, Montgomery, Moore, Person, Randolph, Rockingham, and Wayne
were circularized in May and June, 1926, for toxin-antitoxin campaign.
IV. Venereal Disease Division
Since 1924 the distribution of neo-arsphenamine has been under the State
Laboratory of Hygiene. The Federal appropriation for this work has been
discontinued, so no education or remedial work has been carried on by this
Bureau. However, we receive a large number of letters asking for bulletins,
pamphlets and advice. These are all carefully answered and bulletins and
pamphlets are mailed to those requesting them.
There has been reported to this office the following number of cases of
venereal diseases:
Gonorrhea 4,683
Syphilis 6,372
Chancroid 358
Balanitis 5
*Whole time counties.
40 North Carolina Board of Health
WORK OF THE BUREAU OF MEDICAL INSPECTION
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 each 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
discover the children who have remediable defects, and to have them treated
while curable and before the condition becomes chronic.
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 1. Written instructions for teachers have been
prepared, covering every phase of medical inspection of school children.
Cards for recording the exact history and results of the preliminary
physical examination 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 children in the presence of teachers to demonstrate by
example the need for the examination, the purpose, and how to do it.
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.
Method for Objective 2. 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 sent
to the Bureau of Medical Inspection of Schools of the State Board of
Health at Raleigh. The Bureau has competent agents, who carefully study
and classify these cards into two groups, those representing supposedly
normal or supposedly defective children. Immediately following this study,
this agent, generally a trained nurse, visits the county and makes a re-examination
of all children reported suffering from common defects:
(c) Those of the children thought to be greatly in need of medical, surgical
or dental service are advised of the fact, together with their parents, but
before treatment is finally arranged for, competent medical examination is
made; (d) Special arrangements are made for club operations and dental
treatment, results of which are described under the head of Results Ob-tained
of this department.
ROUTINE WORK
Articles written—Bulletin, 28; words 15,500
Other publications, 3; words 2,380
Pieces of literature distributed 850,000
Twenty-first Biennial Report 41
FORCE EMPLOYED
Director of Bureau, one part-time physician, one full-time field super-visor
of dentists, seven full-time dentists, seven full-time trained nurses,
six part-time trained nurses, one part-time anesthetist, one part-time truck
driver and hospital orderly, one part-time clerk, one part-time stenographer.
BUDGET
Annual amount allotted fi-om Executive Department $10,000.00
Annual amount allotted from special State funds 50,000.00
Amount received from counties 6,924.00
RESULTS OBTAINED
Some of the tangible results of the work of this department may be
enumerated as follows:
1. Thi-ough the system of medical inspection organized and maintained
by this department for finding defective school children, 60,668 children
have received free dental treatment in the public-school clinics during this
period, paid for entirely by funds expended through this division of the
State Board of Health; 54,130 permanent fillings have been placed, thereby
saving that many permanent teeth, which would have been otherwise lost.
The economic value of this specific assistance, as well as the educational
influence on those children treated, and the more than 9,600 additional
children examined by the dentists, but not treated, cannot be worth less
than $10 per child treated, or $606,680. The dental clinics were conducted
in seventy-two counties.
2. Following up the preliminary examination first made by the teachers
and reported on the proper cards, specially trained nurses sent out by this
department have re-examined 171,905 school children. These children had
been reported by the teachers as possibly suffering from common defects..
Most of them were found to have one or more of the common physical
defects, such as decayed teeth and diseased throats. No possible estimate
of the immense educational value can be placed on this service to public-school
children by teachers and nurses.
3. Tonsil and adenoid clubs have been originated and put into operation
by this bureau for the purpose of following the examinations with treatment
when needed. This activity has embraced twenty-seven counties in which
clinics have been held. A total of 3,714 school children have been operated
on in these clinics. The financial equivalent of one of these operations,
negotiated through private methods, without considering the far-reaching
effect on the whole life of the child of neglecting to have this important
operation done, cannot be less than $50. In fact, the operation alone costs
more in many places of the State. Thus the total money value of 3,714
successful operations is certainly not less than $185,700. But the most
important consideration is that a very small percentage of the children so
essentially helped could even have had the opportunity otherwise.
42 North Carolina Board of Health
MALARIA CONTROL
The Department created for the Investigation and Control of malarial
fevers is financed jointly by the State Board of Health and the International
Health Board. The main and primary object of the Department is to con-fine
its eff'orts to studying the prevalence, geographic distribution of ma-larial
fevers, factors responsible for transmission and to suggest to county
health departments the most economical means of control. There is a
secondary object of perhaps even greater importance which has guided the
department in formulating its policies; this is the stimulation of a perma-nent
interest and activity in the administration of public health activities
whereby disease prevention can be carried on economically and on a large
scale by free and generous support of full time county health departments.
The department thus created has been instrumental in the organization
of two additional county health units, thus making a total of nine county
health departments whose duty it is to carry on control measures wherever
the disease is prevalent enough to justify the eff"ort and the expenditure
of public funds.
The policies pertaining to the organization and conduct of the depart-ments
undertaking malaria control are determined by the State Board of
Health. The details pertaining to county organization has been delegated
to a staff member of the International Health Board, who is executive head
of the departments and who directs the field activities of the newly created
county organizations in the control of the disease.
Main Objectives
County organizations created by joint funds of the International Health
Board, State Board of Health, and counties for the investigation and con-trol
of malarial fevers, have the prime objectives in view
1. Geographic distribution of the disease.
2. The incidence of the disease and the extent to which it is
a menace to the health and economic efficiency of the people.
3. Factors responsible for transmission and spread.
4. The possibility of controlling the disease within the eco-nomic
reach of the people.
In order to explain the procedure followed by each county health organi-zation
the methods and relation to the objectives as advised by the depart-ment
will be considered.
Method for Objective One
Malaria a Rural Disease: Malaria is essentially a rural disease for
the reason that the mosquitoes held responsible for the transmission of
the disease are essentially a rural species and any reduction in the incidence
of the disease will benefit the rural moi-e than the urban population. The
serious loss from the disease is not due to the costs of treatment and deaths,
but rather to the loss of efficiency of labor, loss in net crop productions and
in the predisposition to other and more fatal diseases.
Certain biological facts concerning the malarial mosquitoes explains the
rural nature of the disease. While the mosquitoes which have been incrim-inated
as the principal vectors of the disease are domestic in their adult
habits, they may be considered only partially domestic in their breeding
Twenty-first Biennial Report 43
habits as natui-al and permanent collections of surface water are more
often selected for bi'eeding areas. The larvae of anopheles will thrive best
in natural collections of water, such as, slowly running streams, edges of
shallow ponds, barrow pits, and seepage areas. Permanent water collec-tions
of this natux'e are common to rural and not to urban districts. The
density of anopheles may be said to be in direct proportion to the oppor-tunities
offered for propagation. That malaria is essentially a I'ural dis-ease
is demonstrated by its disappearance from areas where the land has
been drained and brought under cultivation.
Since the reduction in the density of malarial mosquitoes is in direct
ratio to the reduction in collections of surface water in which the mos-quitoes
may breed, the control of the disease through the application of
anti-mosquito measui'es in the aquatic stage is biological in scope.
Method Used in Determining Prevalence and Geographic Distribution
On completion of the organization of the departments, the health officers
seek to outline or determine the areas of concentration of the disease in
their respective counties, and, in view of the fact that malaria is essentially
a rural disease, control measures are confined principally to the rural sec-tion
and small villages of the county. The first step of the departments has
been to gather data as to the apparent prevalence of the disease in the
county by the examination of school children between the ages of 2 and 12
for enlarged spleens, the taking of history indices as to positive or negative
malaria, the establishing of blood indices and the securing of mortality
statistics from the State Board of Health. From the data elicited during
this preliminary survey, the health officer obtains a fairly accurate idea as
to the prevalence and distribution of the disease in his respective county.
From such records it is naturally shown that certain foci of infection exist
in the county and are the only areas requiring immediate control measures.
Having established the area or areas where the disease is most prevalent,
the department prepares a survey, or spot map, showing each home thereon
in relation to permanent collections of water, with special reference to
those streams breeding malaria mosquitoes. In areas where anti-mosquito
measures are considered feasible, all the collections of water are indicated
on the survey map and character indicated as to whether permanent or
temporary. The density of mosquitoes in relation to occupied houses is a
feature, also of the department. From the data elicited during this sur-vey
the health officer is in a position to determine the most feasible and
economical measures of control which in the tidewater section consists of a
combination of all measures at our command.
Examination of Children for Splenomylogy
In order to elicit the smaller degree of enlargement and the better to
determine the exact degree of enlargement in children, it is necessary to
place the child in a recumbent position with the thighs and legs flexed.
The examiner sits at the right side of the child with the head of the latter
on the examiner's left. The child's clothing or belt is loosened so that
the hand of the examiner can be freely placed upon the bare skin, below
and above the costal margin on the left side of the abdomen.
First the region between the costal margin and the umbilicus and be-tween
the umbilicus and pelvis is palpated for the detection of spleenic
44 North Carolina Board of Health
MALARIA
Twenty-first Biennial Reiport 45
MALARIA
1921 1922 1923
a
S.
o
a.
~ c ^
c (i'^
CI
a.
^5
Q
(1,
1924
a.
1925
3 14.0
3 3.6
6.8
4.5
9.4
9.5
34.3
47.3
Jones 10,096 3 29.7
Lee 13,713 -. .„...
Lenoir 30,604 3 9.8
Lincoln 17,975
Macon 12,994 ....
Madison ...20.083 ....
Martin 21,297
McDowell ......17,262
Mecklenburg .82,806
Mitchell 11,421 ....
Montgomery ..14,607 1
Moore 22,065 1
Nash 42,194 4
New Hanover 41,946 4
Northampton 23,317 8
Onslow 14,792 7
Orange 18,332 ....
Pamlico 9,060 8 88.3
Pasquotank ....17,821 3 16.8
Pender 14,788 2 13.5
Perquimans 11,150 4 35.8
Person 19,223 ....
Pitt 46,995 8 17.0
Polk 9,016 .... ......
Randolph 31,067
Richmond 26,478 ....
Robeson 55,406 1 1.8
Rockingham ... 45,339 ....
Rowan 45,072 2 4.4
Rutherford .....31,896 .... ......
Sampson 36,932 2 5.4
Scotland 15,636 ....
Stanly 28,591 .... ......
Stokes 20,640 .... .
Surry 32,891 ....
Swain 13,660 _..
Transylvania .. 9,629
Tyrrell 4,849 1 20.6
Union 36,454 2 5.4
Vance 23,320 ....
Wake ._. 76,998 2 2.5
Warren 21,798 1 4.5
Washington ...11,485 4 34.8
Watauga 13,620 ....
Wayne 44,867 8 17.8
Wilkes 33,009 .... .....
Wilson 38,134 1 2.6
Yadkin 16,540
Yancey 15,560
10,218
13,921
31,303
18,050
13,065
20,083
21,609
17,594
84,213
11,278
14,607
22,516
42,949
42,830
23,405
14,851
18,623
9,060
17,921
14,788
11,158
19,389
47,945
9,138
31,207
27,085
54,674
46,132
45,745
32,209
37,552
15,660
29,365
20,683
33,175
13,950
9,846
4,849
36,737
23,667
78,226
21,934
11,522
13,477
45,685
33,252
39,014
16,639
15,871
4 39.1
4 12.7
1 4.9
2 9.2
5.9
1 2.3
3 7.0
5 21.3
4 26.9
6 56.2
2 11.1
2 13.5
2 17.9
4 8.3
1 1.8
4 8.7
3 7.9
2 41.2
6 16.3
2 2.5
1 4.5
2 4.3
3 7.6
10,341
14,130
32,003
18,126
13,137
20,083
21,921
17,927
85,620
11,278
14,607
22,967
43,704
43,714
23,493
14,910
18.914
9,060
18,021
14,788
11,166
19,555
48,895
9,261
31,347
27,692
54,674
46,926
46,419
32.522
38,172
15,684
30,139
20,726
33,459
14.240
10,063
4,849
37,020
24,014
79,454
22,070
11,560
13,477
46,503
33,495
39,894
16,738
16,182
5 48.3
3 9.3
2 9.1
5 5.8
1 6.8
1 4.3
3 6.8
6 25.5
3 20.1
12 132.4
1 5.5
2 13.5
2 10.2
3 6.1
2 4.3
1 2.6
1 3.3
1 2.9
1 20.6
1 2.7
3 3.7
1 4.5
8 69.2
7 15.0
10,463
14,338
32,702
18,201
13,208
20,083
22,234
18,259
87,028
11,278
14,607
23,419
44,460
44,599
23,583
14,970
19,206
9,060
18,123
14,788
11,175
19,722
49,846
9,385
31,488
28,299
54,647
47,720
47,093
32,835
38,792
15,708
30,913
20,770
33,743
14,530
10,280
4,849
37,303
24,361
80,682
22,207
11,598
13,477
47,321
33,738
40,744
16,837
16,493
1 9.5
4 17.9
4.2
6.7
4'.2
40.0
55.1
5.5
1 2.0
1 2.1
1 3.2
4 82.4
1.2
60.3
10.5
9.8
10,586
14,546
33,401
18,276
13,280
20,083
22,546
18,591
88,435
11,707
14,607
23,870
45,215
45,483
23,672
15,029
19,498
9,0b0
18,224
14,788
11,183
19,889
50,797
9,508
31,629
28,907
59,018
48,515
47,768
33,149
39,413
15,732
31,688
20,814
34^027
14,820
10,498
4,849
37,586
24,708
81,910
22,344
11,636
13,989
48,139
33,981
41,654
16,936
16,804
3 28.3
3 8.9
1 5.4
1 4.4
1 5.3
1 1.1
2 8.4
5 33.2
1 S.l
2 22.0
1 8.9
8 15.7
2 6.9
1 1.6
1 2.0
2 5.0
2 8.0
1 1.1
6 51.5
5 10.3
4 9.6
Total 2,614,335 172 6.5 2,649,982 177
August 16, 1926.
6.6 2,686,325 151 5.6 2,722,669 123 4.5 2,811,969 123 4.3
46 North Carolina Board of Health
enlargement of the greater degree. If the spleen cannot be detected the
child is insti'ucted to take a deep breath. The examiner places the tips
of the fingers of his right hand on the abdomen just below the costal mar-gin
and makes slight but not deep pressure just at the time the child takes
a deep breath. If the spleen is enlarged it may be felt as it descends be-ing
pushed down by the diaphragm during deep inspiration. Care must
be taken not to press too deeply for then the descending margin of the
spleen may not be felt. Spleens that are readily palpable or of the higher
degrees of enlargement may be detected without the necessity of the
child's taking a deep breath.
The spleen may be palpated more easily in children between the years of
two and twelve than those younger or older.
The following classes of spleens are used
:
1. Negative on deep inspiration.
2. Palpable on deep inspiration.
3. Palpable on normal inspiration but not one finger's-breadth
below the costal margin.
4. One finger's-breadth below the costal margin on normal
inspiration.
5. Two finger's-breadth below the costal margin on normal
inspiration.
6. Three finger's-breadth belov; the costal margin on normal
inspiration.
History Index as to Positive or Negative Malaria
For this purpose house to house surveys are made and the presence or
absence of malaria is recorded for each individual for the two preceding
years. Case histories are accepted as positive only when the individual
gives a history of repeated periodicity.
Parasitic Index
As a further means of arriving at a conclusion as to the prevalence of
the disease in a county, a parasitic index is established. For this purpose
a thick, with a corresponding thin smear is taken from each person, will-ing
to have it done. As the smears are taken they are numbered with
the ordinary soft lead pencil by writing direct into the dried blood the
serial number of the individual, which corresponds to the history index
number. Thick smears are examined fifteen minutes and then five minutes
before calling negative.
Intensive Mosquito Survey
The next step toward arriving at a solution of the mosquito problem in
places where anti-mosquito measures are thought to be applicable consist
in intensive surveys for the breeding places, in the collections of water
indicated on the survey map. This is accomplished by one collecting adult
mosquitoes from regular collecting stations, second, by collecting Larvae
and Pupae and breeding them out. All collections made are classified as
to species, character of water from which collected, whether permanent or
temporary, and day of collection.
Twenty-first Biennial Report 47
Method of Objective Three
From the data elicited during the preliminary survey to determine the
incidence and geographical distribution of the disease and biological factoi's
responsible for transmission. The Health Officers, through the association
of the general director, determines w^hat plan of procedure to make in
formulating their program of control.
Results Accomplished During the Organization Period of the Bureau
It is physically impossible, with the present personnel, to resurvey all
counties undertaking measures for the investigation and control of malaria
fevers, as well as placing the department at a prohibitive cost, I am there-fore
giving only one concrete example of what a county organization may
expect in the way of reducing the incidence of the disease when the attack
is made in an intensive way.
Resurvey of South Creek Section
BEAUFORT COUNTY
South Creek is a small settlement located in the extreme southeastern
part of Beaufort County, North Carolina, on an arm of the Pamlico River.
The community is situated in a small tongue of land which divides an arm
of the river into two branches, called Bond Creek and Muddy Creek.
Neither of these creeks is more than a mile in length. From the broad
northern point, the tongue gradually widens until at a distance of approxi-mately
1% miles it is a little over a mile wide. The land is quite level,
as it is in all this region, and is only a few feet above sea leveh The
ground water level is only 6 feet below the surface. Three or four small
branches, which cut across the area, drain the excess water into the creeks.
If these were kept in good condition, the natural drainage of the land
would probably be fairly good. At the time this survey was made, these
branches were almost completely dry, owing to long continued drought.
Following is given the average precipitation for the past five years in
Wenona and New Bern, two towns situated in opposite directions from
South Creek, in adjoining counties. No records are kept in Beaufort County.
48 North Carolina Board of Health
them out of employment. In 1925, owing to a severe local hailstorm, the
farmers lost absolutely their entire crops, and many migrated to other
localities. About Vs of the houses are now unoccupied. The present occu-pation
of the remaining inhabitants are farming and fishing.
The principal crops are corn and cotton, but the boll weevil has invaded
this section as well as the rest of the State. Much of the land is cut over
timber land, on which nothing is grown. My impression is that not over
% the available land is under cultivation, and even this estimate may
be high.
Past History of Malaria
The South Creek section has always been known as a bad malarial
region. Accounts of blackwater fever are common, while, according to the
inhabitants, every fall saw a visitation of the disease to a majority of the
inhabitants. Of more interest than these accounts, are the doctor's reports.
Dr. John Bonner, now Health Officer of Beaufort County, for many years
lived in Aurora, and did most of the practice of South Creek. His interest
in malaria, his principal source of income, led him to keep records of his
calls for several years. His records show, that in the years 1920 to 1922,
inclusive, there was a large number of calls for malaria every week,
especially in September and October. The peak was reached in October,
1922, when in one week, he visited 45 new patients with malaria.
In January, 1923, the newly-organized Health Department of Beaufort
County, began a vigorous county-wide campaign against malaria. Blood
examinations made on about 7,000 inhabitants of the county, showed a
general average of 45% positive. In the South Creek section, of 239
white people examined 99, or 42% were positive; 789c were tertian, 20';c
aestivo-autumnal, and 1% quartan. In the negro colored school, of 43
children examined, 30 were positive, a rate of 70 9o- During the succeed-ing
summer and fall, the people were urged to take quinine according
to Bass' treatment. According to my census, 56 people now present took
the entire course of treatments, while 12 took part of the course. Some
of them have continued taking treatments every year since that time.
The county did not distribute the quinine free, but the people had to buy
it. At the instance of the Health Officer, all storekeepers in the county
agreed to sell it at cost. Immediately its price dropped from $1.50 or
more to an average of 80 cents, and sales began to climb. There are
three storekeepers in South Creek. They estimate their sales as follows:
SALE QUININE IN POUNDS
1922 1923 1926 to date
Store No. 1 2 16-18 less than three pounds.
Store No. 2 2 15-20 none.
Store No. 3 1.5 11-12 about 1 pound.
From total sales of approximately five pounds in 1922, the amount rose
in 1925 to over 42 pounds from these three stores alone. The price of
quinine was somewhat less in Aurora, and it is reasonable to suppose
that some quinine was bought in that town. At the same time the sale
of chill tonics fell off, and only a little is sold now. If it did nothing else,
this campaign certainly popularized the use of quinine.
Twenty-first Biennial Report 49
Referring again to Dr. Bonner's records it will be seen that in 1923, at
no time did his calls rise above seven per week, even in the season of
greatest transmission. In 1924, the highest number seen was 12, in one
week in October. Recox'ds for 1925 are not available, but the general im-pression
is that there was very little malaria there the past season. This
is probably true, especially since it was a year of deficient rainfall.
Present Survey
The present survey was undertaken during the second week in August,
1926, for the purpose of determining the amount of malaria present, and
the opportunities for its transmission, and the reasons for any change
that may have occurred.
The survey was made by a house-to-house canvass, and the following
information was secured:
Name, age, sex, race, length of residence in locality, history of acute
malaria within past year, type of house and condition of screens, and
history of intensive quinine treatment.
At the same time, spleen examination was made on all children under
15 years of age, and blood smears were taken from approximately half
the people. After the history was concluded, the house was carefully
searched for adult mosquitoes.
Results of Survey
A total of 161 persons were taken in the census, from 41 occupied
houses. Seven occupied houses were not taken in the census, since the
occupants were not at home when the census was made. Of this number
120 were whites, and 41 negroes. Separation was not made into the sexes,
since this was not deemed important.
The following gave a history of at least one chill, followed by fever and
sweating, since March, 1925. Since the use of quinine is so general, and
is taken for almost any ailment, it was difficult to elicit a history of more
than three or four chills from anyone.
1925 1926
Mar1ch A2pril J2une4July4Aug.7Sept.2Oct.1Dec.1Marc2h Ma3y Jul1y Aug. Total 30
(Dupl) (Dupl)
Whites, 22, Negroes, 8, and equally distributed through all ages. It is
quite possible that some of these histories were not malarial.
Following are the results of the blood and spleen examinations:
Number Spleen Palpable Blood
Age Examimd Examined No. % Examined Positive
0-2 5 3 .. -
2-4 10 10 • 6 1
5-9 25 25 4 18
10-14 31 23 3 22
15-19 11 -- ._ 8
20-39 41 -- - 16
40 up 88 -. - 12
161 61 7 11.5% 82 1
50 North Carolina Board of Health
All spleens except one were only palpable on inspiration. The one was
one finger's-breadth below the costal margin. A spleen rate of 11.5%
indicates only a very moderate degree of endemicity. This is borne out
by the results of the blood examinations, with only one positive out of 82
examined. It must be remembered, of course, that the malaria curve
usually does not begin to rise until the first of August, and that this
survey was made in an abnormally dry season as well.
Nevertheless, it seems clear that there is only a small amount of
malaria present when the survey was made, and that this condition has
prevailed for the past few years.
Distribution of Positive Cases—(Spleen and Blood)
When spotted on the map of the area, it is seen that four of the eight
cases are grouped in the center of greatest population, near the point of
land, and, at least at the time of the survey, fairly distant from any
breeding places for mosquitoes. Two more cases occur in the same point,
but somewhat removed from the other four, and these are situated near
several large ditches, which at the time of survey were dry. The ditches
are not shown in the map. The two remaining cases are scattered. One
palpable spleen occurred in a house which is reported to have had several
cases of blackwater fever in the past few years. The last case occurred
in March, 1926, according to the doctor's report, but the child was not
prostrated, and soon recovered. This child is still taking quinine regularly.
Length of Residence of Positives
All eight positive cases (spleen and blood) have lived in the area all
their lives. The one blood positive case was in a boy just three years old,
whose mother, when the blood was taken, said she was sure the boy had
malaria. We had been giving him small doses of quinine, but had stopped
it some time previous to our visit.
Comparison of Findings in 192.3 and 1926, in Those People
Present Both Years
From the original records of the 1923 work, I secured the results of
the blood examinations in those people who were still present at the time
of the survey in 1926. Following is a summary of the results:
1923 1926
No. Cases Present No. Neg, • Positive Pos. Pos.
Both Years Vivax. Falcip. Quart. Spleen Blood
69 32 31 6 2.0
The 1926 figures should not be expressed in percentages, since these
people, all of whom were examined in 1923, were not all examined in 1926.
There is, however, a marked reduction in the incidence of malaria in these
two years.
Adult Mosquito Catches
At the same time that the census was made, opportunity was taken to
look for mosquitoes in the houses. Twenty-two of the total of 41 houses
were carefully searched. A total of four anophelines, all quadrimaculatus,
were found. Two of these were found in house No. 1, and two in house
No. 2. These may have come from a ditch just outside the area which
was not searched for larvae.
Twenty-first Biennial Report 51
Probable Causes for Decrease in Malaria in the Area
While it is impossible to state the exact amount of malaria which used
to be present, there seems to be no doubt that formerly the disease was
very prevalent. The fact that 45Vo of the people of the county were found
with parasites is indicative of this especially during the autumn. It also
seems to be true that the incidence of malaria has decreased remarkably
in the past three or four years. I shall now take up some of the possible
causes of this decrease.
1. Intensive Quinine Treatments in 1923 and Succeeding Years.
As already described, examination in 1923 showed 45% of the people
with one or more classes of malaria parasites in their blood. The indica-tions
are that the intensive treatment was successful. Fifty-six (56)
people now present took the full course of treatment prescribed, and 12
others completed part of the course.
In addition to the 1923 campaign, in 1924 and again in 1925, blood smears
were made from a large number of people in the area, and those positive
were urged to take treatment. The fact that quinine sales increased
about 10 times in 1923 indicates that a large amount was used.
The intensive treatments of 1923 doubtless sterilized the blood of a
fairly large percentage of the population that year, and the treatments
of the succeeding years did the same thing for a lesser number. Even
in the presence of the vector in considerable numbers, this must have had
an effect in reducing the transmission. The rainfall of 1923 was only
slightly below normal, probably not enough so to influence the amount
of anopheles breeding. It is the consensus of opinion that quinine treat-ments
was the greatest single factor in reducing malaria in that year,
although it alone probably cannot be held responsible for the decrease.
Perhaps the greatest good from this campaign, however, was the
popularization of quinine in adequate doses for chills. The lessons learned
that year have certainly not been forgotten. It is common to find people
who are now taking quinine every autumn, because they were taught to
do so by the health officials. They also use it whenever they have a chill,
instead of chill tonic; and they use it in large enough doses to have a
therapeutic effect.
2. Rainfall.
The rainfall in 1923 was slightly below normal; that of 1924 fifteen
inches above normal, and a slight increase in the amount of malaria prob-ably
occurred, but 1925, and 1926 have been years of abnormally low
rainfall. At the time of the 1926 survey, all the usual water courses were
dry, or practically so. Conditions were distinctly unfavorable for mosquito
breeding, and as a consequence the mosquito index was undovibtedly low
and hence transmission was perhaps almost nil. It would be interesting
to see what effect the late August rains will have on breeding.
3. Drainage.
While a drainage district has been formed and is in operation in an
adjoining area, the value of the land does not permit such a district to
be formed in South Creek. As stated elsewhere, natural drainage is prob-ably
good except in a few low-lying areas, and this drainage has been
52 North Carolina Board of Health
favored by a few well-placed ditches which have been dug. Once a year
these ditches are cleaned out by the farmers, but during all the rest of
the year they are not