The Health bulletin [serial] - University of North Carolina at Chapel Hill

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^ifo'ISmI TKis Bulletin will be senifree to dny citizen of fKe Ski^e upon request tPublished monthly at the ofSce of the Secretary of the Board, Raleigh, N. CEntered as second-class matter at PostofSce at Raleigh, N. C. under Act of Angnst 24, 1912Vol. 66 JANUARY, 1951 No. 1

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Ddcon, M.D., President AydenHxnBEET B. Haywood, M.D., Vice-President RaleighH. Lee Large, M.D Rocky MountJohn LaBruce Ward, M.DAshevllleJasper C. Jackson, Ph.GLumbertonMrs. James B. Hunt Lucama, Rt. 1John R. Bender, M.DWinston-SalemBen J. Lawrence, M.D RaleighA. C. CxjHRENT, D.D.S GastonlaEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OflBcer, Director Personal Health DivisionC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionJohn H. Hamilton, M.D., Director State Laboratory of HygieneJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionC. P. Stevick, MJ)., M.PJI., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin^ which willbe sent free to any citizen requesting it. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any inwhich you may be interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitis Infantile Paralysis Typhus FeverCancer Influenza venereal DiseasesConstipation Malaria Residential SewageDiabetes Measles Disposal PlantsDiphtheria Pellagra Sanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFlies' Teeth Whooping coughTuberculosisEpilepsy, Feeble-mhidedness, Mental Health and Habit TrainingRehabilitation of Psychiatric PatientsThe National Mental Health Act.SPECUL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal Care.First Four Months.Prenatal Letters (series of nine Five and Six Months.monthly letters).Seven and Eight Months.The Expectant Mother.Nine Months to One Year.Infant Care.One to Two Years.The Prevention of Infantile Two to Six Years.Diarrhea.Instructions for North CarolinaBreast Feeding.Midwives.Table of Heights and Weights.Your Child From One to SixBaby's Daily Schedule.Your Child From Six to TwelveGuiding the AdolescentCONTENTSPageTributes to Dr. George Marion Cooper 3

mwrn[£l||PU6LI5A\ED BYTAE NRTM CAROLINA STATE B^'ARD-zAEALTAl BVol. 66 JANUARY, 1951 No. 1J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorGeorge Marion Cooper, M.D.— 1876-1950The Health Bulletin sorrowfully marks the passing ofDr. George Marion Cooper, for nineteen years itseditor andfor thirty-five years a distinguished member of the staff of theNorth Carolina State Board of Health.We dedicate the pages of this issue to a partial expressionof appreciation of the man and the good service which herendered in promoting the health of allthe people of NorthCarolina.

The Health Bulletin JantLary, 1951STATE OF NORTH CAROLINAGOVERNORS OFFICERALEIGHW Kerr ScottGOVERNORIn the death of Dr. George Marion Cooper, AssistantState Health Officer, North Carolina has lost a faithful publicofficial and humanity a devoted friend. He was interested inand gave his efforts to the solution of more public health problemsthan any other man of his generation. Although he wasqualified for leadership in any phase of public health work, hewas willing to serve in the ranks. However, he was looked tofor advice and guidance by every State Health Officer and everyother Health Official with whom he worked.Dr. Cooper was able to place himself alongside thosehe served; to interpret their problems and minister to theirneeds in a sympathetic aind effective mcinner. He was able toserve his State over a period of many years without assumingany attitude of proprietorship. On the contrary, he remaineda faithful servant of the people. He occupied a place in NorthCarolina history which was unique. In his relationship to Churchand State, Dr. Cooper gave his best.GovernorJamuary 3, 1951

January, 1951The Health BulletinRESOLUTION OF RESPECT TO THE LATEDOCTOR GEORGE MARION COOPERThe following Joint Resolution, in^troduced in the Senate by Senator PaulJones, was placed upon its immediatepassage by unanimous consent on January17, 1951, then sent by special messengerto the House which took similaraction. The Resolution was passed andratified on the same day.WHEREAS, the death of Dr. GeorgeMarion Cooper, Assistant State HealthOfficer, which occurred on Monday,December 18, 1950, removed from ourmidst one of the greatest Public Healthofficials and humanitarians North Carolinahas ever known; andWHEREAS, his efforts in behalf ofthe underprivileged, especially amongmothers and babies, not only weresignally outstanding, but bore widespreadand beneficial results in everypart of oiu- State;Now, therefore, be it resolved by theSenate, the House of Representativesconcurring:Section 1. That official recognitionbe given the life and services of thisdistinguished and useful native ofSampson Coimty, who, for thirty-fiveyears was associated with the StateBoard of Health.Sec. 2. That a copy of this resolutionbe given the Secretary and State HealthOfficer, and copies to Doctor Cooper'sthl-ee surviving children.Sec. 3 That today's adjournment bein honor of Doctor Cooper.Sec. 4. That this resolution shall bein full force and effect from and afterits ratification.Jan. 17, 1951TRIBUTES TO DR. G. M. COOPERWhen advised of the death of Dr.G. M. Cooper, Assistant State HealthOfficer, Dr. J. W. R. Norton, Secretaryand State Health Officer, made thefollowing statement:"North Carolina has lost its greatestPublic Health Official of all time. Heserved longer, engaged in more activitiesand did more to make North CarolinaPublic Health conscious and tomini ster to its Public Health needs thanany man in the history of the State. Hepioneered more Public Health servicesthan any other man I know, not only inNorth Carolina but in the nation. Bothpersonally and professionally he hadfew peers, if any, and no superiors anywhere.His was constantly an up-hillfight against ignorance, misinformation,indifference and short-sighted selfishinterests. The two greatest groups ofhis beneficiaries were imder-privilegedmothers and children, in whose behalfhe not only worked unceasingly and forwhose relief he was instriunental insecuring millions of dollars in publicfunds, which he administered wherethey would do the most good among thegreatest nimiber of people. During hisservice with the State Board of Health,the maternal death rate was reducedto one-fourth and the infant death rateto one-half of those rates prevailing inNorth Carolina when his service began.This progress was due to the work ofmany devoted physicians and assistingpersonnel; Dr. Cooper was the patientplarmer, the daimtless and resoiircefulleader, the tireless worker."I feel in the passing of Dr. Cooperan over-whelming sense of personalloss. In generations to come, the descendantsof those he has helped willrise up and call him blessed. His S3mipathieswere broad and he worked tirelesslyin behalf of those he sought to

6 The Health Bulletin January, 1951serve, and without hope of personalaggrandizement. He was not only apillar of strength in the P'^oiic Healthstructure, but ever mindful of his familyand personal friends and just as zealousin the work of the Presbyterian Church,of which he was a life -long member anda ruling elder at the time of his death.He was my personal friend and thepersonal friend of all who worked withhim in any capacity. Our best expressionof faith in and love for him willbe through closing ranks and marchingon toward the goals toward which hestrove so long and so well."Dr. Clyde A. Erwin, State Superintendentof Public Instruction, paid thistribute to the late Dr. Cooper:"I feel a deep personal loss in thedeath of Dr. Cooper. He has been a dearfriend of mine for many years. In additionI consider his loss to the State irreparable.No one in my opinion hasgiven of himself more vmselfishly normore effectively in the service of thepeople. His keen understanding of theproblems of public health and his dedicationto the solution of these problemsis a landmark along the road of humanprogress."Statement by Dr. Ellen Winston,Commissioner of Public Welfare, on thedeath of Dr. George M. Cooper."In the passing of Dr. George M.Cooper, the State Board of Public Welfare,has lost a staunch supporter andfriend. His loss will be felt by welfareworkers throughout the State who haveknown and loved him. He was evermindful of the importance of the unitedefforts of health and welfare in his workin promoting North Carolina's healthprogram. As an eminent citizen and devotedleader in seeking social betterment,Dr. Cooper made a lasting contributionto this State and to thenation."A GREAT PHYSICIANWhen a North Carolinian who hasbeen taking notice of public affairs fora quarter of a century reflects on thelength, breadth and depth of the serviceof Dr. George Marion Cooper, assistantstate health officer who died atRaleigh early Monday morning, he isconstrained to conclude: Here was thepublic servant made perfect.It will have been printed elsewhere inthe Daily News, but we think any estimateby an editorial commentatorshould include the tribute paid him byDr. Roy Norton, state health officer:He served longer, engaged in moreactivities and did more to make NorthCarolina public health conscious and tominister to its public health needs thanany man in the history of the state. Hepioneered more public health servicesthan any other man I know, not onlyin North Carolina but in the nation.Both personally and professionally hehad few peers, if any, and no superiorsanywhere. He was constantly an uphillfighter against ignorance, misinformation,indifference and short-sightedselfish interest. The two greatest groupsof his beneficiaries were underprivilegedmothers and children, in whose behalfhe worked unceasingly and for whoserelief he was instrumental in securingmillions of dollars in public funds, whichhe administered where they would dothe most good for the greatest numberof people ... In generations to come,the descendants of those he helped willrise up and call him blessed.Ordinarily we are inclined to discountestimates made by professional, businessor governmental associates whoknow what they are expected to say,but Dr. Norton is as objective as wouldbe any good reporter who has for yearsseen Dr. Cooper in action.If we were called upon to name hisgreatest characteristic, we'd make itcourage. He was himself frail, with adeafness which kept him from beingchosen as chief of the health service

January, 1951The Health Bulletinmore than once; but this may have beenat times of assistance to him in hiswork. Certainly he refused to listen tocoimsel of the faint of heart; there wasno contact between him and those whofeared the political effect of any movementfor bettering health conditions.But if he were resolute, none couldquestion his willingness to work in harness.His fellow workers all down theyears have sworn by him, and in hisentire public lifetime, which was one afew years shorter than the lifetime ofthe DaUy News, there has never to cm'knowledge been offered a printed wordof disparagement of Dr. Cooper by aresponsible citizen.Even when there was objection bydoctors of medicine to some his advancedsteps in caring for the health ofschool children the objectors soon subsidedand without daring to questionthe good faith of a really great physlciaiL—Greensboro Daily News, Dec. 20, 1950UNSELFISH SERVICEThe death of Dr. George M. Coopermarks the end of a career of a manwho served his fellow man, his Stateand his profession with imselfish devotionfor four decades.It would be difficult to overestimatethe value of Dr. Cooper's services. Asa young physician in Sampson Countyhe saw the need for carrying advancedmedical knowledge to all of the people.In his own practice he was the firstphysician in this State to use typhoidvaccine in North Carolina.He soon extended his practice to theentire State, joining the then youngState Health Department in 1915 andserving as Assistant State Health officerfrom 1923 until his death yesterday.Dr. Cooper's primary work was in thefields of maternal and child health. Nostate has made more progress in thoseimportant fields in the last 30 yearsthan has North Carolina. And for muchof that progress the State is indebted tothe tireless labor of this self-effacingman.Dr. Cooper's labors were by no meansconfined to maternal and child health.Those labors embraced the whole areaof public health and he has left hismark in that entire field.North Carolinians are grateful to thispioneer in public health work, who alwaysplaced the well being of the manyabove the good of the few.Raleigh News & ObserverWAS A HEALTH PIONEERDr. George M. Cooper, pioneer publichealth official and Assistant StateHealth officer in North Carolina sinceMarch 1, 1923, was in a very large measureresponsible for the fact that theNorth Carolina Health Departmentstood among the first in this Nation.Dr. Cooper was a native of SampsonCounty. He became interested in publichealth work and might well be creditedwith being first to realize the need formaking possible hospital and medicalfacilities for the rank and file of thepeople of this State.Dr. Cooper was said to be the firstphysician in North Carolina to use typhoidfever vaccine. Dr. Roy Norton,State Health Officer, paid deserved tributeto Dr. Cooper, who was not onlyhis assistant but assistant to his predecessorsand often served as ActingHealth Officer. Dr. Norton said of himthat he was North Carolina's "greatestpublic health official of all time."Only because of his affiiction withtotal deafness and his self sacrificing

8 The Health Bulletin January, 1951modesty kept George Cooper from beingnot the assistant but the StateHealth Officer for the past 25 or moreyears.The Free Press is glad to add a tributeto his memory. He served longafter the usual retirement age, being74 when he died Monday in Raleigh. Inthe days when county health departmentswere few and far between inNorth Carolina and the progressivecoxmty of Lenoir became the secondcounty in the State to provide full timeservice, Dr. Cooper rendered much helpin getting things started.He was an honor to his profession, aChristian gentleman and his good workwill be felt by generations yet unborn.—Kinston (N. C.)Daily Free PressDR. GEORGE M. COOPERFuneral services for Dr. GeorgeMarion Cooper, assistant State healthofficer since March, 1923, will be conductedTuesday morning at 11 o'clockfrom the First Presbjrterian Churchhere. Dr. Cooper, 74, died at Rex Hospitalearly yesterday morning after morethan a week of critical illness with aheart ailment. Dr. J. A. Christian, pastorof the First Presbs^terian Church,and Dr. H. P. Powell of Edenton StreetMethodist Chiu-ch will officiate at therites. Afterward, the body will be takento the Royall Funeral Home in Clinton,where it will lie in state from 12:45 to1:45 p. m. Burial will follow in theClinton Cemetery. The body will remainat Pennington-Smith Funeral Homehere until just prior to the 11 a. m. rites.Pallbearers will be Drs. A. C. Bulla,John H. Hamilton, Roy Norton andThomas Worth, all of Raleigh; Dr.Street Brewer of Clinton; and C. B.Taylor, Fred Harding and Jeff D. Johnson,Jr., all of Raleigh. A public healthpioneer at both the State and nationallevels, he had been with the StateHealth Department for 35 continuovisyears. Earlier he had been a generalpractitioner in his native SampsonCounty, where he was the first Tar Heelphysician to use tjTDhoid vaccine. Survivorsinclude three children. Dr. GeorgeM. Cooper, Jr., of Raleigh, John PhilCooper of Winston-Salem, and Mrs. A.Sam Krebs of Cinciimati, Ohio; onebrother, Thomas Cooper of Petersburg,Va.; a sister Mrs. Bard Fitzgerald ofGretna, Va.; and three grandchildren.— Raleigh News and Observer,Dec. 19, 1950BIOGRAPHICAL SKETCH OFGEORGE MARION COOPER, M.D., LL.D.By William H. Richardson.State Board of Health, Raleigh, N. C.Born in Clinton, North Carolina,April 24, 1876. Educated in public andprivate schools of Sampson County.Taught school in public and highschools of Sampson County 1897 to 1901.Graduated in medicine at the UniversityCollege of Medicine in Virginia atthe end of foiir years' attendance, 1905.licensed to practice medicine in NorthCarolina in Greensboro 1905. Locatedat once in Clinton, forming a partnershipwith Dr. Frank H. Holmes. This partnershipcontinued active for about eightyears, both physicians doing generalipractice with a great deal of surgery,obstetrics and gynecology.Soon after beginning practice. Dr.;'Cooper became interested in some

1He;CarolinaJ systemJanuary, 1951 The Health Bulletin 9method of controlling the ravages oftyphoid fever and the terribly highdeath rate from colitis and similar diseasesamong infants, and in helping tocoimtermand the death warrant whichin those days hiing over a patient assoon as a diagnosis of tuberculosis wasmade, by joining the movement forearly diagnosis and rational treatment.Dr. Holmes died of tuberculosis eighteenmonths after the partnership was discontinued.Then Dr. Cooper quit privatepractice to devote his full time to preventivemedicine and public healthwork.As part time Coimty Physician ofSampson County from 1909 to 1913,with the aid of the Mayor and TownBoard, Dr. Cooper cleaned up the townof Clinton and used the first typhoidvaccine used by any physician in NorthCarolina as an experiment in mass controland prevention of typhoid feverby vaccination of the civil population.For twenty-one months following thiswork in 1911 and 1912, there was nota case of typhoid fever in that townfor the first time in its history.October 1, 1913 he became a full timehealth of&cer of Sampson County, beingabout the fifth such local health ofiBcerin North Carolina. During 1914, he conductedwith the aid of the InternationalHealth Board two experiments in communitysanitation, one at Salemburgand the other at Ingold. Notable andlasting results were achieved in both,which afforded guidance for subsequentwork elsewhere.was President of the SampsonCounty Medical Society in 1910, andPresident of the North Carolina PublicHealth Association in 1913 and 1914.He was appointed head of the Departmentof Rural Sanitation and a memberof the executive staff of the NorthState Board of Health andmoved to Raleigh and assumed theseduties May 1, 1915.In 1917, he was made head of theschool health work for the State Boardwith the title of State Medical Inspectorof Schools. In that position he plarmedand put into operation in 1918 theof dental work for all Statepublic school children and engaged andsupervised the first dentists for schoolhealth work. That year he was madean honorary member of the State DentalSociety, an honor continued to thisday and valued highly. Under the system,since gradually expanded, morethan three million school children havereceived free treatment, to make nomention of the most important aspectof the work, education. In 1919, he devisedand put into effect the systemof club operation for the removal ofdiseased tonsils and adenoids of schoolchildren, and supervised these clinicsfor most of the time until 1931. Operationswere performed on 23,211 childrenliving in every school district in 86 ofthe State's 100 counties, with the lowestmortality record in the history of suchwork in the United States. The educationaleffect of these two movementsfor better health for all children hasbeen incalculable.On March 1, 1923, he was appointedAssistant State Health OfiBcer and Editorof the Health Bulletin continuingas Editor until 1942. From September1, 1923, to September 1, 1924, during theyear's leave given Dr. W. S. Rankin,State Health OfiBcer, for work in NewYork, Dr. Cooper again became ActingState Health OfiBcer. Upon the returnof Dr. Rankin September 1, 1924, hewas continued as Assistant State HealthOfiBcer, Director of Health Education,until the resignation of Dr. RankinMay 30, 1925, when he was again madeActing State Health OfiBcer and servedin this capacity until the assumptionof ofiBce by Dr. C. O'H. LaughinghouseOctober 1, 1926. During Dr. Laughinghouse'sterm of ofBce until his deathAugust 26, 1930, Dr. Cooper was Directorof Health Education.Upon election of Dr. J. M. Parrott asState Health OfiBcer on July 1, 1931,he became Director of the Division ofPreventive Medicine in the reorganizedState Board of Health. This Divisioncomprised School Health Work, Maternaland Child Health Services, HealthEducation, editorial work. etc. Thiswork continued until the death of Dr.Parrott, November 7, 1934. He was Act-

10 The Health Bulletin January, 1951ing State Health OfBcer during the intervalbetween Dr. Parrott's death andthe beginning of Dr. Carl V. Reynolds'administration as Health Officer.In 1934 Doctor Cooper was unanimouslyelected President of the RaleighAcademy of Medicine. Upon assumptionof duties as State Health Officerby Dr. C. V. Reynolds, November 10,1934, following the death of Dr. Parrott.Dr. Cooper was elected AssistantState Health Officer and reelected foiirtime since, his present term to expireJuly 1, 1951. His other duties were thesame as during the Parrott administration,and in addition as Director ofMaternal and Child Health Services forthe United States Children's Bureau,he has had the responsibility of administeringthe Emergency Maternityand Infant Care work for service wives.During the war period, approximately44,600 maternity and infant cases wereaided to the extent of having theirdoctor and hospital bills paid.In 1941, Dr. Cooper was elected Presidentof the North Carolina Conferencefor Social Service.In 1942, Dr. Cooper was the recipientof one of the highest honors that cancome to a citizen of North Carolinawhen the University of North Carolinaconferred upon him the honorary degreeof Doctor of Laws in recognitionof his work in Health Education. Inconferring the degree, President FrankP. Graham read the following citation:"GEORGE MARION COOPER, ofSampson County, nationally distinguishedas a public health officer, quietand unassuming but relentlessly effective,he has as state health officer servedfor a longer period and in more fieldsthan any other person. He has been aleader in practical programs for themedical care of the poor and has workedcourageously to lift North Carolinafrom the disgrace of its high birth mortalityof children and mothers. His work,pioneering in America, both for the improvementof the health of school childrenthrough free dental and tonsilclinics, and for the improvement of thehealth of mothers and the birth ofchildren, has become and will continueto be an example to this and other nationsand a benefaction to this andsucceeding generations."The honor which the Ladies of theState Auxiliary conferred upon him bynaming the Bed in the Eastern NorthCarolina Tuberculosis Sanatorium atWilson for him is highly prized and willbe gratefully cherished by his childrenand many friends always.Dr. George M. Cooper, head of theDivision of Preventive Medicine, NorthCarolina Health Department, honoredwith a 1949 Lasker Award of the PlannedParenthood Federation of Americafor outstanding services in maternaland child health and for his efforts inmaking his State the first in the Unionto include birth control in its publichealth services.On April 24, 1950, he celebrated his74th birthday probably by putting in ahard day's work and on May 1,he observedthe completion of thirty-fiveyears' continuous work on the staff ofthe State Board of Health.The above isjust a brief part of therecord, and does not describe the intensitywith which he had put himself,mentally and physically, into manyyears of efforts to improve the healthof the citizens of North Carolina, andthe many lives he has been instrumentalin saving, particularly mothersand babies. As the shadows lengthenedrapidly toward the west for him, hisone regret was that he had not beenable to accomplish more for the plainpeople of North Carolina.

January, 1951 The Health Bulletin 11DR. GEORGE M. COOPER — AN APPRECIATIONEarnest A. Branch, D.D.S., Director of Oral Hygiene DivisionNorth Carolina State Board of HealthIn the death of Dr. George M. Cooperon December 18, 1950, North Carolinadentistry lost one of its best friends. Itwas Dr. Cooper, a physician directingthe Bureau of Medical Inspection ofSchools of the North Carolina StateBoard of Health, who conceived andpromoted the idea of including dentistryin the State's Public Health Program.This was in 1918. Appearing on theprogram of the North Carolina DentalSociety during their meeting in the oldOceanic Hotel at Wrightsville Beach,Dr. Cooper outlined a proposed plan ofdental health education. This plan providedfor employing full time dentistson the staff of the State Board ofHealth and for sending these dentistsinto the schools of the State to teachMouth Health and to make dental correctionsfor the underprivileged children.From the beginning the objectivewas health education.The proposal came from an understandingheart and mind. Dr. Cooperknew from personal experience the sufferingcaused from lack of dental attentionin childhood. He knew from hisexperience as a physician and a publichealth worker the great need for dentalhealth education and for dental serviceamong our children.Dr. Cooper's presentation before theDental Society struck a responsivechord, and it was Dr. J. Martin Flemingof Raleigh who made the motion thatthe North Carolina Dental Society goon record as heartily endorsing the planand that the Society pledge Dr. Coopertheir loyal support. This was done, andNorth Carolina became the first Stateto put dentistry in its Public HealthProgram.Dr. Cooper, assisted by members ofthe dental profession, went before theState Legislature and secured fundswith which to begin operations. Severalyoung dentists were employed, and,from that day to this, the program hasbeen functioning.Because of the vision and work ofthis public health pioneer thousandsand thousands of children have receivedtheir first dental service, thousandsand thousands and thousands of teethhave been saved. North Carolinianshave become more and more MouthHealth conscious, and dentistry's healthservices are more widely recognized andappreciated. Dr. George M. Cooper wastruly a great benefactor of the childrenand of the dental profession of NorthCarolina.January, 1951GEORGE MARION COOPER, M.D., 1876-1950By Waltfb J. Hughes, M.D.Bennett College, Greensboro, North CarolinaJohn Milton in his sonnet "On HisBlindness" said, "They also serve whoonly stand and wait." Milton was blind;Cooper had defective hearing. GeorgeMarion Cooper did not serve by standingand waiting, but projected his personality,with arduous activity, into allthe significant social movements of histime. He brought to the field of publichealth and preventive medicine theforce of his intellect, his creative ability,and great imagination. His achievementswere epical. He was an ablepublic health statesman, a courageousand fearless spokesman in all thingsthat mitigated against the health and

12 The Health Bulletin January, 1951welfare of the people of this commonwealth.His administrative ability hasbeen most constructive in the reductionof maternal and infant mortality, inschool health services, and in the advancementof preventive medicine ingeneral. During his entire tenure as ahealth officer, he indicated to all thepeople the democratic way of living. Hewas impartial in the relationship withall of his subordinates and believed inequality of opportunity in order that allthe people might share in being liftedup to a higher standard of usefulnessand healthful living. His coimsel wassought by many and his advice was fullof wisdom and as soothing as the benedictionthat follows after prayer. Forall of these things the people of NorthCarolina, and the generations yet tocome, owe him a lasting debt of gratitude.TO THE EDITORTo the Editor:—Somehow I passedover in the news the death of Dr. G. M.Cooper, and am indebted for the informationto the brief eulogies by NellBattle Lewis and C. A. Upchurch, Jr.,in the News and Observer. I wish to adda personal tribute to him as not onlyan able and zealous crusader for publichealth, but especially as a warm-hearted,friendly human. I became acquaintedwith him years ago through an occasionalarticle I offered to the StateHealth Bulletin, of which he was solong the able editor.As a friend I pay tribute to two rarecharacteristics which I have seldomseen equaled in another. Few have sucha capacity for warm, generous friendship;few such a cheerful and delightfula mastery of a personal handicap. Hisdeafness he simply accepted and turnedinto a pleasing virtue. Cheerfully andgracefully and unobtrusively he seatedyou in front of him, turned the receiverof his hearing apparatus toward you,and talked delightfully without a traceof embarrassment or restraint. It wasthe zeal of one in love with life, love forhis job, and love for his friends and colaborers.It was the mark of a healthymind and of a full-grown personality.Few have been so generous to recognizeand heartily to praise any worth orability seen in another. Delightfully unconsciousof his own talents andachievements, he was always alert andeager to discover and praise any talentor virtue or accomplishment seen inanother. Perhaps this is the highest attainmentof a healthy mind and of imalloyedgreatness. Face to face, byphone, or through the mail, and withthe heartiness of a father to a son, hepassed on to the writer of an article heused in the Health Bulletin any favorablereaction that came to him as editor.I loved and admired him as few otherfriends of a lifetime, and I fear I "shallnot look upon his like again."Wake Forest—S. L. Morgan, Sr.GEORGE MARION COOPER, M.D.By The EditorIn the passing of George MarionCooper thousands upon thousands ofpeople felt a deep sense of personal loss.It is impossible to write about himwithout emotion. For more than thirtysevenyears he had been a wholetimepublic health physician. Even before hebecame health officer in his own SampsonCounty he had, as a practitioner,seen the dire need of his patients andhad been doing much in the field ofpreventive medicine. With this back-

January, 1951 The Health Bulletin 13ground Dr. Cooper felt the call to devotehis life to public health just asgenuinely as any minister of religionever felt the call to preach the Gospelof Jesus Christ. To Dr. Cooper the desireto save human beings from diseaseand the prolongation of their lives wasa compelling force. To this cause hededicated his life.When the history of public health inNorth Carolina is written it will be essentiallya biography of George MarionCooper. Public health was in its infancywhen he entered the specialty. Duringthe long period of service with the StateBoard of Health he witnessed muchgrowth and expansion. Early successesin the effort to reduce the prevalenceof infectious diseases resulted in a growingappreciation of public health, increasesin appropriated fimds, additionalworkers were recruited, moreproblems were attacked and new programsdeveloped. In fair weather andfoul—his was a stablizing and wholesomeforce. In most successful endeavorshe was a guiding and sustaining influence.When mistakes were made andthings went wrong it was frequently becausehis advice was not sought or wasignored. Although North Carolina hascontributed many illustrious names tothe Honor Roll of PubUc Health, Dr.Cooper's long career in North Carolinacaused many throughout the nation toconsider him as "Mr. Public Health InNorth Carolina."There will probably be some disagreementin selecting Dr. Cooper's outstandingqualifications. To those who readhistory his ability to make long-rangeplans would probably be placed first.It would require much research work tolist all of the programs which werestarted by him. Three of his early campaignsdemonstrate the range of hisplanning. Take the tonsil-adenoid clinicfor instance, the initial objective was, ofcourse, Ito cure the trouble caused by diseasedtonsils and adenoids, but the longrangeeffect was to educate the peopleas to the value of competent adequatelytrained medical specialists. Most of theolder. Eye, Ear, Nose and Throat physiciansin the State appreciate the firmfoimdations of public confidence builtby Dr. Cooper's early clinics. The DentalProgram, started in 1918 while Dr.Cooper was directing the School Healthwork, resulted in Dr. Cooper's electionas an honorary member of the StateDental Society, and laid the foundationfor the formation of the Division ofOral Hygiene in 1931. The OrthopedicClinics organized by him have smoothedthe way for thousands of crippledchildren for years past and will offerhope for the crippled children of thefuture. It is no wonder that orthopedicsurgeons were among the first to suggesta suitable memorial to Dr. Cooper.As Editor of the Health Bulletin fornineteen years, he established the formatwhich has become recognized as asymbol of North Carolina's Health Program.While other State Boards ofHealth have considered it advisable tostreamline their publications or to makethem into picture magazines, the HealthBulletin has remained, and with thehelp of a kind Providence will remain,a plain little publication with a simplemessage—told in plain straight-forwardwords and go to the 60,000 homes, officesand libraries of the State and Nationeach month.There is much in Dr. Cooper's life andrecord to remind one of the ApostlePaul. Dr. Cooper's thorn in the fleshwas deafness—it affected his life greatly—it deprived him of some honors thatmight have been bestowed upon him.He had a most remarkable memory,probably part of this intellectual attainmentwas due to inherent ability. Itwould seem, however, to those who knewhim intimately that a considerable degreeof his most accurate memory wasdue to his defective hearing. He converteda defect into an asset. Dr. Cooperhad courage, the courage to flght forthat which he believed to be right—thecourage to fight for those who could notdefend themselves, the courage to fightthose in high places who disregarded orwere unmindful of the rights of all to ahealthy existence. Dr. Cooper gave publichealth a sound doctrine—Like theApostle Paul—he fought a good fight,finished his coxirse,, and he kept the

14 The Health Bulletin January, 1951Faith. The torch lighted by ThomasFanning Wood passed on to Richard H.Lewis, to W. S. Rankin and to GeorgeM. Cooper still burns. Those who nowreceive the torch may not hold it ashigh or as steadily but they are solemnlydedicated to hold it tight and to endeavorto advance it without faltering.Some of Dr. Cooper's own editorialsin the Health Bulletin give a clear pictiureof what he considered the HealthBulletin should beNOTES AND COMMENTJanuary, 1939— "With this issue theHealth Bulletin enters it fifty-fourthyear, the present number being Number1 of Volume 54. It has thus completedfifty-three years of its monthly visits tothe citizens of the State of North Carolinawho are interested enough to writeand ask that it be sent to them.This issue goes into seventy-six countieswith organized full-time health departmentservice, either on a countyimit or a district basis, and in some instanceswith a city health departmentat the covmty-seat and a county healthdepartment fvmctioning for the county.The reader may compare the situationin this State now with reference to publichealth service with this month fiftyfouryears ago when Dr. Thomas FanningWood, the first State Health Officer,issued the first number. At that timethe total appropriation for the StateBoard of Health work was $2,000 annualy.Dr. Wood, of course, worked ona part-time basis and a part-time clerkin his office wrote out the script in longhandfor the first publication. Today inthese seventy-six counties, there aremore than five hundred full-time workers,including health officers, nurses,clerical help, sanitary inspectors andengineers, etc. This is exclusive of theState Board of Health oragnization andalso exclusive of the many full-timeemployees of city water departmentssuch as chemists and engineers. It is theconviction of this writer that no moneythat the State and the localities haveever spent has resulted in more benefitto the citizens than that of the healthworkers. Many of these workers are unknownto the general public, theirnames seldom occur in the State papers,they are not given honorary degrees bythe State's colleges, they are seldomever any of them elected to office of anykind. Many of them receive daily complaintsfrom citizens about trivial matters.Most of them take such patientlyand try to explain the purpose of theirwork and the protection that it affordsthe people. The Health Bulletin as amonthly reminder throughout all thesemore than fifty years has served tokeep before the people of the Statemany of the practical requirements ofpublic health practice. All of the contributorsand the editors who havemanaged the affairs of the Health Bulletinand who have tried to get it outmonth by month throughout the yearshave always had uppermost in theirminds the hope that they would be providinginformation that might enablepeople to know how to protect themselvesfrom preventable diseases anduntimely deaths. About 46,000 numbersgo out each month. As was pointed outsome time ago, the little publicationgoes each month to people living atnearly 1,400 out of the 1,500 post officesin the State, it goes into every countyand to some readers on almost everyrural delivery route in the State.The Editor is frequently encouragedin many imexpected ways. For example,sometime ago on a particularly blueMonday morning a card requesting thatsome special Uterature be sent to twoindividuals of a certain county was received.The card was dated at the particulartown mentioned simply "Simdaynight." It was sent in from a R. F. D.route and started off by saying: "DearEditor, I hasten to assure you that yourHealth Bulletin is profitably read bymany families who never write to sayso." Then went on to add the nameswhom they wished to receive the HealthBulletin in the future.It is pleasant to think that the ideaexpressed by the writer that the publicationmay be profitably read by fami-a fact.lies who never write to say so isAnyhow, it is hoped that that is a fact.An effort is always made in every Issue to

January, 1951 The Health Bulletin 15try to publish at least one article carryinginformation which would be helpful toany reader. That idea has been the keyeffort running through every issue ofthe publication for many years. It ispleasant to know that there are readerscomprising hundreds of young peoplewho have set up housekeeping and whoare now rearing families of their ownwhose parents received the Health Bulletinthrough the years and duringwhich time the young folks became interestedin the material published.In the beginning of this new year, itseems to many people that there aremore problems confronting the worldthan at any time since the close of theDark Ages. The complexities of modernlife and the strain of living today putsgreater stress on the nervous system ofthe average individual than probablyever before in the history of the world.It Is more necessary today to takethought of the physical, mental andmoral health of the individual and ofthe public than ever before. On theother hand, more protection againstpestilential diseases is afforded the peopleof the world today than ever before.In the past, great plagues such as yellowfever, bubonic plague, smallpox andother epidemic diseases have decimatedthe population of the world. It varies inthe opinion of some historians to theextent of as much as 50 per cent of thepopulation of the world at one time.With the exception of influenza, towardthe control of which little progress hasbeen made, the great cities and thicklypopulated sections of the world are inlittle danger. All of this is due directlyto the protection afforded by the scientistsand active workers in the publichealth field.In the year that the Health Bulletinwas first published, it was the commonrule in North Carolina for every familyto have typhoid fever among some of itsmembers before the children of thefamily reached maturity, and it hasbeen estimated that at least one out offour members of the average familydied of the disease before all the otherchildren reached matiu-ity. The averagefamily lost a large per cent of thechildren born as a result of the diarrhealdiseases of childhood beforereaching the end of the first year oflife.There is a long way to go in the fieldof prevention of disease before theState reaches the position it ought tooccupy as one of the low mortalityStates, in the matter of infant deathsand deaths from such diseases as diphtheria.Diphtheria can and should becompletely prevented, but in the faceof that fact the State has had a higherdeath rate from diphtheria and a highercase rate during the last two or threeyears than most of the other States. Inthe field of total infant deaths, it hashad a little better record, but not much.The discouraging feature of the pastyear's work has been that infant deathshave not continued the downward trendstarted the year before, but apparentlya larger number have occurred thanoccurred in 1937, although completeand accurate data are not yet available.It is with confidence that the facesof public health workers in this Stateare set toward the future, and it ishoped that the new year will result ingreater progress in public health workthan ever before in the history of theorganization."NOTES AND COMMENTJune, 1939—"On the front cover thismonth, we are publishing a picture ofthe old Dr. Thomas Fanning Woodresidence, 201 Chestnut Street, Wilmington,North Carolina, where the StateBoard of Health oflBce was first set upand operated for many years, and wherethe first issue of the Health Bulletinwas published. That issue was April,1886, 53 years ago. This picture was intendedfor the April issue of the HealthBulletin as an anniversary number, butillness of the editor prevented its appearingat that time.As stated once or twice before inthese columns, the Health Bulletin wasfounded by Dr. Wood while Secretaryof the State Board of Health and issuedregularly month by month from theOflBce of the Board of Health which was

16 The Health Bulletin January, 1951his private office in Wilmington. Thepublication continued regularly until hisdeath in August, 1892.Not long ago, the editor had the privilegeof visiting in the home where Dr.Wood's two daughters, Misses Jane andMargaret Wood still live. They showedthe editor the very room from whichthe Bulletin was issued through theyears, from April, 1886 until his deathin August, 1892. They informed the editorthat Dr. Wood had associated withhim a young physician at that time bythe name of Dr. Robert Jewett who assistedhim in doing some of the writingand the routine work of the office. Theysaid that Dr. Jewett was still living inretirement at his home on GreenvilleSound in New Hanover Coiinty. OnMay 6, the Associated Press announcedfrom Wilmington that Dr. Jewett haddied that morning at the age of 79.As stated above, the Health Bvilletinwas founded by Dr. Wood and his advisersamong the membership of theState Board of Health. With just a fewalterations, the size and general appearanceof the publication is the sametoday as it was the first issue. It isslightly larger and about twenty yearsago, the present management of theHealth Bulletin made some improvementsin the title page and In page 3,which has been carried as changed eversince.Dr. Wood was made Secretary andthe first State Health Officer followingthe creation of the State Board ofHealth by the Legislatvure in 1877. Dr.Wood was at that time practicing medicinein Wilmington. He was coming tobe a botanist of national reputationwhich he carried on as a hobby. He hadalso founded and conducted for severalyears up to that time the North CarolinaMedical Journal, now known asSouthern Medicine and Surgery andpublished in Charlotte. Sometime afterDr. Wood's death. Dr. Jewett obtainedcontrol of the North Carolina MedicalforJournal and owned and published itsome foiu" or five years, when it wassold to Dr. Dickson Register, a native ofDuplin County who was practicingmedicine in Charlotte and coming to beat that time a widely known physician.At Dr. Wood's death, however, Dr. R.H. Lewis of Raleigh succeeded him asSecretary and State Health Officer andimmediately moved the office of the IState Board of Health from Wilmington.to Raleigh. The Bulletin has been issuedmonthly from Raleigh ever since. Dr.Wood and Dr. Lewis were both, ofcourse, part time State Health Officers.The two of them combined served formore than thirty years in the office.The first announcement of the publicationof the Health Bulletin wasmade at the Conjoint Session of theNorth Carolina State Board of Healthand the North Carolina State MedicalSociety at New Bern on May 20, 1886.Dr. J. W. Jones of Tarboro was presidentof the North Carolina State Boardof Health and in his annual report t»the Conjoint Session made the officialannouncement of the founding of theHealth Btilletin in the following languagequoted from the transactions of theNorth Carolina State Medical Societyfor that year. The record of the HealthBulletin for the following fifty yearsmust accord to Dr. Jones a place asa major prophet. But with what sacrificein time and labor only a few menknow!Dr. Jones: "Gentlemen of the MedicalSociety and the State Board of Health:Prom time to time and little by little,we have gotten the ports of the NorthCarolina Board of Health together. Weoccupy it. It is in motion ...."The North Carolina Board of Health,organized and equipped in all it departments(a part time State Health Officer,a part time stenographer, and a totalannual appropriation of $2,000!—Editor),with a monthly Bulletin of Health,through which we may communicate,correspond, and instruct, unites in ConjointSession with the North CarolinaMedical Society, to exchange views andpurpose plans that shall best advanceour common work of making our peoplehealthier, happier, wealthier and wiser.

MEDICALLIBRARYU. OF N, C .CHAPEL HILL. N. C.TIT^I TKis Bulletin will be sent free to dni| citizen of fKe 5fai-e upon requesi IPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 66 FEBRUARY, 1951 No. 2^gSgSiLake at Airlie Azalea Gardens, Wilmington, North Carolina

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. DncoN, M.D., President AydenHubert B. Haywood, M.D., Vice-President RaleighH. Lee Large, M.D Rocky MountJohn LaBruce Ward, M.DAshevilleJasper C. Jackson, Ph.GLumbertonMrs. James B. Hunt Lucama, Rt. 1John R. Bender, M.DWinston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and Director State Laboratorj^of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S. , Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionC. P. Stevick, M.D.. M.P.H., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any inwhich you may be interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitis Infantile Paralysis Typhus FeverCancer Influenza Venereal DiseasesConstipation Malaria Residential SewageDiabetes Measles Disposal PlantsDiphtheria Pellagra Sanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFlies Teeth Whooping CoughTuberculosisEpilepsy, Feeble-mindedness, Mental Health and Habit TrainingRehabilitation of Psychiatric PatientsThe National Mental Health Act.SPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal Care.First Four Months.Prenatal Letters (series of nine Five and Six Months.monthly letters).Seven and Eight Months.The Expectant Mother. Nine Months to One Year.Infant Care.One to Two Years.The Prevention of Infantile Two to Six Years.Diarrhea. Instructions for North CarolinaBreast Feeding.Midwives.Table of Heights and Weights.Your Child From One to SixBaby's Daily Schedule.Your Child From Six to TwelveGuiding the AdolescentCONTENTSAqua PuraToday's Community Concept Of School Health^5"These Little Ones" 8Notes and Comment 11Page

1 ingmilPUBLISAED BYTAE N^A CAROLINA STATE B^ARD-^AEALTAI BVoL 66 FEBRUARY, 1951 No. 2J.W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorAQUA PURABy William H. RichardsonRaleigh, North CarolinaThe progressive action by which thecitizens of Raleigh recently voted fundsfor the erection of a sewage disposalplant and the improvement of the publicwater supply, has focused attentionupon water in its various uses and itsassociation with Public Health.Water is one of the most important,and sometimes neglected, substancesused in helping to sustain life. Whenyou woke up this morning, you brushedyour teeth, washed your face and hands,and, perhaps, drank copiously of refreshingcold water from your faucet.The purposes for which water is usedare very numerous. First, we consumeit as something necessary to our healthfulexistence. We use it for generatingelectricity for power and light, for bearcommerce,and for various otherpurposes. We not only use water tocleanse the body, but the ChristianChurch uses it, sympolically, to cleansethe soul. Water plays a prominent partin certain purification rites in other[re-1 ligions.No greater calamity can befall a cityor community than a water shortage orfamine. We are giving much attentionnow to the preservation, or reconstruction,of our drinking water supplies, in«case of atomic attack. We are also devisingways and means of protectingthe population against mass slaughter,through germ warfare upon our watersupplies. There is pending in the presentLegislature a bill designed to correctstream pollution.So much by way of introduction.When you drink a glass of water, doyou think about the processes throughwhich it has passed on its way fromthe source, out yonder somewhere, toyour stomach? Have you ever visitedyour local water shed, or inspected theprocesses through which the water ispurified in order that you may be protectedagainst water-borne diseases.And have you ever considered the yearsof scientific training required of thewaterworks operator, and the importantresponsibility you have placed upon himto make sure you are getting a safewater supply? Just what does happenbetween source arid stomach?The State Board of Health maintainsa division called the Sanitary EngineeringDivision, which is vitally interestedin your water supply, and throughwhich services are performed aboutwhich you may know little or nothing.For the answer to the question, "Whathappens to drinking water, from sourceto stomach?" let us consult one of thosein the Division above referred to who isconcerned with that form of public servicewhich guarantees you a pure watersupply and consequent protection againstdisease.Two Primary SourcesThere are two primary sources fromwhich our public water supplies must

The Health Bulletin February, 1951be derived. These are surface sources,such as lakes and streams, and undergroundsources that are brought to thesurface through man-made wells ornatural springs. Most public suppliesare, because of the large volume requiredto supply communities, taken fromrivers and creeks, which often are impoundedto form large storage lakesin fact, all of the major ones come fromsurface sources.To the average individual, it may appearquite difficult to pump water froma river or creek and so treat it that itwill be safe and palatable for use byhuman beings. Frankly, it is not asimple task; however, developments inthe science of water treatment, broughtabout by extensive study and researchon the part of sanitary engineers, scientistsand the medical profession, haveresulted in the perfection of processes,equipment, and knowledge of chemistryand bacteriology which make it possibleto satisfactorily purify surface water forhvunan consumption.emphasized that a word of cau-It istion is proper at this point. Surfacestreams which are overly-polluted, bydomestic sewage or industrial wastes,either cannot be satisfactorily treatedor the cost of treatment is prohibitive.In view of this, it is liighly desirablethat every water consumer, and polluteralike, put his shoulder to the importantand necessary problem of properlymaintaining streams used as sources ofwater supply in North Carolina, in suchcondition as to permit their presentand future use for this purpose.In many instances, the authority forthis article points out, surface streamsconstitute the only adequate sources ofpublic water supplies. The supplies derivedfrom underground sources areobtained either from springs or wells.Water from wells and springs ordinarilyis clear and satisfactory, without treatment.Nevertheless, in some cases, undergroundwater contains minerals dissolvedfrom the water strata whichimpart either hardness, iron or othermaterials that make it undesirable fordomestic use. In such cases, it must betreated by certain processes well knownto the waterworks profession.Harmful Substances RemovedThe fact that most public water suppliesare obtained from surface soiu-cesmakes it necessary that the water betreated for the removal of substanceswhich cause turbidity, color, or undesirableodors and taste.Treatment also must be provided toremove the harmful bacteria, thus providingfor your use and well-being aclear, sparkling, safe water.In the course of water purification,the treatment processes usually beginwith the storage of water in lakes orreservoirs. Following storage, the wateris pumped to modernly-designed andefficiently-operated plants where limeand alum are added and thoroughlymixed with the water, in specially designedmixing and coagulating basins.A gelatinous floe is formed in thesechambers, which enmeshes the mud,color bodies and many of the bacteriain the water, which, when permittedto settle in the sedimentation basins,leaves the water clear. It is then passedthrough sand filters to remove any remainingfloe and turbidity, followingwhich chlorine is applied to kill allharmful bacteria which may have survivedthe previously mentioned treatmentprocesses.But, the foregoing does not tell theentire story of the preparation andcare that goes into the work of providinga safe and palatable water supply.Even after clarification and disinfection,water, being a luiiversal solvent,must be treated to prevent corrosion ofthe distribution system, which, if permitted,results in "red water" that willstain the lavmdry and the porcelainfixtures of the bathroom and kitchenand will produce unpleasant odors andtaste.The above information has been givenin an effort to better acquaint the consumingpublic with the preciseness towhich water works operators must adhereand to the innumerable scientificdetails which are involved in producing

February, 1951The Health Bulletina water supply that is both safe andsuitable for your use.The information presented in thisdiscussion, which is designed to emphasizeone of the many services PublicHealth renders, was obtained from Mr.Earle C. Hubbard, Principal SanitaryEngineer, in the Sanitary EngineeringDivision of the State Board of Health,whose duties involve supervising the designand operation of public water andsewerage systems, and advising municipaland institutional oflBcials and theirengineers regarding the type of facilitiesand water works materials neededto provide safe and adequate supplies.Approved Plants SafeIn conclusion, Mr. Hubbard statedthat water from all approved publicsupplies in North Carolina may be consumedwith a feeling cf uerfect safety,because of the long -icUxS and hardwork of those public officials whose dutyit is to see that water offered for publicconsumption is safe. So, turn on yourspigot and have a drink to the healthof those who look after your water supplyand do not forget to let them knowthat their efforts are appreciated.This article is designed to give informationon what your State Board ofHealth is doing to protect you and yovursagainst those illnesses which are preventableand the conditions which bringthem about. If you should ask yourfamily physician to name the waterbornediseases to which you would besubject without a safe and pure watersupply, his answer would include manywhich now occur only in rare instances,because of the fact that we have madesuch advances in the science of sanitation.The responsibility involved in theprotection of your drinking water isonly one of many which fall upon theshoulders of the Sanitary EngineeringDivision. This Division not only supervisespublic water supplies as to theirsanitation, but also is concerned withenvironmental sanitation, the inspectionof public eating places, milk, beddingand shellfish. It also has sectionswhich are concerned with insect androdent control. Many of the servicesperformed by this Division of the StateBoard of Health are so routine thatthey are taken for granted. While thepersonnel of this Division is non-medical,in the generally accepted term, theywork under the direction of the medicalmind, even as all other enlisted inthe service of Public Health.TODAY'S COMMUNITY CONCEPT OFSCHOOL HEALTH*Davh) Van deb Slice, M.D.,** Coordinator of Health ServicesOakland Public SchoolsGreat strides have been made inschool health in the relatively shortperiod since 1894, when the first schoolhealth program in the United Stateswas established in Boston. In those dayspublic schools were "hotbeds" of contagion,"and it was not uncommon forschool doctors to find children withdiphtheria, whooping cough or scarletfever in the classroom. The positionthat health occupies in the schools todayis the result of an evolutionary processwhich can be roughly divided intofive stages:Stage I was characterized by an effortto detect and exclude those pupilswho, because of communicable disease,threatened the welfare of others.In Stage II there was added the responsibilityof finding pupils with physi-•Reprinted with permission from California'sHealth.••Prior to his appointment by the OaklandPublic Schools in August, 1950, DoctorVan der Slice served for two and one-halfyears as School Health Consultant for theCalifornia State Department of PublicHealth. This article was prepared duringthat period.

6 The Health Bulletin February, 1951cal defects, and of taking steps to securecorrections.Stage III was marked by a growingconsciousness that health activities werecarried out not only for corrections butfor educational values as well.Stage IV was marked by an expansionof Stage III, and included such conceptsas: (a) all teachers are healthteachers, (b) personal health includesphysical, mental and emotional health,(c) the health program concerns itselfwith community as well as personalhealth, (d) health education is a 24-hour-a-day program—365 days a year,and involves the cooperation of thehome and community agencies as wellas the schools.Stage V, the present one, is marked bya growing realization on the part ofschools, health departments, professionalgroups and community organizationsof their interdependence in carrying outthe school health program. They recognizethat each has a contribution tomake and that no one of them can dothe job alone.Each advanced stage has included thebest of the practices and experiencesgained from earlier stages.School health programs have steadilyincreased in breadth of services andcomplexity of organization. Forty yearsago all health responsibility in theschool was assumed by the doctor orthe nurse, but this is not the case today.Today the job is shared with teachers,parents, dentists and dental hygienists,psychologists, psychiatric socialworkers and psychiatrists, healtheducators, counselors, students andothers. This has required the setting upof machinery within the school for coordinatingefforts of various professionalworkers and groups involved in theschool health program. This has usuallytaken the form of a school health committee,a health coordinator, or both.The modern school health program.to be most effective, must also be inproper relationship to oth.^r communityprograms of public health and childwelfare. The idea that tl:i school healthprogram should be an isolated endeavor,operating apart from the rest of thecommunity is being strongly challenged.There is a growing acceptance of thefact that, in general, the school child'shealth reflects the foundation of hishealth laid during the preschool years,the health of his family and the adequacyof health facilities in the communityin which he lives.Parents have the primary responsibilityfor the health of their children.How well the family meets its responsibilityin relation to providing food, ,rest, recreation, and medical and dentalservices, plus a healthful environment,is a highly important factor in relationto the child's health status. The job ofthe school health worker is to helpmotivate the parent to carry out responsibilitiesof the home and to stimulatecitizens to provide necessary communityfacilities.Today's community concept recognizesthe advantages of integrating schoolhealth services with community healthservices, of promoting the health ofparents, especially mothers during theprenatal period, and of providing continuedhealth supervision during infancy,childhood and adulthood.Not only do community health programactivities affect the school child,but the family health status Ls frequentlyinfluenced through the schoolhealth program. For example, a nurseparentconference or a medical examinationat school may reveal a familyhealth problem of greater significanceand urgency than the child's healthproblem alone. Clearly, solution of afamily health problem also benefits thechild.On every hand there is evidence ofthe ever-increasing interest and activityin school health work, not only byschools and health departments, butalso by parent groups, medical anddental societies and other communityagencies.Two years ago the National Congressof Parents and Teachers asked theHouse of Delegates of the AmericanMedical Association to request statemedical societies to appoint committeesor arrange for representation in conferencesin the .several states betweenmedical societies, dental societies, healthdepartments, educational agencies and

February, 1951The Health Bulletinthe National Congress of Parents andTeachers, looking toward the improvementof health services and health educationfor school children. The AmericanMedical Association demonstratedits interest by calling two conferences,one in 1947 and the second in 1949, todefine the role of the practicing physicianin the school health program.FYom these conferences came recommendationsthat every local medicalsociety should appoint a school healthcommittee to study ways in which thephysician's time may be used more effectivelyin the schools. Several localmedical societies in California have alreadyappointed school health committeeswhich are cooperating with theschools in the development of the schoolhealth program.Another promising development inrecent years has been the increase incooperation between schools and healthdepartments in relation to the schoolhealth program. Most states now haveformal plans for cooperation betweenstate health departments and state departmentsof education with respect toschool health programs. In Californiathe closely related work of the StateDepartments of Education and PublicHealth in their responsibilities for thehealth of the school-age child is coordinatedthrough the California StateJoint Committee on School Health.On the local level, an increasing numberof county and city joint schoolhealth councils are being formed inCalifornia. Some have been initiated bythe schools, others by the local healthdepartment. While council representationvaries, it usually includes schooladministrators and teachers, membersof the school health staff, health departmentrepresentatives, parents, representativesof medical and dentalsocieties, voluntary health agencies andother community organizations with aparticular interest in child health.The school health council facilitatesjoint program planning and the formulationof policies to guide the schoolhealth program. Fullest use of communityresources is possible only whenthere is joint planning and active participationof many different communitygroups.Joint planning, with a sharing of responsibilitiesfor different aspects of theprogram, has become a more and morecommon practice, particularly in ruralareas where neither schools nor healthdepartments have sufficient staff or resourcesto carry out an adequate programalone. A division of responsibilitiesand a sharing of personnel betweenschools and health departments makespossible the fullest utilization of existingfacilities and permits the best useof professional skill and time. Almostuniversally, both schools and healthdepartments are under-staffed and cannotafford to use the time of their personnelfor any but the most essentialand most productive activities. Theycaimot afford the luxury of duplicatingservices.However, there are many communitiesin which this fine working relationshipand this spirit of cooperation, which isso conducive to developing the best typeof school health program, do not prevail.Although school health policiesof a general nature have been formulatedand approved by many nationalhealth and education organizations forat least 10 years, and are now wellestablished, they affect school healthpractices in all foo few local areas.Joint planning of school health programswould give an opportunity to reviewand discuss these policies in termsof how well they are fitted to localsituations and to apply those which areworkable.Joint planning opens the way to acritical analysis of the total schoolhealth program with a view of determiningwhat the needs are and thendeciding how best they can be met regardlessof what the traditional patternhas been. Some of the patterns inuse today were established at the turnof the century and do not take intoconsideration the newer knowledge concerningthe growth and developmentand the behavior of children, nor dothey recognize improved school healthmethods and practices, which have demonstratedtheir worth.There have been many recent ad-

8 The Health Bulletin February, 1951varices in school health, such as: (1)the increased participation of the classroomteacher, (2) improved schoolhealth records (which more fully utilizethe contribution of the teacher, nurseand physician), (3) improved screeningdevices to select pupils with probablevision defects and hearing losses, (4)greater participation by practicingphysicians, (5) fewer but more thoroughmedical examinations giving priority toreferred cases and new entrants, (6)the establishment of otological, cardiacand other diagnostic facilities whichprovide a more accurate diagnosis ofpupil health problems, and (7) establishmentof more adequate special educationfacilities for children with handicappingdefects.Despite these examples of progress,many of the answers pertaining to theschool health program are still unknown.There is a great need for experimentation.For example, there are greatgaps in our knowledge concerning aproper secondary school health program.There is a need for trying newmethods in an attempt to find out whatworks and what doesn't work under today'sconditions. Continual programevaluation is needed in order for us tomodify our activities and to make themmore successful, retaining things thatprove to be effective and dropping thosewhich prove ineffective.#/THESE LITTLE ONES"By William H. RichardsonRaleigh,North CarolinaThe challenge given by the Master,"Isasmuch as ye have done it unto oneof the least of these, my brethren, yehave done it unto me," has come downthrough two thousand years of historyas an inspiration to those who wouldhelp the weak, especially, little children.North Carolina's Public Health Programhas been characterized by manyhelpful and worthwhile undertakings;but none of these, perhaps, has beenmore synonymous with the spirit of theGreat Physician than the program designedto find, treat and rehabilitatechildren who, otherwise, might constitutea burden on society and go throughlife with a feeling of futility and a senseof their deformity.The Crippled Children's Section ofthe State Board of Health is a monumentto the untiring efforts of the lateDr. George M. Cooper, under whosedirection this program was organized,in April 1, 1936, following the availabilityof Federal Social Security funds. Dr.Cooper, in his administration of theprogram, spent many sleepless hours,taxing his wits as to how the workmight be continued. There were timeswhen he was almost, but not quite, discouraged.Even though it was necessary,often, to scrape the bottom of the barrelfor money with which to carry onthe program, Dr. Cooper usually founda way.Let us consider, now, the way inwhich this program for these little onesis conducted. First, the child in need oftreatment is located, usually by theLocal Public Health nurse, or the familyphysician.Conditions For AcceptanceThe list of conditions which are acceptedby the Crippled Children's Sectionof the State Board of Health maybe outlined as follows: Congenital ab-;normalities, including harelip, cleftpalate, dislocation of hip, club feet,missing or extra bones. Birth injuries,also, are included, as well as tuberculosisof the joint, rickets, poliomyelitis,arthritis, osteomyelitis — which meansinfection of the bone—, curvature ofthe spine and burns.If the child is found to be in needof hospitalization, after passing throughone of the clinics, and if the parents say

Febriuiry, 1951The Health Bulletinthey are unable to pay for the servicesneeded, application is made to the localwelfare board, which investigates thecase in question. If the child's parentsare found to be actually unable to pay,the case is certified and the child isplaced in a hospital. If the parents areable to pay all or part of the expensesincurred, an effort is made to work outa satisfactory plan for treatment.It might be well, just here, to considerthe number of clinics conducted bylocal health departments, in cooperationwith the State Board of Health and theDepartment of Vocational Rehabilitation.There are, at the present time,twenty-eight clinics, so well distributedthat each child is within sixty miles ofone of these. Taking part in the program,besides the local Public Healthstaffs, are thirty-one physicians. Theseinclude orthopedic surgeons, plasticsurgeons and pediatricians. A reportrecently prepared by the CrippledChildren's Unit shows that 11,998 examinationswere done in 1949. There were,at the last count, twenty thousandchildren on the State register.In requesting a State appropriationof one hundred thousand dollars a year,it was pointed out to the legislative appropriationscommittee that there areno existing State funds to finance surgicalcare of indigent children, withcleft palates, congenital defects, deformitiesfrom burns, and orthopedic conditionsin hospitals other than the StateOrthopedic Hospital. This hospital, locatedat Gastonia, does not have facilitiesfor all these conditions and doesnot have the capacity for all of the indigentchildren needing care for problemswhich it is equipped to handle.There have been over three thousand,five hundred cases of polio in our Stateduring the past four years. This, ofcourse, has increased the necessity fororthopedic treatment.Funds Once ExhaustedFunds from all sources were exhaustedin 1949 and the work was stoppedduring the last quarter, except foremergencies.The State Board of Health asked aone hundred thousand dollar annualappropriation by the State in matchingFederal funds for the next biennium. Itis pointed out that this may mean anadditional three hundred thousand dollars,annually, from Federal funds.Hence, this would be a sound investment,aside from the humanitarianaspects of the program. No State matchingfunds, conceivably, may mean noState Board of Health Program forCrippled Children.Now that we have considered themechanics of the program and havepointed out the desirability for adequatefunds, let us consider some of the actualwork which is done for these little ones,to set their feet in paths of usefulnessand to hold before them, as they growup, incentive enjoyed by their physicallyfit companions and school mates.Authorization for hospitalization entitlesthe child not only to treatment,including both orthopedics and plasticsurgery, but to braces, crutches, casts,orthopedic shoes, and other correctivedevices. Plastic surgery corrects deformitiesfrom burns, harelips and thelike. When the child leaves the hospital,it is subject to a follow-up program,during which systematic visits are madeto the home, to see that the orthopedicrecommendations are being carried out.From Birth to 21Most of the clinics are held in localhealth departments and all personsfrom birth to twenty-one years of ageare eligible. Incidentally, it may bepointed out that 1,253 children whoneeded treatment in 1949 did not receiveit, because of inadequate funds.Of the polio victims, many still arein need of surgery. There is more humaninterest, both concealed and visible,in the rehabilitation of childrenthan in almost any other humanitarianproblem confronting the American people.When a child is born into thisworld, it comes not of its own accord,but "of the will of the flesh." It mustaccept conditions under which it isborn, without recourse, and with noremedial measures at its command.Such children often are doomed to livesof hopelessness and their spirits compelledto live in bodies that are distorted

10 The Health Bulletin February, 1951and deformed, which could be madenormal, in a vast majority of instances,through modern orthopedic and plasticsurgery.The matter of Crippled Children constitutesnot only a Public Health problem,but a stern public responsibility.We spend many thousands of dollarsevery year on methods designed to improveour crops and our farm animals.All this is necessary, of course, but ofhow much more value is a baby boy orgirl than a baby cow or pig ! Within thememory of those now living in thepresent generation,bovine tuberculosishas been conquered in cows; throughvaccination, hog cholera has been attacked,with success. As a result, wehave better cows, which mean moremoney for their owners; we have betterhogs, which means more money formeat; we have better peanuts to feedthe hogs, because the Governmentguarantees the price of peanuts.Science Works WondersWe now see fewer deformed children,than in the past, it seems, but that isdue to advances in plastic and orthopedicsurgery; to Federal funds and, insome instances, to contributions fromprivate philanthropic agencies, such asthe National Foundation for InfantileParalysis, and the North Carolina Leaguefor Crippled Children.If you live in a county where anorthopedic clinic is held, it would payyou to visit the clinic and see just whatis being done for the unfortunate childrenof the State.The program for crippled children hasbeen underway now long enough forsome definite results to be evident.Many children who, but for this treatment,would never have been able touse their hands and feet, have beentrained to become men and women withuseful trades, following their physicalrehabilitation. Some are shoe makers.some are operators of various machines,while others have learned to be radiorepairmen and even watch repairmen.Pictures have been taken of childrenwhen treatment began, when their deformitieswere very pronounced. Later,pictures of the same children revealthat orthopedic and plastic surgerycould and did restore these childrenalmost to a normal appearance.If one should think of a crippledchildren's clinic as a scene of gloom anddespair, this would be an entirely erroneousconception. When those in needof orthopedic and plastic repair workare taken to a clinic, every effort ismade on the part of those in charge todispel any fear or misgivings on thepart of the child. If they are hospitalized,the surroundings during treatmentare made as bright and cheerful asthose in any home, insofar as is humanlypossible.Plenty of IncentiveIt is no wonder that the State Boardof Health ismaking every effort to securea yearly investment by the Stateof one hundred thousand dollars, inorder to meet the requirement thatFederal funds be matched. It is notalways easy to secure appropriations,with so many demands being made onthe public treasury, but experience invariablyhas shown that money investedin building up wrecked lives has paidgood dividends. Once the crippled children'swork is given adequate funds andthe results demonstrated, there is littlelikelihood that these will be denied inthe future. Already, a remarkable recordhas been made by the CrippledChildren's unit and those agencieswhich cooperate with it. Progress hasbeen difficult, at times, and the wayahead has been uncertain, but surelysuccess must crown the efforts of thosewho are trying so earnestly to re-buildthe lives of these little ones.

February, 1951 The Health Bulletin 11NOTES & COMMENTBy The EditorDR. ELLIOT—On February 1st Dr.A. H. Elliot joins the staff of the NorthCarolina State Board of Health as theDirector of the Division of PersonalHealth. Since 1931 Dr. Elliot has beenHealth Officer for the ConsolidatedBoard of Health for the City of Wilmingtonand New Hanover County. Heis known throughout the State as agood health officer. His program in NewHanover County was well balanced andincluded most of the activities whichare generally recognized as good publichealth procedures. Practically all of theactivities considered to be a part ofthe responsibilities of the Division ofPersonal Health are component partsof Dr. Elliot's program as a CountyHealth Officer. He will, therefore, befamiliar with the broad phases of thework which he will confront in his newcapacity. In succeeding the late Dr.George M. Cooper as the Director ofthe Division of Personal Health, has adifficult assignment. However, those ofus who know Dr. Elliot have every confidencethat he will do a creditable job.• * * *TUBERCULOSIS STATISTICS—Weare including in this issue of the Bulletinthe vital statistics of tuberculosiswhich ordinarily would have appearedin the November issue. We hope thatour tardiness in publication of this informationwill not detract from the interestwhich this important informationshould command.* • * •REPORT ON STUDY OF REGIONALBLOOD GROUP DISTRIBUTIONSThe blood type of 141,774 men andwomen who voluntarily contributedblood to the American Red Cross fromJanuary 1948 through March 1949 isthe subject of a report in the Journalof the American Medical Association.The information was gathered from15 representative cities and their outlyingareas. The regions includedYakima, Wash.; Rochester, N. Y.: Detroit;Massachusetts (^42.3 degrees latitudenorth); Omaha; Columbus, O.;Washington; St. Louis, Stockton, Calif.;Wichita, Kan.; San Jose, Calif.; Springfield,Mo.; Charlotte, N. C; Los Angelesand Atlanta.The total percentage of persons fallinginto each blood type from all 15regions was as follows: O blood group,45.55 per cent; A, 40.77 per cent; B,9.96 per cent; and AB, 3.72 per cent.The O type blood can be used in alltransfusions regardless of blood typeof the recipient."In the event of an emergency requiringlarge quantities of blood," thereport said in part, "the southern areasnow appear to be comparatively favorablesources of O and the northernareas of B."The results showed, to some extent,that for each degree of latitude proceedingfrom north to south the Ogroup percentage increased, on theaverage, .32 per cent. Prom north tosouth the B group percentage decreased.17 per degree of latitude. No east-westtrends were discovered.The report brought out that from regionto region the greater the O, A or Bpercentage, the smaller on the averagewas the percentage for the remaininggroups within the trio, but AB group"tended to be stable."In conclusion the report said that"population changes could be responsiblefor marked changes (in regionallocation of blood types) within thespan of a very few years."Associates of the American Red Crosswho made the study were: George W.Hervey, Sc.D.; Dr. Louis K. Diamondand Virginia Watson, M.S., of Washington,D. C.* * • *AMERICAN HEARING SOCIETY817 14th St., N. W.Washington 5, D. C.Kenfield Memorial ScholarshipIn 1937 a sum of money was subscribedin memory of Miss Coralie N.

12 The Health Bulletin February, 1951Kenfield of San Francisco, California,a teacher well known throughout theUnited States for her high ideals andadvanced methods in teaching lipreading.This money, placed in the KenfieldMemorial Fund, is administered by theAmerican Hearing Society and providesan annual scholarship. The amount ofthe Kenfield Memorial Scholarship for1951 is one hundred dollars ($100.00).Applications for the scholarship willbe considered from any resident of theUnited States who desires to teach lipreading(speechreading) with or withoutother types of hearing and speechtherapy, and who can meet the followingrequirements:A. PersonalWell adjusted individual witha pleasing personality, legiblelips, a good speech pattern andno unpleasant mannerisms.B. EducationCollege graduate with a majorin education, psychology, and/or speech. If the applicant ishard of hearing, 30 clock hoursof private instruction under anapproved teacher of lipreadingor 60 clock hours of instructionin public school classes underan approved teacher of lipreadingare required.The winner of the scholarship maytake the Teacher Training Course fromany normal training teacher or schoolor university in the United States offeringa covurse acceptable to the Teachers'Committee of the American HearingSociety. The scholarship must be usedwithin one year from the date theaward is made.Applicants must be prospective teachersof lipreading to the hard of hearing.Those already teaching lipreadingcannot be considered.Applications must be filed betweenMarch 1 and May 1, 1951 with:Miss Rose V. FeilbachChairman, Teachers' Committee1157 North Columbus StreetArlington, VirginiaPLANS ANNOUl^ICEB FOR RAISINGFUNDS FOR MEDICAL SCHOOLSAnnouncement was made of theformation of the American MedicalEducation Foundation, a not-for-profitcorporation vmder Illinois laws, to raisefunds from the medical profession toaid medical schools.The fund, initiated by a contributionof a half-million dollars voted by theBoard of Trustees of the AmericanMedical Association in December, hasbeen widely acclaimed as one of themost constructive programs ever imdertakenby the A.M.A."The medical schools of the UnitedStates stand in need of additionalfinancial support if they are to continueto provide the American peoplewith physicians second to none in thequality of their education and training,"said Dr. Elmer L. Henderson of Louisville,president of the A.M.A."Since the tremendous advances in thehealth of the American people in thelast 50 years have been due in largemeasure to the great improvements inmedical education during the same period,it is clear that insuring adequatefinancial support of our medical schoolsis vital to the present and futvu-e healthof the nation."In annoimcing the formation of thefoundation, the Jovu*nal of the A.M.A.urged the doctors of the nation to contributepromptly and generously."It is plarmed that the foundationwill coordinate its activities closely withother major efforts to raise funds formedical education from voluntarysources which it is hoped will be announcedshortly," said the Journal."Because of rising costs, inflation,fewer large individual benefactions andreduced income from endowments, themedical schools need, without furtherdelay, assistance of the type this fundcan give."It is the desire of the foundationthat the first annual disbursement offunds to the medical schools be madethis spring. It is clear that if the foundation'scontribution is to be an effectiveone, a substantial fund must be

February, 1951 The Health Bulletin 13raised by the medical profession withinthe next few months."The Journal further pointed out thatalmost every physician now practicingreceived his medical education for lessthan what it cost his medical school.It added that many physicians havedischarged this debt to society in full orin part by public and charitable activitiesand by donations to the schoolswith which they have been associated,but continued:"The medical profession has traditionallyaccepted a large measure of responsibilityfor the training of the continuingflow of young physicians, onwhich it must depend for recruits andreplacements in its efforts to servehumanity."It is to be expected, therefore, thatall physicians regardless of the othercontributions they have made to society,will want to share in the responsibilityof making the foundation a success."The American Medical Associationhas indicated its belief that the possibilitiesof securing adequate supportfor medical education from voluntarysources are far from exhausted."• « • *REPORT AIR TRANSPORTATIONOF MOST PATIENTS POSSIBLEA study of the effects of air travel on14,000 patients moved by the MilitaryAir Transport Service between Januaryand October 1949 shows that almost allpatients suitable for transportation byother methods can be transported successfullyby air.Colonel Benjamin A. Strickland, Jr.,of the U. S. Air Force Medical Corps,and Dr. James A. Rafferty, RandolphField, Texas, said in the Journal of theAmerican Medical Association that airtransportation of patients proved "sosuccessful" that it has been adoptedas the "sole method" of moving patientsfor the armed forces.This report is valuable to civilians aswell as military personnel."Today," the doctors explained, "muchof the available expert specialized medicalcare is concentrated in medicalcenters. In many instances patients requiring(specialized) care must betransported to such a center."In general," they continued, "theroutes, altitudes, weather conditionsand types of aircraft utilized wereidentical with conditions of commercialairline operations."A total of 16,020 case reports weremade on the 14,000 patients studied.It was necessary to make more than onereport on some patients if the flightwas a particularly long one or if thenursing personnel changed during thecourse of the flight. One third of thenumber were litter or stretcher cases.Only seven percent (1,135) of the casereports recorded symptoms of any kindduring flight. Most of the symptomsdueto motion, effects of altitude or thedisease itself—occurred at cruising altitudebut they were of a "minor nature."No illaftereffects were reported.Ninty- seven percent of the timesimple treatment relieved the symptoms.Most frequently the patient wasmerely asked to lie down. Only 1.1 percent received medication and that consistedof such simple remedies as aspirin,motion sickness preventives andsimilar medications.According to the report, extremelyfew patients were rejected for airevacuation. For example, among a randomsample of 2,796 patients, only fivewere considered unsuitable for movementby air. The doctors added, however:"In the selection of a patient for possibletransportation by air, certain importantfactors must be considered. Theeffects of air travel on certain diseasesand injuries must be viewed criticallyand each case considered individually.The effects of ascent to altitude, botha reduction in barometric pressure andthe corresponding decrease in partialpressure of oxygen in the inspired air,may have profound effect on certainpathological conditions."* * « •A.M.A. SPONSORS TELEVISIONDRAMA OF FAMILY DOCTORA thirty-minute dramatized televisionshow about a typical family doctor willbe telecast on WABC-TV, New York,

14 The Health Bulletin February, 1951at 8:30 (E.S.T.) Monday evening, January22, under the sponsorship of theAmerican Medical Association, Dr. W.W. Bauer, director of the A.M.A. Bureauof Health Education, announced.Walter Hampden will star as "DoctorWebb of Horseshoe Bend." The storytakes Dr. Webb, a fictitious but typicalfamily doctor, and the young assistantwho will take over his practice, througha typical and eventful doctor's day.theFilm kinescopes will be made ofprogram for subsequent use on othertelevision stations. These kinescopes. Dr.Bauer said, will be available to localmedical societies on application to theBureau of Health Education about sevendays after the New York telecast."Dr. Webb of Horseshoe Bend," aMarshall-Hester Production, New York,is directed by Martin Magner.* * K *URGES TRADING AREA PRINCIPLEIN SELECTING WAR SERVICEDOCTORSThe trading area principle should beused to determine in what communitiesphysicians can be spared for militaryservice dxiring a major war, says theJournal of the American Medical Association.The Journal cites a bulletin of theBureau of Medical Economic Researchof the A.M.A. presenting for the firsttime the size and population of the 757medical service areas in the UnitedStates."Few of these boundaries coincidewith the boundaries of states, countiesand other political areas," the publicationsays. "From the findings of thebureau one can determine the actualmedical service areas served by physicians.Further study will reveal whatmedical coverage actually is availablefor the population of each area."* « * •URGE MORE EXPENDITURESFOR PREVENTION OF BLINDNESSIn 1949 more than $125,000,000 in taxand private funds was spent for careand services to the blind. Money availablefor research in the blinding eyediseases for the same year was less than$1,000,000. Less than $500,000 was spentfor organized prevention services.This striking contrast between thefunds used for aid to the blind andthose used for the purpose of preventionand research is brought out by Drs.Walter B. Lancaster, Boston, andFranklin M. Foote, New York, in theJournal of the American Medical Association.Dr. Lancaster isan ophthalmologist,a specialist in diseases of the eye. Dr.Foote is associated with the NationalSociety for Prevention of Blindness,New York."We should not reduce activities forthose already blind," the doctors pointedout, "but by increasing what we aredoing now to enable persons to keeptheir sight we can gradually reduce thenumber of unnecessarily blind."The report estimated that about 22,-000 people each year have their visionreduced to one tenth of normal vision.Blindness is a major public healthproblem, the doctors said, not merelybecause of its incidence but also becausethe bUnd man or woman lives on formany years often partly or wholly dependenton others.Based on information covering 3,905children in schools and classes for theblind and 46,537 adults receiving aid tothe blind, it is estimated that blindnessin all ages is due to infectious diseasesin 22.5 per cent of the cases, to injuryin 9.3 per cent, poisonings in 0.6 percent, tumors in 0.9 per cent, generaldiseases in 5.5 per cent, prenatal originin 12.2 per cent and causes unknown toscience in 29.9 per cent. The remainderare of undetermined or unspecifiedorigin.Of the blindness resulting from injuries,about half are of occupationalorigin. The others are due to accidentsat play or in the home.From 1936 to 1948 a 25 per cent decreasein blindness among children inschools for the blind as a result of eyeinjuries was noted. This encouragingdrop was attributed by the doctors aspartly due to "wise legislation which hasbeen adopted in 10 states to regulatethe use of air rifles by children and in29 states to control the sale of fireworks."

February, 1951 The Health Bulletin 15Deaths From Tuberculosis By County, Type, and Color:North Carolina, 1949PLACE OP DEATHCOUNTY TOTAL RESPIRATORY OTHER

16 The Health Bulletin February, 1951Deaths From Tuberculosis By County, Type, and Color:North Carolina, 1949

MEDICAL LIBRARYU. OF N. CCHAPEL HILL, N. C.Ii]I(MiIifc iSmP\ TKs BuUetin will be sehi free to dnu citizen of tKe Sktfg upon requcsi IPublished monthly at the office of the Secretary of the Board, Raleigh, N CEntered as second-class matter at Postoffice at Raleigh, N. C. under Act of Augus* 24, 1912MARCH, 1951 No. 3^^.^*>i .w ^ y/»yiiiSS' ^^•^i-.^y fMijvvfiffi^.ffi'^f.^ ^^^IN AIRLIE GARDENS, WILMINGTON, NORTH CAROLINA

^DSMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dexon, M.D., President AydenHubert B. Haywood, M.D., Vice-President RaleighH. Lie Large, M.D Rocky MountJohn LaBruce Ward, M.D AshevllleJasper C. Jackson, Ph.GLvunbertonMrs. James B. Hunt Lucama, Rt. 1John R. Bender, M.DWlnston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastonlaEXECUTIVE STAFFJ. W. R. Norton, M.D„ Secretary and State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and Director State Laboratoryof HygieneC. C. AppLEAVHrrE, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. JARRETT, B.S., Director Sanitary Engineering DivisionC. P. Stevick, M.D., M.P.H., Director Epidemiology DivisionFREE HEALTH LITERATLTIEThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any inwhich you may be interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitisInfantile Paralysis Typhus FeverCancerVenereal DiseasesConstipationDiabetesDiphtheriaDon't Spit PlacardsFilesInfluenzaMalariaMeaslesPellagraScarlet FeverTeethTuberculosisResidential SewageDisposal PlantsSanitary PriviesWater SuppliesWhooping CoughEpilepsy, Feeble-mindedness, Mental Health and Habit TrainingRehabilitation of Psychiatric PatientsThe National Mental Health Act.SPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special IKerature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh. N. C.Prenatal Care.Prenatal Letters (series of ninemonthly letters).The Expectant Mother.Infant Care.The Prevention of InfantileDiarrhea.Breast Feeding.Table of Heights and Weights.Baby's Daily Schedule.CONTENTSFirst Four Months.Five and Six Months.Seven and Eight Months.Nine Months to One Year.One to Two Years.Two to Six Years.Instructions for North CarolinaMidwives.Your Child From One to SixYour Child From Six to TwelveGuiding the AdolescentThe Right to Health as a Basis for Human Rights 3Life and Death in 1950 8Notes and CommentPageH

PUBLI5AED BYTAE NORTA CAROLINA STATE 6*>AF\D>/AEALTA B|Vol. 66 MARCH, 1951 No. 3J.W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorTHE RIGHT TO HEALTH AS A BASIS FORHUMAN RIGHTSWilliam P. Richardson, M.D., DirectorDepartment of Field Training, School of Public HealthUniversity of North Carolina, Chapel Hill, N. C.Most of us accept without questionthe principle that the right to healthis one of the fundamental human rights,as is enunciated in the Universal Declarationof Human Rights adopted by theUnited Nations, but we are not alwaysclear as to all the factors involved inthe implementation of this right. Thepresent discussion will undertake toanalyze these factors and to look brieflyat our progress and needs with respectto them.The "Right to Health" is set forth inArticle 25 of the Universal Declarationof Human rights, which reads as follows:"Everyone has the right to standardof living adequate for the health andwell being of himself and of his famUy,including food, clothing, housing, andmedical care, and necessary socialservices, and the right to security inthe event of unemployment, sickness,disability, widowhood, old age, orother lack of livelihood in circumstancesbeyond his control."Of primary significance, of course, inthe interpretation of this statement isthe definition of the word health. TheWorld Health Organization gives us inits constitution what is probably themost comprehensive definition. It states"Health is defined as a state of completephysical, mental, and social well-being,not merely the absence of disease orinfirmity."If we paraphrase the declaration,then, using this definition we have:"Everyone has the right to standardof living adequate for a state of completephysical, mental, and social wellbeingfor himself and his family, includingfood, clothing, housing, medicalcare, and necessary social services."Stating the Declaration this wayserves to emphasize a point which Ifeel should be basic to oiu- thinking, andthat is that health in the broad senseis a function of all the factors whichenter into what we usually refer to asstandard of living, and not simply ofhealth and medical services. Thesehealth and medical services are of vitalimportance to the attainment and preservationof health, but they are onlyone of the necessary factors. In thiscountry we have been devoting a greatdeal of attention to public health services,hospitals, and medical care, andwe are sometimes prone to overlook thefact that even though these things wereentirely adequate, they would not assurethe individual of a "state of completephysical, mental, and social well-being"in the absence of economic security, decenthousing, proper diet, and educationin health matters.I want to devote the major part ofthis discussion to an analysis of healthand medical services, but I would likefirst to emphasize the importance of

The Health Bulletin March 1951these other factors so that as we thinkand talk about doctors, nurses, healthdepartments and hospitals, we mayplace them in their proper perspectivein relation to the total picture of factorsessential to health.A few examples will serve to illustratethe point. Forty years ago hookwormwas a major cause of ill health in NorthCarolina. Today, although it still exists,it is a very minor problem. This reductionhas been due in no part to medicaltreatment of individual cases, and toonly a limited extent to the health andsanitation program. More importantfactors have been the decline in thenumber of children who go barefootedand the rising standard of living withits effect on practices of excreta disposalat the individual home.At the time of the first world war andthrough the early years of the greatdepression pellagra was widespread inNorth Carolina. Today it is a minorproblem. The most significant contributionsto this decline have been made byfactors other than medical and healthservices, among them improved imderstandingof nutritional needs, risingstandard of living, and changes in ouragricultural economy resulting in morefood and feed crops, livestock, poultry,and dairying.Malaria in the South has been reducedto a negligible problem as muchby the urban trend and screens as bydrainage, spraying and the like.In more underprivileged areas of theworld the importance to total health ofsocial and economic factors is even morestriking. World Health Organization hasset out to attack several of the specificdiseases affecting wide areas of theworld—malaria, typhus, cholera, andcertain parasitic diseases. Although someof these efforts are meeting with gratifyingsuccess—as in the case of malaria—already it is becoming obvious thatthese eradication efforts will be of onlylimited and temporary benefit unlessthe general standard of living can beraised, imless soil erosion can be checked,water resources developed, agriculturemodernized, and standards of housingand basic sanitation Improved.These examples will suffice to Illustratethe importance to health of theseeconomic and social factors. Now toconsider the right to health with specificreference to the area of health andmedical services. Within this area whatare the elements essential to the implementationof the right to health? Iwould suggest five:1. The protection afforded by an organizedpreventive and public healthprogram, bringing to the individual thebenefits of scientific developments whichcan be most effectively applied for theprotection and promotion of healththrough a commvmity approach.2. An adequate number of hospitalbeds, health centers and laboratories,meeting acceptable standards, and convenientlyaccessible to all the people.3. An adequate number of the scientificpersoimel physicians, dentists,nurses, public health workers, and auxiliarypersonnel—required to render neededcare.4. A comprehensive program of healthinformation and education by all groupsand agencies concerned with healthcare, to the end that the individual mayhave an imderstanding of the factorsconcerned with his personal health, ofhow he can make the most intelligentand effective use of the facilities available,and of his part in supporting thesefacilities.5. A method of financing services andfacilities which makes them available tothe individual on a basis which he canafford, and which preserves his dignityand self-respect.Now let us look briefiy at each of theseelements and see how adequately theyare met in the United States and inNorth Carolina, and what are some ofthe special needs.First, preventive and public healthprograms. While such programs are aresponsibility shared by the full-timelocal health department with othergroups, it is generally recognized thatthe service of such a department is abasic necessity, and the extent and adequacyof full-time local coverage givesus a rough measure of achievement inthis regard. Of 3100 countries in theUnited States only 1900 have full-timelocal health departments at the present

March. 1951The Health Bulletintime. Of course many of the 1200 coimtleswithout such service are small, butmany of them are not, and of the 1900counties with the coverage, relativelyfew meet minimimi standards of adequacyas to numbers and qualificationsof personnel. Moreover nearly a thirdat last reports had a vacancy in theposition for health oflBcer.In North Carolina we are somewhatbetter off than the country as a whole.We have health departments coveringthe entire 100 counties. However, ourratio of public health nurses to populationis only a little more than half ofapproved standards, 1 to 9,000 as againsta standard of 1 to 5,000, and there arenine health officer vacancies, affecting13 counties.Next let us look at the physical facilitiesof health care: hospitals and healthcenters. The United States has arounda million and a half hospital beds of allkinds. Approximately 44% of these aregeneral beds, the balance being formental, tuberculosis and chronic patients.Nearly a third of these are unsatisfactoryby the standards establishedby the Public Health Service imder theHospital Construction Act, so that it wasestimated by the National Health Assemblyin 1948 that a total of 900,000new and replacement beds were needed.Some progress, of course, has been madeunder the Hospital Construction Act,but making up a deficit of this magnitudewill be a matter of years, sinceboth personnel and construction are involved.In North Carolina we have a total of27,400 beds of all types, of which 13,500,or about half are general beds. Thesegeneral beds comprise 74% of those weneed according to P.H.S. standards. Wewill, when present construction is completed,meet the required number of bedsfor tuberculosis, but we have only 54%of the needed beds for mental patientsand only 3% of the needed beds forchronic patients. As to this deficit ofmental beds the view has been expressedthat the standard for mental patientsis too high if adequate personnel andfacilities are provided so that all patientsare cured or improved who aresusceptible of cure or improvement. Inother words, it will not take as manybeds if our mental hospitals can providereal therapeutic services rather thanthe largely custodial care they have beenproviding. I am inclined to agree withthis point of view, which would reduceour deficit of mental beds to around 28%.With respect to health centers, thestandards as to the number needed arenot very satisfactory. Certainly, however,we can figure at least one percounty. Both in the country as a wholeand in North Carolina we have madebut a beginning on these facilities. Whenprojects already approved in NorthCarolina are completed we will have thehealth departments in 25 of our 100counties housed in reasonably adequatehealth centers, the other 75 being housedin quarters inadequate in size or appointments,or in imsatisfactory locations.The National Health Assembly madethe point that effective and economicalhealth service will require a great dealbetter integration than exists at presentof the facilities within a given commimityand the facilities within aregion. This is one of the more difficultproblems we face but it is of vital importancethat we begin giving it veryserious attention because without properintegration we will not get the serviceto which we are entitled for the investmentwe are making.The third element in health and medicalservices is personnel. In estimatingpersonnel needs I have used 1960 as thedate of reference since that is the dateon which the National Health Assemblyand several recent studies of nursingneeds have based their estimate. Thefigiu-es quoted represent the more conservativeof the available estimates.As to physicians, the present annualrate of graduation nationally is 1500 lessthan will be required to give us thenumber of physicians we will need by1960. It is likely that the deficiencywill not be quite so great as this figiu-ewould indicate, since there are severalnew medical schools in prospect—includingour own at the University—butit promises to be of significant proportionsnevertheless. Of perhaps greatersignificance than the deficit in numbers

is the problem of maldistribution. Whilethe urban areas generally have an adequatenumber of physicians, manysmaller communities and rural areashave none.With respect to the dearth of physiciansin these smaller communities itshould be pointed out that this is oftenthe fault of the communities themselves.They move heaven and earth toget a physician to locate there, andthen go to a not-too-distant largercenter for their medical care exceptwhen they need a doctor at night or inbad weather. And then they wonder whyhe doesn't stay.There are several categories of physiciansin which the shortage is acute:PsychiatristsNegro PhysiciansPhysicians in government servicesPublic health physiciansAs to dentists most of us have enoughpersonal difficulty getting dental appointmentsto realize that there is aserious shortage, although standards asto the number of dentists who will beneeded once the great backlog of dentalneeds in the population has been disposedof are not as well established asis the case with physicians. The NationalHealth Assembly estimated ashortage by 1960 of 8,000. The shortageof dentists is most acute in the sameareas as physicians, rural communities,public health, government services, andas respect negro dentists. In both physiciansand dentists North Carolina ranksin the lower group of states.In the field of nursing personnel theshortage is serious at all levels fromtrained practical nurses to top flighteducators and administrators. Best estimatesplace the shortage by 1960 at 100,-000 to 125,000 unless the number ofnurses graduated can be greatly steppedup. Coupled with shortage of numbersare grave deficiencies in educationalprogram and facilities. A recentlycompleted two-year survey of nursingproblems in North Carolina highlightsthe inadequacies of many of our schoolsof nursing, and points out that it willbe necessary to double the number ofour nursing graduates in order to providefor our nursing needs by 1960.The Health Bulletin March 1951The shortage of personnel in the variousrelated and auxiliary fields is ofsomewhat the same magnitude as physicians,dentists and nurses. In consideringoiur personnel needs it is necessary,of com'se, to distinguish between needsas determined by standards', and effectivedemand. The estimates I have givenare based on standards, and whether ornot the effective demand will be thatgreat will depend on many factors, butperhaps largely on the prosperity level.We have referred before to the shortageof public health personnel. Basedon minimum standards of the numberof personnel needed for full coverage ofthe United States with local healthservice we will need the following numbers,in addition to people now employed:1.500 more physicians19,000 more nurses4,000 more sanitation workersSmaller numbers of dentists, healtheducators, laboratory workers, etc.The outlook as regards personnel isfurther clouded by the plight of ourprofessional schools. Costs have advancedso drasticly and income has laggedso seriously that many medical, dental,and nursing schools are in a criticalsituation, and their continued progress,and even existence, may depend on someform of Federal aid or support.The fourth element in health care ishealth instruction and information. Thisdoes not lend itself to the kind of explicitdefinition and measurement wehave used on facilities and personnel,but it is of such importance to the fulfillmentof the "right to health" thatit requires some emphasis. Health education—touse a rather inadequate term—is a responsibility of all the groupsand agencies concerned in any way withhealth programs and health care: ourschools and educational institutions,public health agencies, the varioushealth professions, and voluntary healthorganizations. It needs to be directedtoward the goal of giving the individualin.sight in at least three areas:1. The personal practices which makefor healthful living—all those factors inour habits and way of life which are

March, 1951The Health Bulletinconducive to emotional and physicalhealth.2. The immunizations and healthsupervision each individual should have,the kinds of ill health which maythreaten him, and symptoms whichshould warn him to seek medical attention.3. The elements involved in the provisionof complete health care to thecommunity, how he can use these mosteffectively, and the coop>eration he mustgive if they are to function economically,and to the greatest satisfaction of theindividual and the community.You can see that the provision of thiskind of information and understandingis a major and continuing task in whichmany groups and agencies have a heavyresponsibility. If it is not provided nodegree of adequacy in available serviceswill suffice to give us that "state of completephysical, mental and social wellbeing"which we call health.The fifth and final element in theright to health is a method or combinationof methods which makes it possiblefor each individual to secure adequatehealth and medical services at a costwhich he can afford, and under a systemwhich preserves his dignity andself-respect.Let us consider briefly some of thefacts of this problem of financing medicalcosts. There are two facts whichImmediately stand out:1. The greatly increased expensivenessof medical and hospital care in recentyears.2. The irregular and unpredictable incidenceof medical costs.There is no question about the expensivenessof medical and hospitalcare today. The new techniques ofexamination and treatment and thenew therapeutic agents, which havemultiplied the effectiveness of medicaldiagnosis and treatment, cost a lot ofmoney. These costs can be tempered ina measure by more economical administration,better coordination among thevarious individuals, groups, and facilitiesproviding care, by expansion ofgroup practice and by less demand onthe part of patients for luxury care andfacilities, but even with all possibleeconomy the costs of good care are stillhigh.The distribution of the medical caredollar among the various items of expenditureis interesting, and perhaps notquite what most of us would expect.Around 25 cents goes for physicians'services, 21 cents for hospitalization, 14cents for dental care, 21 cents for drugs,and 19 cents for nursing and all othercare.The population can be divided intotliree groups so far as their ability topay the costs of medical care is concerned:1. The indigent and medically indigentwho can pay for none or only asmall part of their care.2. The great middle income group whocould pay their medical costs if theywere spread out uniformly, but whosefinancial competence is jeopardized byprolonged and major illness.3. The relatively small percent ableto meet any eventuality.$2000 a year would appear to be theminimum income on which a familycould be expected to pay for even normalroutine medical costs without assistance.In 1946 twenty eight percent of individualsand families had an income ofless than this figiore. Government clearlyhas the major responsibility forfinancing medical care for this groupthrough some plan which assures themof adequate care, and which does notpauperize them or offend their self respect.This is a responsibility which isbeing met very unevenly and inadequatelyin the country as a whole. Andit is worth noting that the compulsoryhealth insurance plans which have beenproposed would not take care of thisgroup.It is around the needs of the secondgroup, who can meet their medical costsif they can be spread out through somekind of prepayment or insurance plan,that the greater part of current discussionhas centered. There is generalagreement that the principle of contributoryhealth insurance should be thebasic plan of financing medical care fora large majority of the American people,but there is wide divergence as towhether this can be accomplished by

8 The Health Bulletin March 1951voluntary prepayment plans, or whetherit will require a compulsory nationalplan.The National Health Assembly of1948 expressed the conclusion that"voluntary prepayment group healthplans, embodying group practice andproviding comprehensive service, — arethe best available means at this timeof bringing about improved distributionof medical care."There are, of course serious problemswhich have to be solved if voluntaryplans are to meet the country's needs.There is first of all the difficulty of enrollingand collecting from individualswho do not belong to a group which canbe enrolled en masse, and for whichpayment can be made by payroll deduction.The most difficult group toreach, and one which particularly needsthe protection is the rural group. It isvitally essential that some economicalway be found of promoting and handlingprepayment insurance among rural people.Another problem is that of over-useand abuse which can impose so heavy aburden on the program that rates willhave to be set too high for many of thepeople who need the protection most.This is a problem which involves understandingand acceptance of responsibilityfor avoiding unnecessary hospitalizationand care by both patients andphysicians.We can summarize briefly, then, whatwe have been saying:1. Health and medical services areonly one factor entering into the implementationof the "right to health."Economic and social factors such ashousing, good wages, steady employment,and recreation are likewise essential.2. The essential health and medicalservices include an adequate publichealth program, adequate hospital andhealth center facilities, an adequatenumber of properly trained professionalpersonnel, a comprehensive program ofhealth education, and a satisfactorymethod of financing the costs of medicalcare.3. There is a shortage of all categoriesof health personnel. This is especiallymarked with respect to nurses, to ruralareas, and to negro physicians and dentists.4. The problem of more adequate supportfor professional schools traininghealth personnel is an urgent one, withFederal assistance probably the ultimateanswer.5. Contributory health insurance isgenerally agreed to be the basic methodby which the majority of the Americanpeople may best finance the costs ofmedical care. Voluntary prepaymentplans, Blue Cross and Blue Shield, offerthe most efficient means of providingthis insurance. Two problems of theseplans challenge the best efforts of thehealth professions and the public: theprevention of over-use and abuse, andthe development of effective and economicalmethods of enrolling our ruralpopulation.6. Although we have made magnificenttechnical progress in health and medicalcare, there remain serious problems tobe solved before we approach attainmentof the objective set forth by theNational Health Assembly that "adequatemedical care for the preventionand relief of sickness, and the promotionof a high level of physical, mental,and social health should be available toall without regard to race, color, creed,residence, or economic status."LIFE AND DEATH IN 1950William H. RichardsonRaleigh, N. C.How many of you, especially if youare among those in middle or late life,know definitely that your hearts aresound? How many of you are certainthat your blood pressure is not abnormallyhigh; and how many know thatyou have neither cancer, nor any of itsdanger signals. You can receive none of

March, 1951 The Health Bulletin 9this information except from a qualifiedphysician, and even then, only aftera thorough physical examination.There was a very definite motive behindthe asking of the above questions.Out of a total of 31,257 deaths from allcauses in North Carolina, last year, 16,-625 were attributed to diseases of theheart, apoplexy, and cancer. This totalis revealed in the provisional vital statisticsreport for 1950, compiled by theState Board of Health. The total numberof deaths from the same causes in1949 was only 15,525.When more than one-half of alldeaths occurring in the State, in a singleyear, result from just three diseases, wehave much food for thought. There wasa substantial increase in deaths from allthree of these causes, namely, diseasesof the heart, apoplexy and cancer, in1950. As a matter of fact, for some years,there has been a very pronounced upwardtrend in these figures. However,there appears one oasis in the desert ofdegenerative diseases, among which theabove are classed. The bright spot referredto is the sustained downwardtrend in deaths from nephritis. Fromthis cause, there were 1,416 in 1950, comparedwith 2,141 in 1949. This comparisonreflects a decrease of 725 deathsfrom nephritis, or Bright's disease, ina single period of twelve months. Thedecline has been evident now for severalyears, and it is sincerely hoped that itwill continue. In comparison, 910 morepeople died of heart disease in NorthCarolina in 1950 than in 1949; 107 moredied of apoplexy and 83 more of cancer.Top Bracket KillersIf we add to these three causes ofdeaths in North Carolina last year, thetotals of nephritis and all accidents, wehave a total of 20,381. As has previouslybeen stated, deaths from all causes, in1950, numbered 31,257. Incidentally, thisreflects a decrease in all deaths of 159.The decrease in the total number ofbirths was much greater, being 2,781.That is to say, there were only 106,686live babies born in North Carolina lastyear, as compared with 109,467 the previousyear. During the period undercomparison, death claimed 3,691 babiesunder a year old. This was a substantialdecrease under the 4,155 infant deathsin 1949. Last year, 2,688 babies in NorthCarolina were born dead. This figurewas slightly under that of the precedingyear.Now that we have considered the topbracket killers in North Carolina, itmight be well to acquaint you with somefigures relative to those diseases whichformerly took a heavy toll of life eachyear, but have been brought well undercontrol. For many years, the sceptrewas held by tuberculosis which remainedthe king of killers, for decade after decade.In years gone by, when one wastold that he or she had tuberculosis, orconsumption, funeral preparations werebegvm. In fact, the patients sometimeswere not told imtil their conditioH becameevident to themselves. Tuberculosis,at one time, was considered absolutelyincurable, but now we know better.With the perfection of X-ray andits increasing use in the detection oftuberculosis, thousands of people arebeing cured every year, especially thosein whom the disease is discovered inits early stages.T.B. Campaig^i ProgressesFor several years now, the State Boardof Health has been engaged in an intensivecampaign for the detection oftuberculosis. Up to now, about one anda quarter million chest pictxires havebeen made. All-out surveys have beencompleted in many counties, and thework still goes on. The ultimate goal isto secure an X-ray chest picture of everyperson in North Carolina over fourteenyears old. The death toll from this diseaseis continuing on the decrease inNorth Carolina. As an example of this,the total number of tuberculosis deathsin this State in 1950 was only 789, ascompared with 973 in 1949. Numerically,this was a decrease of 193, an excellentpercentage.Before the discovery of means of immunizationand the improvement of oursanitary facilities, typhoid fever claimeda tremendous toll in North Carolinaeach year. During 1950, there were onlythree such deaths among the more thanfour million people within the bound-

10 The Health Bulletin March 1951aries of our State. The previous year,the total was seven. Despite the sensationalreferences to polio in certainquarters, there were only twenty-fourdeaths from this cause throughout theState last year. This was only one inexcess of the twenty-three which occurredin 1949.In connection with preventable deaths,it is well to point out one field in whichno progress seems to have been made. Werefer to accidental deaths. During 1950,automobile accidents accounted for thedeath of 1,089 persons in North Carolina,as compared with 954 in 1949.Many people think of motor vehicles asbeing responsible for most accidentaldeaths. This is not true. Out of a totalof 2,340 deaths from all accidentalcauses in the State last year, 1,251 hadno connection with motor vehicles, butoccurred, for the most part, in our homesand were preventable. An entire broadcastrecently was devoted to this subject,as some of you may recall.The Meaning of StatisticsIt has been stated that statistics,viewed as just so many figures, havelittle or no meaning. It is only whenthey are properly and helpfully interpretedthat they become significant andhelpful. Vital statistics are highly important,because they constitute thebookkeeping of life and death, and affectthe entrance into and exit fromthis world of every human being. For apartial interpretation of the figuresgiven you, let us go to the physician incharge of the Division which gatheredthese statistics. Reference here is to Dr.Charles P. Stevick, who has made thesepertinent observations: "WhUe commtmicablediseases have been pusheddown, the coming of civil defense hasgiven to this problem a new significance.War always is accompanied by an increasein certain communicable diseases."It might be well to point out justhere, however, that prior to the discoveryof modern methods of immunization,it was often the case that moremen in the armed services died of diseaseswhich then were not preventablethan from bullets. During the War Betweenthe States, cholera, smallpox, andtyphoid fever killed thousands of soldiersThe same was true in the Warwith Spain. But around the turn of thecentury, preventive medicine took on anew meaning. With the discovery andperfection of means of immunization,disease casualties in our armed forceshave decreased each world war. However,the death rate among civiliansfrom the destructive weapons of warhas constantly been on the increase. Ithas been pointed out that, when andif the next war comes, there will notbe a safe spot on the face of the earth.Dr. Stevick went on to point out:'"Even with modern means of immunization,communicable diseases andepidemics present a war-time problemas evidenced by the present, or recent,typhus epidemic among the soldiers ofnorthern Korea and Communist China.But, because of our advance in medicalscience, our servicemen in Korea, so faras we know, have been free from preventablesickness."Dr. Stevick significantly pointed outthat immunization of children now notonly is necessary for their own protection,but is a part of the preparednessprogram for civil defense. We must notforget the communicable disease problemwhich, although it may be of smallproportions at the moment, requiresmaintenance control. Any relaxationmight well mean relapse into conditionswhich formerly existed.Future Health FrontierIn conclusion. Dr. Stevick made thissignificant observation; that, with theelimination and control of preventablediseases of childhood, the degenerativediseases among those in middle and latelife constitute the Public Health frontierof the future. Even now, special studiesare being made of these diseases, witha view to their future control if, withall the facts in hand, this, perchance,may be brought about. Secrecy no longerisa factor in dealing with human sickness.It is necessary for the patient toknow the nature of his or her illness,in order to bring about that cooperationwith the physician which is so vitally|jnecessary, if a cure is to be efifected.

March, 1951 The Health Bulletin 11Medical science proceeds on the theorythat "while there is life there is hope."In many instances, when the period ofhopelessness arrives, the patient is tooill for it to make much difference, anyway.Unfortunately, however, some ofthe degenerative diseases have progi-essedso far when their symptoms becomeplain to the patient that the result isfatal. It is, therefore, of the utmost importancethat every person, especiallythose in middle and late life undergothorough physical examinations at intervalssuggested by their physician.This may mean the difference betweenlifeand death.NOTES & COMMENTBy EditorRADIO BROADCAST—Dr. Roy Norton,State Health Officer, has announcedan expansion of the State Board ofHealth's broadcasting activities. Formany years, a weekly program has beengiven over Station WPTF in Raleigh,known as "Your Health and You." Thisprogram from 9:15 to 9:30 each Saturdaymorning. The same program is nowheard over Stations WBT in Charlotteand WWNC in Asheville. The Charlotteand Asheville programs are transcribed,while the Raleigh program is given byWilliam H. Richardson, Public Relationsofficial for the State Board of Health,as in the past.In making the announcement of thisexpanded service, Dr. Norton said, "StationWPTP gives us its hearty cooperationin securing time on the Ashevilleand Charlotte stations. I wish to expressmy appreciation of this, as well as thecontinuing courtesies WPTF has shownthe State Board of Health in furnishingfree time for the past twenty years."Incidentally, this is the oldest continuingpublic service radio program in theState.The broadcast over WBT in Charlotteis heard each Saturday at 5:35 p. m.,Asheville iswhile that over WWNC inheard at 3:15 each Saturday Afternoon.* * * *MEMBERS OF LOCAL BOARDS OFHEALTH ATTEND SCHOOL—TheSchool of Public Health at the Universityof North Carolina has been offeringcourses for the training of health officers,public health nurses, sanitariansand health educators. On the 28th ofFebruary and the 1st of March of thisyear a course was offered for membersof local boards of health. This institutewas the result of the long felt need onthe part of members of local boards ofhealth for a better understanding oftheir place and responsibility in thepublic health program. Approximately25 board members attended the conference.This was in excess of the numberexpected.The program for February 28th is asfollowsThe Responsibility of Government forHealth, E. G. McGavran, M. D.,School of Public HealthLegal Responsibilities and Opportunitiesof Local Boards of Health, Wm.M. Cochrane, Assistant Director, Instituteof GovernmentFederal-State Relationships in PublicHealth, J. W. R. Norton, M. D. N.C. State Health OfficerRelationship Between the North CarolinaState Board of Health and LocalBoards of Health, C. C. Applewhite,M. D., N. C. State Board ofHealthMerit System Principles and PersonnelPolicies as Related to LocalHealth Departments, Donald Hayman,Assistant Director, Institute ofGovernment."The Challenge of Public Health Today,"Harry S. Mustard, M. D., ExecutiveDirector, New York StateCharities Aid Association, and Memberof the New York City Board ofHealthOn March 1st the Board members andthe Lecturers were divided into discussiongroups. The discussions manifestedthe keen interest and clear understandingby the Board Members of their

12 The Health Bulletin March 1951duties and responsibilities. It is encouragingthat the institute was so successfulthat another one will be conductedin the not distant future.DDT INSECTICmE ISSAFE IF WISELY USEDDDT, an essentially poisonous material,can be used with a wide marginof safety if it is wisely used, reports theCommittee on Pesticides of the Councilon Pharmacy and Chemistry of theAmerican Medical Association in theJournal of the A.M.A.DDT—in the form of powders, solutions,emulsions and aerosols—has beenwidely used in recent years to controlplant and animal pests as well as disease-carryinginsects with a greatdealof success.The committee, which recently reviewedliteratvu-e and case reports onthe substance, points out that the poisonouseffect of DDT on living organismsdecreases with the increase in complexityof the organism. Thus insects, alower type of organism, are destroyedby the substance while human beingsand the higher types of animals are"not likely" to be harmed.Some human deaths, however, havebeen caused by DDT and therefore"certain precautions must be observedto guard against its potential toxicproperties," they added.A warning was given to farmers tobe careful when applying DDT to foodor fodder crops. DDT applied directly tothe edible portions of a plant may resultin poisoning. It should not be usedon dairy cattle or animals being preparedfor slaughter, the committeepointed out, since there is a danger ofaccumulation of the substance in themilk and tissues of treated animals.Other precautions suggested by thecommittee are as follows:"DDT insecticides should never bestored in food cupboards or medicinechests where there is a likelihood ofcontamination of food or mistaken use.All exposed foods, utensils and workingareas must be covered when kitchen anddining areas are being sprayed. Children'stoys or cribs and rooms occupiedby sick people should not be sprayed.Use of oil solutions on household petsshould be avoided and DDT powdersshould be used only where they cannotbe licked off. Intimate skin contactwith aerosol discharge is to be avoided.Plants and aquariums in the homeshould be removed or covered before applyingDDT sprays or aerosols. The useof oil solutions in the vicinity of openfires should be avoided because of theinflammability of such mixtures ...."Persons exposed to large amounts ofDDT dusts and powders under confinedconditions or where dust particles arenot carried away by free movement ofair current should wear respirators.(Chronic poisoning from DDT may resultfrom prolonged ingestion or exposureto small amounts.)Such conditionsmight be encoimtered in mass delousingprocedures, larviciding with dusts, andmanufacturing of formulating operations.Protective clothing should be wornwhen there is a possibility of greases andoils contaminating the skin, thereby enhancingthe absorption of DDT dusts orpowders ...."Frequent or prolonged exposure toemulsions or solutions of DDT in petrolemnoils and organic solvents should beavoided unless protective clothing, gogglesand neoprene or solvent-resistantgloves are worn. (Oily solutions may beabsorbed through the skin.) Clothingmust be changed promptly if concentratesare spilled on them. A contaminatedskin area which has come Incontact with DDT soaked clothing orspilled DDT concentrates should bewashed immediately with soap andwater. Concentrates should be mixed inwell ventilated rooms and fire precautionobserved when volatile and inflammablesolvents are present ...."Operators involved in large scalespraying or fogging with solutions of 5per cent or more of DDT should wearrespirators and other protective devices.Smoking is to be avoided during sprayingwhen combustible mixtures are used.Greaseless skin lotions should be usedon exposed body surfaces when irritantsolvents are present in the formulation.

March, 1951 The Health Bulletin 13Clothes should be changed and the bodycleansed after each day's operation."REPORTS ADVANTAGES OFROOMING-IN PLAN FOR INFANTSRooming-in, the practice of keepingthe newborn baby in his mother's roomInstead of in the hospital nursery, isadvantageous to infants, parents andgrandparents as well as to pediatriciansand hospital administrators, writes Dr.Angus McBryde of Durham, N. C, inthe Journal of the American MedicalAssociation.Dr. McBryde, pediatrician at DukeHospital and Duke University School ofMedicine, reports on the success of therooming-in plan at the hospital since itwas initiated three years ago. Dioringthat time, 2,067 infants have been bornat the hospital with 1,862 of them beingsuccessfully kept in their mothers'rooms. The 205 babies, only 10 per cent,who were not kept In their mothers'rooms suffered from abnormalities orthe condition of the mother was consideredunfavorable to such an arrangement.Giving a brief history of the developmentof hospital nurseries, Dr. McBrydebrought out the fact that before 1890,babies were always kept in their mothers'rooms. However, the high incidence ofinfection in mothers made it necessaryto remove the baby from close contactwith the mother and nurseries werecreated.. Today, as a result of modernobstetric methods infection in newmothers is rare and the advantages ofkeeping an infant close to his mothersuggest a return to the practice ofroomrng-in.The infant. Dr. McBryde said, benefitsfrom the close physical contact with hismother by helping him adjust to hisnew world."Only by having him constantly nearthe mother, where she can hear andsatisfy his demands, can he be withoutdiscomfort or distress," he added. "Weencourage the mother to feel that cryingrepresents the infant's need for her,in terms of either warmth or food, andso the infant may be taken into herbed at any time.""The early closeness of the parentchildrelationship, as it is initiated inrooming-in," he went to to say, "may bethe first step in forming the properclose family relationship." He believesthe strict adherence to rigid forms ofchild training and lack of affectionatetreatment are often factors resulting inaggressive, maladjusted children.The advantages of room-in for themother begin, according to the article,"with the satisfaction and delight inmeeting and handling her baby early."Formerly, the article continued,mothers, as well as fathers, after returninghome were afraid to handletheir baby and were bewildered andanxious about his perfectly normal reactions,such as sneezing and crying,when he wanted anything from attentionand food to a dry diaper.In contrast, the procedure at DukeHospital is to bring the child directlyfrom the delivery room into the mother'sroom where he is kept in a bassinet ather side during her entire stay at thehospital.During the first 24 hours, staff memberswatch the infant closely as themother has often received sedatives oris exhausted. At the end of 24 hours,however, the mother is usually ambulatoryand may aid in the care of thechild if she wishes.Dr. McBryde reports almost "universalapproval" of the rooming-in plan bymothers in both the wards and privaterooms. Very few mothers, he said, failto take advantage of the opportunity tohelp care for the baby.Caring for the infant is made convenientfor the mother. All equipmentfor the baby is kept on an enamel trayon a table near her bed. The plan hasbeen found to be satisfactory and approximatesthe usual home arrangement.Dr. McBryde said.The fact that mothers now have moreconfidence in their ability to care fortheir children as a result of the rooming-inarrangement is shown by the 90per cent decrease in telephone calls fromnew mothers during their first week athome, he pointed out.

14 The Health Bulletin March 1951Visitors are limited to the father andgrandparents, who are allowed to visitwhenever they wish and may aid in thecare of the infant so long as they washtheir hands and are free from infection.A marked change in the attitude ofmany fathers toward their babies hasbeen noted by Dr. McBryde. "They beginto share the responsibility at onceand therefore do not feel that care oftheir infant is completely in the mother'sprovince dviring the early months."He concluded:"Now that such a large percentage ofinfants are born in hospitals, it behoovesall of us to make that process as safeand sane as possible. It is hoped thathospitals in the future will be builtwithout nurseries for normal newborninfants who are born of healthymothers."* :;: * *CANDY-LIKE RAT POISONSARE THREAT TO CHILDRENRat poisons disguised as candy-likesubstances, especially those containingthallium, are a real threat to children,according to an article in the AmericanJournal of Diseases of Children, publishedby the American Medical Association.Thallium, a poisonous metal, is especiallyeffective as a rodenticide becauseit is odorless and tasteless and easilytransformed into highly palatable concoctions.Drs. Clifford G. Grulee, Jr., of NewOrleans, and Earl H. Clark of Denver,authors of the article, after describingthe poisoning of four children who atea thallium compound thinking it wascandy, expressed the need for morecontrols in the use of the metal. All fourchildren attended the same pre-schoolnursery in Galveston.The doctors, formerly associated withthe University of Texas Medical Branchin Galveston, reported that there is nosatisfactory treatment for thallium poisoningand that two of the four childrenwho ate the poison died.Thallium poisoning, they said, is hardto diagnose, as the only characteristicsymptom attributed to it is baldness andthis usually does not develop until aboutthree weeks after swallowing. Untilbaldness appears, clinical findings arenot definite, although evidences of respiratorytract disease and central nervoussystem involvement may be present,they added.On investigation as to the source ofthe poison in this instance, it waslearned that the child who had offereda substance as "candy" to his companionslived next door to an exterminator.Further investigation showed that theexterminator used a mixtiore of thalloussulfate, cereal and syrup as a rodenticide,a practice common in that community."The insidious exposui'e and highmortality in the four cases reported,"said the doctors, "strongly emphasizethe dangers of and the need for furthercontrol in the use of thallium compounds."* * * -A-REPORT PHYSICIANPARTICIPATION IN SCHOOLHEALTH SERVICESA gratifying level of interest, understandingand participation in localschool health programs on the part oflocal medical societies is shown in asurvey by the Bureau of Health Educationof the American Medical Association,according to the Journal of theA.M.A.The results of the survey—made underthe direction of Donald Dukelow, M.D.,and Fred Hein, Ph.D., of the A.M.A.'sBureau of Health Education, Chicagowere compiled from more than 1,000returned questionnaires from local medicalsocieties throughout the country."In general," the Journal said "thereport shows that individual physiciansand medical societies are active in manyaspects of school health services."The poll revealed these facts:One third of the medical societies replyinghave a school health committee.One fourth of the communities haveschool health councils, almost all ofwhich include medical society representation.More than half of the medicalsocieties report school physicians mostlyon a part time basis. Eighty per centof the communities told of established

March, 1951 The Health Bulletin 15methods of referring children to a physicianthrough their families.Procedure by which the family physiciancan inform the school of a child'sspecial health needs was found in 64per cent of the communities. Two thirdshave modified physical education tomeet special needs of pupils, and onefourth provide corrective exercise onmedical prescription.Basic health services for athletes arereported by four out of five. First aidfacilities are present in over three fourths,but only one third have completeplans for emergency care.Exclusion and readmission for communicabledisease were found acceptableto school and health officials in 87per cent of the communities. Only halfreported reemployment and periodichealth appraisal of school personnel.The U. S. Office of Education, in cooperationwith the Public Health Serviceis now making a companion surveyof health services in city school systemsof the nation, the article brought out.The report concluded:'"Since the survey conducted by theAmerican Medical Association, addressedto the county medical societies, hascovered the relationship of such societiesto the local school health program, thetwo surveys will provide a rather completepicture of the school health servicesavailable to children."REPORT FATAL EFFECTS OFANTIHISTAMINES ON CHILDRENThe disastrous effects of an overdoseof an antihistamine on young children asa result of accidental swallowing arecompUed in a report by two physiciansof the University of Michigan MedicalSchool. Their observations serve as awarning to parents to keep these andother potent drugs out of the reach ofchildren."The susceptibility of children to theconvulsant action of antihistaminicagents is striking and impressive," Drs.James B. Wyngaarden and Maurice H.Seevers of Ann Arbor say in the Journalof the American Medical Association.They added that "the mortality rate ininfants in whom convulsions develop isvery high." Antihistamines are beingwidely used in treatment of allergic diseasesand cold symptoms.(Dr. Wyngaarden is presently locatedat Massachusetts General Hospital, Boston.)According to the article, there are atleast eight known deaths of childrenimder two years of age attributed to thesedrugs. Five of the deaths were accompaniedby convulsions.Treatment of convulsions from antihistaminicagents in infants has beenfound to be "none too successful," theysaid, since treatment is entirely symptomaticas a specific antidote is lacking.Only two cases of recovery from convulsionscaused by antihistaminic agentsin children under two are known.The doctors described the suddendeath of a 22-month-old boy who hadbeen in good health except for a mildupper respiratory tract infection. He wasbrought to a physician about two hoursafter the alleged swallowing of a numberof dimenhydrinate tablets (used formotion sickness, such as seasickness andcarsickness). At first the baby was overstimulatedand later generalized convulsionsand skin rash developed.Despite efforts to save him, the childdied 41/2 hours after swallowing thedrug. As a result of postmortem examinationthe dimenhydrinate was listedas the cause of death "either as adirect toxic effect or partially as anindirect change resulting from anoxia(oxygen deficiency)."The more violent reaction of a threeyear-oldgirl to an antihistamine wasalso reported in the article though,fortimately, the girl recovered.The girl "was found in a drowsy, listless,fretful state. She became disorientatedand walked with a staggering, awkwardgait. Jerkings of the extremitiesdeveloped, and then she experiencedgeneralized clonic convulsions."She had been playing l^i hours earlierin the bathroom from which 17 capsules

16 The Health Bulletin March 1951of diphenhydramine hydrochloride (usedin treatment of allergies) were laterfound to be missing. Treatment was begtmabout five hours after the supposedingestion. The description of her conditioncontinued:"There were recvu-rent generalizedconvulsions for about eight hours; theface was flushed, and the pupils weredilated and nearly fixed. Between seizuresthe child cried out and talked in arambling manner and showed hyperextensionof the trunk (bowed stiffeningof the back) and involuntary movementsof the extremities. The next day sheappeared normal."The same issue of the Journal containsan editorial commenting on newcontrolled studies of the use of antihistaminesin the treatment of colds.These included Navy male recruits duringtwo influenza episodes.Two antihistaminic drugs used intherapeutic dose "did not prevent thecommon cold or modify the course inthose who developed colds," and showedno superiority over placebos (harmlesspills containing no medication), theJournal points out.* * );: ;:=EXPERTS TELL AT WHAT DISTANCEONE SHOULD VIEW TELEVISIONFor eye comfort, how far should aperson be from the screen to view television?Dr. William Blake, of Astoria, LongIsland, N. Y., put this question to theJournal of the American Medical Association.Because of its controversialnature, the Journal submitted the questionto three "competent medical authorities,"and they all came up withvirtually the same answerAs a general recommendation forsmall or moderate-sized screens, a distanceof roughly 10 times the diameterof the screen is found most comfortablefor clear viewing and avoidance of eyefatigue.This, substantially, is the same opinionas that expressed by the American Societyfor the Prevention of Blindness.One authority whose answer is printedin the A.M.A. Journal, says "the optimaldistance from which one should watchtelevision varies from one person to another,depending at least partly on hisstate of refraction and on the size ofthe screen. Placement of furniture androom size also influence one's preference.In general, a distance of 10 feetor more would be preferable, since thenthere is necessary only a moderateamount of convergence and accommodation.One should avoid sitting closerthan five feet."The authority said further that ifeye fatigue occurs at a distance roughly10 times the diameter of the screen ina person with no visual abnormalities,"the distance may be changed.""In fact," he continued, "changing occasionallyfrom one chair to anothershould help in avoidance of fatigue notonly of the sense of vision but of theneck muscles. Regardless of the distanceof viewing, there seems to be no evidencethat eye fatigue in the 'normal'eye will cause pathological changes. Thechief problem is that of comfort."One of the other authorities, whoseanswers also were published in theA.M.A. Journal, said that the more defectsthere are in the television picture,"the greater is the tendency for visualfatigue.""This," he said, "includes such defectsas out-of-focus pictures, those that aretoo dim, too flat and with too much contrast,and those that weave and jump.The viewing distance should thereforenot be near enough for these defects,especially the graininess, to be overlyapparent.. This is more important thansize of the picture, although the graininessand size may go together. Furthermore,the appearance of graininess willincrease with the increase in brightnessof the screen. Television should be observedin a lighted room, so that thereis not too great a contrast between thescreen and the background."The third authority said that "whentelevision is viewed from a distanceless than 10 times the diameter of thetelevision tube, no harm whatever isdone to the eyes but the picture losesin quality as the scanning lines thenbecome visible.."

MEDICAL LIBRARYU. OF N. C.CHAPEL HILL. N. C.^ N nUbifiv.wsPullisKedly TfllMrflCflKllNA 5IMR°AM)^flEALTAI TKis Bulletin will l>e sent free to ani| citizen of fKe State upon request IPublished monthly at the office of the Secretary of the Board, Raleigh, N. CEntered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 66 APRIL, 1951 No. 4NORTH CAROLINA STATE BOARD OF HEALTHBUILDING, RALEIGH, N. C.

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Ddcon, M.D., President AydenHuBKET B. Haywood, M.D., Vice-President RaleighH, Lib Large, M.D Rocky MountJohn LaBruci Ward, M.DAshevllleJasper C. Jackson, Ph.GLumbertonMrs. James B. Hunt Lucama, Rt. 1John R. Bender, M.DWlnston-SalemBin J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and Director State Laboratoryof HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. JARRETT, B.S., Director Sanitaiy Engineering DivisionC. P. Stevick, M.D., M.P.H., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any inwhich you may be interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitis InfantHe Paralysis Typhus FeverCancer Influenza Venereal DiseasesConstipation Malaria Residential SewageDiabetes Measles Disposal PlantsDiphtheria Pellagra Sanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFiles Teeth Whooping CoughTuberculosisEpilepsy, Feeble-mlndedness, Mental Health and Habit TrainingRehaDllItatlon of Psychiatric PatientsThe National Mental Health Act.SPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal Care.First Four Months.Prenatal Letters (series of nine Five and Six Months.monthly letters).Seven and Eight Months.The Expectant Mother.Nine Months to One Year.Infant Care.One to Two Years.The Prevention of Infantile Two to Six Years.Diarrhea.Instructions for North CarolinaBreast Feeding.MIdwIves.Table of Heights and Weights.Yovir Child From One to SixBaby's Dally Schedule.Your Child From Six to TwelveGuiding the AdolescentCONTENTSThe Cancer Program In North Carolina 3How Many Lives For A Dollar? 4Individual Health 8Outhne Campaign Against Chronic Diseases 9"Immunization And Civil Defense" 15Page

^m^.^^^S-^KIPU6LI5AED BYTAE WhJtX CAROLINA STATE B'^ARD'/AEALTAlVol. 66 APRIL, 1951 No. 4J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorTHE CANCER PROGRAM INBy James F. Robertson, M.D.Chairman Executive CommitteeWilmington, N. C.NORTH CAROLINAIt has been my privilege to haverather intimate contact with manyphases of the Cancer Program in ourState, and I can vouch for the fact thatmuch yet needs to be done on manyfronts before any appreciable change inour vital statistics will be seen. Statisticsshow that deaths from Cancer in NorthCarolina are growing by leaps andbounds, and this rapid increase certainlycannot all be laid to the fact thatpeople live longer and therefore thereare more citizens in the cancer agegroup. The rapid increase in the deathrate definitely places this disease in theforefront of those conditions whichshould be of grave concern to PublicHealth Officials. Deaths from Cancer inNorth Carolina in 1948 were 2,661; in1949 there were 3,197, and in 1950 therewere 3.733.The only way we have at this time tofight Cancer is to discover it early, inits very beginning and eradicate it bysurgery, x-ray or radium.Acting on this premise the StateBoard of Health in cooperation with theNorth Carolina State Medical Society,and the American Cancer Society beganin 1948 to set up Cancer Clinics in varioussections of the State. The AmericanCancer Society undertook to publicizethese Clinics and acquaint the publicwith the danger signals of Cancer andurge everyone over thirty-five years ofage to go to a Clinic for examination.The State Medical Society through theLocal County Medical Societies furnishesthe physicians, surgeons and specialiststo examine the people who cometo the Clinics. No charge is made toanyone applying for examination tothese Clinics. They are supported by taxmoney, and must of necessity be free toany citizen. No treatment of any kind isgiven in the Clinics, and no medical adviceis given to any examinee, exceptto tell them to report back to their doctorwho will advise them what wasfound and what to do about it. In thecase of every person examined in one ofthese Clinics a letter is sent to the examinee'sprivate physician advising himwhat was found and making certainrecommendations.In the case of those found to haveCancer, who are imable to pay for thetreatment needed, and who are certifiedby their County Welfare Departmentas being indigent, arrangementsare made whereby either the StateBoard of Health or the American CancerSociety will go fifty-fifty with theCounty to finance the necessary hospitalor other treatments.As proof that these Clinics are gettingresults I woud like to cite some figuresfrom the Clinic in New Hanover Countywhich will have been in operation threeyears by the time this Bulletin gets intoyour hands. During the first year ofoperation there were forty one cases of

The Health Bulletin April, 1951cancer discovered (not including casesof known Cancer who came to theClinic). Of this 41, 18 or 44% wereclassified as early, and 23 as late. In1949 there were 71 cases of Cancer discoveredin the Clinic, 48 or 67.6% werefound to be early. In 1950, 72 cases ofCancer were discovered in the NewHanover Clinic, and of this group 55 or76.4% were classified as early. Thismeans that more and more people aregoing to the Clinics for examinationswhere there is still a possibility of acure. These Clinics only scratch thesurface as far as the eradication ofCancer is concerned, but they serve toalert the public to the danger, and toimpress upon them the necessity ofroutine examination and of immediateexamination if any of the well knownsignals of Cancer are present.I doubt if there is a physician whohas worked for any length of time inone of the Clinics who will not admitthat he has learned a great deal aboutCancer. I wish every physician couldserve in a Clinic, once a week for a year;we would all then be more Cancer consciousand would automatically look forCancer in the areas where they occurmost frequently. Vis: skin, tongue andmouth, breasts, uterus and rectum.At the Annual Meeting of the NorthCarolina Division of the American CancerSociety last October it was decidedto appoint a Committee to look into thefeasability of the establishment of ahome for indigent, incurable cancercases. To those of us who have givenmuch thought to the matter, the needfor such a home where terminal carecovild be given seemed to be one of themost pressing problems.This Committee explored many possibilities,and has spent considerabletime seeking a suitable location andtrying to get an appropriation from theLegislature in order to remodel somebuilding for this purpose. At this timeeither some of the buildings at CampButner, or the buildings—now abandoned—andformerely used as a CountyHome near Lumberton, seem to offerthe most practical solution to the problem.But unless some funds are forthcomingfrom the State to put the Buildingin operating condition we are doomedto failure. Once the building is rehabilitatedand equipped, we believe wecan find the means to operate it. Thoseof us who see much of Cancer in its advancedstages know what a hopeless andtragic situation it presents to that immediatefamily. The patient is usuallyelderly and must of necessity live withsome member of the family. This throwsa tremendous financial and economicburden on a family which is alreadystruggling to make ends meet. The resultis often a broken home, and theCancer Patient has the additional worryof knowing he is unwanted and is helpingto use up the family's meagre resourcesin a hopeless struggle againstsure death.HOW MANY LIVESFOR A DOLLAR?By Mrs. George E. Marshall, State CommanderExecutive Vice-President American Cancer Society,North Carolina Division, Inc.Mount Airy, North Carolina"Three and one-half million veterans... an average cost of $3,000 per case... a grand total of ten billion dollars!"I backed up and read again. Yes, I wasright the first time. Unless by somemiracle of research a change is wroughtin the present incidence of cancer, somethree and one-half million of the 18,-000,000 living veterans of our ArmedServices will have cancer, will be hospitalizedby the Veterans' Administration,or will be eligible for VA hospitalization.Three thousand dollars for alife! The total cost, in cold cash, willapproach ten billion dollars. We, thetaxpayers, foot the bill.

April, 1951The Health BulletinPlease don't misunderstand me. I don'tbegrudge one dollar spent for themost expert medical care of our veterans.And, incidentally, a large part ofthe taxpaying public is veterans. I dobegrudge and resent the toll of lives,veterans and others, claimed by America'sNumber 2 Killer, cancer. It isn'tnecessary. It isn't tolerable! Cancer isfrequently curable. Early cancer isusually curable. Cancer is the ynost curableof all the highly fatal diseases.Yet more than thirty-one hundredNorth Carolinians paid the forfeit fordelay in 1950. Six times that numbersome eighteen thousand Tar Heels—arevictims of cancer tonight, as I talkthis over with you. Half could be saved.Half do not need to die! You can helpto save them! How?Just this week a past-president of theState Medical Society said: "If we hadsuch figures in accidents or polio, thepublic would be up in arms! They'd fleethe state — go to Arizona!" Hysteriawon't help. Action, intelligent action, onthe part of every responsible citizen willhelp. We're in this thing together. Cancerenters one home out of two, strikesone person out of five, accounts—at presentrates—for one out of every sevendeaths in the nation. Whose lives, whosedollars are at stake? Yours and mine!We have a right and obligation to beconcerned, to take action.There are, of course, those who wouldsay I am prejudiced when I claim thatthe finest men and women in NorthCarolina are the volunteers in theAmerican Cancer Society. Perhaps I amprejudiced by ten years working withvolunteers of all t3T)es—civic mindedlay men and women, teachers, socialworkers, scientists, clergymen, laAvyers,dentists, nurses, and busy physicianswho give up their one day off to drivehundreds of miles—at their own expense—toplan the next step in NorthCarolina's progressive plan for conqueringcancer. How far they have come inthe past ten years! How proud we areof them! For the real story of what themen and women of North Carolina havedone about cancer—a story I wish therewere time for me to tell you tonight, Isuggest that you read The 'Forties andForward to Cancer Control.But there's a second group of unsungheroes and heroines in the evolvingdrama of the defeat of cancer in NorthCarolina. They are those, perhaps manyof you, who, while not active membersor volunteers of the ACS, contributefinancially that the work may go forward.No contribution is too small tolend its voice to victory. The dime in thecoin can may save more than one life.Quarters for research add up to nearly$50,000 of American Cancer Societymoney your money—invested in scientificstudy of cancer right here in NorthCarolina.When I pay for a job, I like to knowthat the work is well-done and that I'vegotten the most for my money. I don'tbelieve that I am too unusual in thatrespect either. And so, in the time remaining,I should like to sketch in foryou the fate of the dollar marked cancercontrol. Those of you who are businessmen and women will appreciatethe significance of—and our pride inthe American Cancer Society's approvalby the Better Business Bureau and theNational Information Council. That is,to the business world, what the seal ofapproval of the A.M.A. is to the medicalprofession. It means that the expertscommend our financial practices. Butback to that dollar!Let us "make change"; for the firstthing we do is to set aside a sacredtwenty-five cents. I say "sacred" in allseriousness. That small, flat quarter,perhaps worn thin at the tobacco market,may bury the test tube in whichthe ultimate answer to the riddle ofcancer will be found. Twenty-five centsof every dollar goes directly to cancerresearch. Some nine thousand Tar Heellives are dependent upon the answersthose quarters are seeking. The bestscientists of the nation, selected by theNational Research Council, are thetrustees of this hope for tomorrow.North Carolina is proud of the recognitionof her own men of science by theNational Research Council and of DukeUniversity, the University of NorthCarolina, and Wake Forest College,

6 The Health Bulletin April, 1951where cancer research is under way.A nickle and a dime! They won't buymuch in this day of inflation. But thathumble sum may save several lives!Divide the cost of one medical film purchasedby the State Division of theAmerican Cancer Society (average costwholesale, $160.00) by the number ofNorth Carolina physicians seeing it inone year. There are approximately threethousand doctors in the state. Beforetwelve hundred have seen the film, theexpenditure will have fallen to fifteencents or less per physician viewing it.Who would hesitate to invest fifteencents to bring his doctor the latest techniqueson cancer? Who dares guess howmany patients will benefit?Since, we are told, more has beenlearned about cancer in the past decadethan in the previous three thousandyears, even our youngest doctors arebusily engaged in professional study ofcancer. This job of professional educationis a tremendous one involving thenation's leading medical authorities. Itis too big for North Carolina to swingalone. We have asked—demanded moreaccurately expresses it — that our nationalofiice, through its Medical andScientific Division, develop the programand tools the doctors of our state andthe other forty-seven deserve and want.To defray the cost of this vital workand other tasks too cumbersome for usat county and state levels— we send ourdues, fifteen cents out of every dollar,to National. Over eight cents of the fifteengoes into education, chiefly professionaleducation; although it alsopays for the production of motion picturesand literature for the public. Youmen who have seen THE DOCTORSPEAKS HIS MIND and you womenwho have seen the new BREAST SELF-EXAMINATION know what potentweapons in life-saving our films are.Another two cents of the fifteen goesto the service program—to provide assistancein planning facilities (tumorclinics, detection centers, etc.) in NorthCarolina and throughout the nation.North Carolina has ten times the facilitiesfor diagnosis and treatment ofcancer it had ten years ago, in 1941, butneeds still more. Our two cents will helpus plan them wisely. It also brings usthe latest techniques of making thecancer patient more comfortablethrough volunteer services such as surgicaldressings. With another two andour na-a fraction cents of the fifteen,tional office administers the work in research,not only for ACS but for theDamun Runyon and Babe Ruth cancerresearch funds, as well as all phases ofeducation and service at the nationallevel. The remaining three cents is devotedto the Cancer Crusade, which, asyou know, is the joint mass educationand fund-raising program during themonth of April, set aside by Act of Congressand Presidential Proclamation asCancer Control Month.Now we have paid our insurance forthe future, research, and have enabledour professional men to keep abreast ofthe rapid changes in the cancer front.What about the money we use righthere at home, the remaining sixtycents? What does it buy?Service to the cancer patient and thepotential cancer patient is an obviousand understandable objective of theAmerican Cancer Society. This servicetakes two forms: professional service,which is costly, and volunteer or layservice, which takes time and devotionbut which is done "for free" by trainedvolunteers, people of heart. By way ofillustration, since 1945 the county Unitsand State Division of the ACS havematched dollar for dollar with local Departmentsof Public Welfare on thehospitalization of indigent cancer patients.By the end of this fiscal yearthe five year total of that item will havereached or surpassed the hundred thousanddollar mark in this state. But canceris not limited to the poor. All citizensmust have access to facilities fordiagnosis and treatment of cancer. Agrant-in-aid of $25,000 of our moneyenabled the State Board of Health toactivate its Cancer Section three and ahalf years ago. That $25,000 served asa magnet to draw federal and, later,state tax money into the progressiveprogram of Cancer Detection Centersoperated across the state today by

April, 1951The Health Bulletincounty Medical Societies in cooperationwith the State Board of Health. Anadditional $25,000 of ACS money hasbeen allocated to hospitals in the stateto open or improve tumor clinic facilitiesor to purchase equipment neededin cancer therapy.If we could convert volunteer serviceinto dollars and cents, the contributionfrom that direction would probably exceedthe concrete figures given above.One Unit reported 2,555 hours of volunteerwork in the Detection Center inone year. At the rate of 80(f an hour,that service would have cost the Center$2,000! The same Unit made and distributedover 40,000 cancer dressingsduring the same period. Over the counterdressings of this sort cost a cancerpatient as much as $30-$40 per month.These, of course, were free.Yes, service, professional and lay, isa major task and one that is far fromfinished or even half-way adequatelymet for the moment. There will be nolet-up in the pleas for service until themen and women of North Carolina areeducated to the point of seeking medicalattention at the first sign of adanger signal of cancer! This presupposesa working knowledge of the SevenDanger Signals on the part of everycitizen—and the intelligence to "StrikeBack at Cancer." Service for the immediatevictims is vital, to give them achance for cure; but education beforethe killer strikes is the salvation ofevery fifth person walking the streetstoday! This is our first and most imperativeassignment—to reach them beforecancer does!We need help to do this. That is why,in less than five years more than $15,-000 of our half dollars and dimes hasbeen devoted to education of professionalgroups—physicians, nurses, publichealth workers, and teachers. Thatmoney has bought not only the films fordoctors but postgraduate medicalcourses, medical symposia, and professionaljournals placed in the hands ofevery physician in the state. It hasbought workshops for nurses and teachersand short covurses in cancer forpublic health students. Four teachersfrom one covmty attended such a workshop.They requested and secured permissionfrom their superintendent toshow THE TRAITOR WITHIN at thefall faculty meeting. A teacher's life wassaved as the result of that film showing.The superintendent called on \is totell us so in person. Our ciirrent budgetfor professional education in the stateis $17,000, for public education, $39,000.But I have fallen into the common,current day practice of talking in termsof "big" money. Let us re-examine thatsixty cents. It is the same money, merelymultiplied by the number of dollarsgiven, which we dicussed a moment ago.Counties may—and many of them dosubmit projects approved by their medicalrepresentatives and receive fundsfor local administration. A number ofthe smaller Units choose to look to theState Division to match dollars withtheir Welfare Departments and to providetheir educational tools. The choiceis theirs. If they handle money on alocal budget, they must, of course, auditand account for its use at the end ofthe fiscal year. It is encouraging to seemore county Units "flexing theirmuscles", so to speak, and saying "Wecan plan the job right here at home."More important than where themoney is spent is where the results ofits expenditxire reach. Let me illustrateagain. A simple leaflet, one purchasedat the state level, made its way, as amail enclosure, into the light bills ofone of our larger towns. In a Negrorooming house that leaflet was droppedon the floor, unnoticed when the billwas opened. It was stepped on. Dirtyand tattered as it was, it still served itspurpose. One of the roomers picked itup. She promptly went to a tumor clinic.Yes, it was cancer and she was "foundin time." That little leaflet didn't costa penny, but—it saved a life. In anotherNorth Carolina city it was the leafletin a bank statement that brought abeautiful young woman to the tumorclinic. Still in her twenties, she too hadcancer. A chance to live for less thana cent!And one cancer leaflet will be avidlyread by any number of people. A tea-

8 The Health Bulletin April, 1951Cher recently asked students to getonthe leaflets she gave them— thesignatures of every adult who read theleaflet. Some of those leaflets were returnedliterally covered with autographs.The difference education makes isclearly evident in the state's oldest CancerDetection Center, where, in 1948,less than half the cancers diagnosedwere early or curable. Today threefourths of the cancers found are found"in time."The American Cancer Society can'tspend $3,000 on a single case of cancer.But, with the very dollar you give, wemay buy enough education for veteransto save the VA and the American taxpayerover $100,000!A dollar can buy a lot of Tar Heellives!INDiVIDUAL HEALTHDr. Hubert A. Royster,Contributing EditorMuch is being said and done for theand itpromotion of the public health,is without question one of the vitalthings of this age. To those engaged inpreventing disease and making theworld a more healthful place to live inthis generation will owe its greatestachievement. In North Carolina, as inother States, health matters are beingmanaged commendably and great creditis due our legislators, medical officials,and some intelligent laymen forthe increasing interest everywheremanifested. I believe that progress isbeing made.But (and this "but" will represent anaddition rather than an antithesis) wemust go behind the returns, if the campaignis to be really successful. Publichealth problems can not be thoroughlysettled in the herd. In other words, wemust go after the individual and thenoiu- task will be the promotion of individualhealth as the basis of soundpublic health. I do not mean to say thatwe should neglect our opportunities ofreaching the people collectively, but ourappeal, I think, should always be to theindividual. We must teach him, warnhim, encourage him, reason with him,set him a good example. So shall heleaven the lump.The query, "Am I my brother's keeper?"has been answered in the affirmativeby all those who are altruistically•Reprinted from the February, 1912 HealthBulletinconcerned in public health. I believe justas firmly that we are also our own keepers.If I am a healthy person, I am ofvalue to the community as a worker andrelieve it of a bmrden; if I am sick, temporarilyor permanently, I become adrag and a tax in proportion to my disability.Such facts are well understood.How necessary, then, that each individualshould keep himself at all times inthe best possible condition. This is thedoctrine to preach. Herbert Spencergave out the text years ago: "Perhapsnothing will so much hasten the timewhen body and mind will both be adequatelycared for as the diffusion of thebelief that the preservation of healthis a duty. Few seem conscious thatthere is such a thing as physical morality."There are, of course, numbers of peoplewho are not responsible for theirstate of health. Many are handicappedat the start; others are not to blame forconditions that arise afterward, throughno fault of their own. Some are bornsick, some achieve sickness, and somehave sickness thrust upon them. Everyone is expected to do his best with whathe has. The way to health is throughright living. So that, besides educatingthe public to avoid disease, it is essentialto train the individual to liveright. This is the old theory of vitalresistance. We can escape sickness intwo ways—either by getting out of itsreach or by throwing it off when it

April, 1951The Health Bulletincomes. Both means are desirable. Thefirst is secured through public health,which protects us from disease; the secondthrough individual health, whichenables us to fight disease.Now, the individualism which I amemphasizing must apply with equalforce to the individual health officerand the individual family physicianas well as to the individual layman.From all accounts there is need of muchsweeping in front of the doors of somehealth authorities. "Practice what youpreach" may be too unjust an admonition,but that is the substance of whatis needed. The public is surely prone tojudge us as well by the laws as by thecompany we keep. I understand thatsome physicians are not careful to seethat the plainest hygienic rules are carriedout in their own households. Individualdoctors even allow themselvesto get into irregular habits of living andindulge in gross lapses of physical laws.I have heard that at least one medicalman in this State and the wife of anothercontracted smallpox. A sanitaryinspector in one of our principal citiesalso had a severe case of the same disease.He was allowed to qualify for hisofiice, although he had never been vaccinated.Physicians have been heard tosay that they did not "believe in" diphtheriaantitoxin or that certain ideas inregard to sanitation were "all tommyrot."Such assertions tend only to bringinto bold relief the ignorance of thosewho make them, if they do not do actualharm to the cause of health advancement.These things ought not so to be.I sometimes believe that a part of ourmoney and some of the time of ourhealth experts might well be spent ininstructing the doctors themselves inmatters of health. Many a twist andsnarl in their mental and moral fibrecould then be straightened out. Someschools are now given special coursesand granting a degree of Doctor ofPublic Health. These courses will be improvedand enlarged until there aredeveloped specialists in public healthwho shall be able to train others in thework all over the land. This conditioncertainly is coming to pass.The whole affair is a matter of teachingand preaching, and, as in all trueeducation, it is the individual we areafter. In the last analysis we want toget hold of the average man, the mostuninformed man, and tell him how tolive right. Laws are good and we musthave them; but there are some thingsthat can not be legislated into people.I am not now nor have I ever been engagedin public health duty. My worklies in an entirely different field. PerhapsI have no right to present theforegoing criticisms and observations. Ihave done so solely upon the groundthat I am interested in my native Stateand in the health of her people.OUTLINE CAMPAIGN AGAINST CHRONIC DISEASESThe efforts to reduce the toll of cerebralpalsy, epilepsy, diabetes, blindnessand deafness were outlined at the NationalConference on Chronic Disease.Plans were laid for new attacks on theproblems of these ailments and for theirprevention.The three-day Conference, sponsoredby the Commission on Chronic Illnessin cooperation with the U. S. PublicHealth Service and the National HealthCouncil, brought together representativesof the medical profession and layorganizations interested in chronic diseases.The Commission is an independentnational agency founded jointlyby the American Medical Association,the American Hospital Association, theAmerican Public Health Association andthe American Public Welfare Association.A report prepared by the AmericanAcademy for Cerebral Palsy said thatthe prevention of that disease dependsfor the most part on good prenatal andobstetrical care, good pediatric care inthe early months of life, and the preventionof accidents, infections andother causes of brain damage. Early detection,diagnosis, treatment and train-

10 The Health Bulletin April, 1951ing are necessary to prevent and minimizethe effect of the disease, the reportadded.Many patients with epilepsy can livea normal life and nearly all can bemade useful members of a communitythrough medical care and education ofthe patient, family and public, said areport of the American Chapter, InternationalLeague Against Epilepsy."The psychologic handicaps of theepileptic are for the most part the resultsof social ostracism imposed by thepublic," said the report. "Preventioninvolves a change in the public attituderegarding epilepsy."Preventive measures can reduce thenumber afiQicted by blindness, accordingto a report of the National Society forthe Prevention of Blindness. The nation'safaicted were estimated at 260,000persons totally blind, 340,000 with visionbarely useful and 1,000,000 blind in oneeye.Screening tests among school childrenhave become important factors in theprevention of deafness, said a reportof the American Hearing Society. Itadded:"There is needed an awareness that ahearing test is the only means of findinghearing loss in the early stages.Even though restoration to normalhearing may not be achieved, progressionof the deafness may be arrested incases diagnosed early."Hereditary indications were cited inconnection with cerebral palsy, epilepsy,diabetes, blindness and deafness. Thereports recommended close observationof persons with a family history of thosediseases, and more education as tofamily implication of certain hereditarydiseases or those with an hereditarypredisposition.Obesity Reported as Chronic DiseaseFactorPoor eating habits that cause childrenand adults to become excessively overweightor underweight are responsiblefor the development of many chronicdiseases, according to a report of theNational Conference on Chronic Disease:Preventive Aspects."An estimated 25 to 30 per cent ofthe adult population in the UnitedStates is overweight and the percentagemay reach as high as 60 per cent inwomen of the 50 to 70 year age group,"according to the Experimental Biologyand Medicine Institute of the NationalInstitute of Health.Delegates from 46 national healthgroups attending the three-day Conferenceon chronic disease prevention weretold that programs to control obesitycould do much to prevent diabetes, gallbladder disturbances, heart and circulatoryabnormalities and hernias that occurin hundreds of thousands of peopleeach year.Emphasizing the dangers of excessivedieting the report stated that "weightcontrol is primarily a form of medicaltreatment and should not be undertakenwithout medical supervision."The incidence of diabetes, increasingat the rate of 50,000 cases each year, ismore than twice as great in obese adultsas in persons of average weight. Eightyper cent of diabetes in adults is associatedwith obesity, according to a reportof the American Diabetes Association.Programs to control obesity were suggestedas a means of reducing the incidenceof this disease. Emphasis wasplaced on the need to find and treatmore cases of diabetes in the earlystages to prevent complications. Waysand means of setting in motion theseand other programs for prevention ofchronic disease were considered thisweek by conference delegates.Occupational HazardsOccupational hazards also play a rolein certain chronic diseases of the respiratorytract, heart and blood vessels,alimentary tract, liver, nervous system,muscle and boney structures, eyes, ears,and skin, according to a report by agroup of authorities in the industrialhealth field. The report called for anaccelerated industrial health program.TuberculosisUndernourishment, fatigue, overcrowding,low economic status, poorpersonal hygiene and silicosis are among

April, 1951 The Health Bulletin 11the contributing causes of tuberculosis,the National Tuberculosis Associationreported. The disease is spread by contactwith tuberculosis persons and bythe use of unpasteurized milk from tuberculouscows. An estimated 500,000people in the United States now havethe disease.The report emphasized the importanceof expanded mass chest x-raysurveys and wider use of tuberculintests to find cases in time for successfultreatment of the individual and to protectother members of his family fromthe disease.Emotional Factors in Chronic DiseaseContinued emotional disturbancesplay a part in causing some chronic diseases,according to the American PsychiatricAssociation.Body structure or function may undergochanges imder prolonged emotionalstrains. These physiologicalchanges can cause certain chronic diseases,the report said. Also, poor dietand accident proneness, possible resultsof a change in the individual's habits,may in turn produce chronic disease ordisability.Emotional factors were considered importantas causes contributing to hypertension,rheumatoid arthritis, epilepsy,colitis, ulcer, asthsma, and certain skindiseases.RAPID GROWTH OF VOLUNTARYHEALTH INSURANCE REPORTEDVoluntary health insurance is spreadingso rapidly that a coverage of 90,000,-000 Americans against the major costsof illness should come within the nexttwo or three years, said Dr. Elmer L.Henderson of Louisville, president ofthe American Medical Association.Writing in the Journal of the A.M.A.,Dr. Henderson said that between 70,-000,000 and 72,000,000 people now havesome form of voluntary health insurnance.Dr. Henderson, in reporting the rapidgrowth, said the second Blue Shieldmedical care plan, the United MedicalService, operating in the New York metropolitanarea, has just passed its 2,-000,000 mark in enrolment. The firstplan to reach that figure was the MichiganMedical Service. He said further:"Together, the achievements of thesetwo great medical care plans illustratedramatically the eternal truth whichsome of our detractors would denythat voluntary health insurance is agrowing, successful, practical method oftaking the economic shock out of illness."The United Medical Service, for instance,has reached its present size insix and one-half years. It operates inthe 17 southern counties of New YorkState, with the active approval of theMedical Society of the State of NewYork and of the medical societies inthose 17 counties. Half a million memberswere gained during 1950 — onefourth of the total enrolment. The goalfor the next year or year and a half hasbeen set at further increase of 1,000,-000 members."It is pertinent here to cite some figuresshowing the remarkable growth ofthe nonprofit medical care plans overthe nation. There now are 72 BlueShield plans in 41 states. Participatingin their operation are 113,000 out of the150,000 physicians who are in active,private practice. Last year the BlueShield plans paid out $150,000,000 forsurgical and medical services renderedto member patients; this at the rate of82 cents of every dollar paid in premiums."The Blue Shield plans are enrollingmembers at the rate of 28,000 everyworking day, and they now protect approximately12 per cent of the population—more than 17,000,000 persons.Other nonprofit medical care plans notyet in the Blue Shield group cover anadditional 2,250,000 persons. During 1950the Blue Shield plans of the nationgained 5,000,000 new members, an alltimerecord growth."The Blue Cross hospital plans keptpace. They added more than 3,000,000new members in 1950, carrying them beyondthe 40,000,000 mark in total enrolment.Out of every premium dollar,Blue Cross plans are paying out closeto 88 cents in benefits for services totheir member patients.

12 The Health Bulletin April, 1951"But the spirit of competition, of improvement,is by no means confined tothe non-profit medical care plans. Finaland complete figures from the insurancecompanies and the various otheragencies in the health insurance fieldwill not be available for several months,but it is a conservative estimate, basedon all known developments in 1950, thatbetween 70,000,000 and 72,000,000 Americansnow have some form of voluntaryhealth insurance coverage."SIX-POINT PROGRAM IN FIGHTAGAINST TB OUTLINEDA six-point program forthe preventionof tuberculosis— "the white plague"—is presented in Today's Health, publishedby the American Medical Association.The program, outlined in an articleby Dr. J. De Witt Fox of Takoma Park,Md., recommended:(1) Stay away from known spreadersof tuberculosis germs.(2) Watch out for people who coughand spit.(3) Avoid frequent colds and infections.(4) Live a healthful life. Eat a wellbalanced diet. Get plenty of rest andsleep.(5) Get to know a good doctor. Seehim whenever you need advice. Havehim check your health at regular intervals.(6) Beginning in your teens, have achest x-ray each year. This is the bestway to find tuberculosis early.Dr. Fox pointed out that for centuriestuberculosis was a leading cause ofdeaths in Europe. As recently as 1900it was the most frequent cause of deathamong Americans, killing about 200 per100,000 population. Since then it hasdeclined gradually as a cause to eighthplace with a mortality rate of 30 deathsper 100,000 population.He ascribed this decline as "largelydue to the unremitting efforts of physicians,nurses, public health workers anda well-informed public."He pointed out that while some drugshave been found that hold promise inthe cure of the disease, the best weaponsstill are prevention and early treatment."Because tuberculosis is a contagiousdisease, one should avoid contact withpeople known to have it in active form,"he advised. "This includes even ourdearest relatives; tuberculosis plays nofavorites. The disease is spread bygerms carried in the sputum (coughedupdischarge) of a person with activetuberculosis. The important thing incontrol is to prevent drops of sputum ordust containing the germs from reachingothers."He said tuberculosis is likeliest to developwhen bodily defenses are temporarilyweakened by fatigue or stress.He urged extra rest and sleep after recoveryfrom a cold or other infection.Other recommendations were a wellbalanceddiet, plenty of water, cleanliness,fresh air, outdoor exercise andsunshine. Periodical chest x-rays, hesaid, will reveal tuberculosis in its earlystage when early cure is possible.* * * *SAYS CIVIL DEFENSE PLANNINGMUST INCLUDE GERM WARFAREPlans for civil defense in event ofwar must include the possibility of biologicor germ warfare, a national healthdirector said today, adding that moreknowledge and better equipment arenecessary if maximum protection of thepopulation is to be insured in case ofsuch an attack.Dr. Victor H. Haas of Bethesda, Md.,Director of the National MicrobiologicalInstitute of Health, Public Health Service,Federal Security Agency, discussesbiologic warfare in an article in theJournal of the American Medical Association.The article was prepared by Dr.Haas at the request of the Council onNational Emergency Medical Service ofthe A.M.A."It is possible," Dr. Haas said, "thatbiologic warfare may never be employed.. . still, plans for defense must takeinto account all the conceivable capabilitiesof a potential enemy, includingbiologic warfare."Dr. Haas believes that the goal of anenemy who intentionally spreads germswould be to cause incapacitating illnessesrather than extensive fatalities.

April, 1951 The Health Bulletin 13This would tax medical, health and ecoinomic facilities to a great degree. As anillustration, he cited industrial plants inwhich effectiveness would fall off sharplyif even less than 20 per cent of theemployees failed to report for work andthe serious handicaps which would resultif key individuals died or could notreport for work."Whatever the direct damage in termsof sickness, death, decreased efficiencyand confusion, there would also be apsychological reaction on the part ofthe attacked population. Fear of theunusual or the unknown has panicpotentialities, and this aspect of theproblem would require serious consideration;undoubtedly an enemy wouldmake every effort to exploit it."One of the principal routes whichwould be used to spread germs, in Dr.Haas' opinion, would be the air, althoughdrinking water, milk and otherfoods, drugs, cosmetics, money or papersare also possible methods of dissemination.Our physical senses alone wouldnot tell us that germs are present asthey would probably be odorless, tastelessand colorless, he said.None of the present methods of testingwater, milk and food products andof sampling air are immediately applicablefor detection of biologic warfareagents, Dr. Haas said."While these limitations must be faced,they do not justify a policy of inactionor delay. Some of the simpleroperations of sampling and identificationshould be put into effect, and itmay be anticipated that experience andresearch will ultimately overcose manyof the initial difficulties, while otherscan be minimized by efficient organization."He advised "more knowledge and betterequipment ... to permit developmentof defense against biologic warfareto the extent that would permit maximumprotection of personnel subject toattack."The nine specific research projects henamed as necessary to strengthen ourdefense are: 1, development of airsampling devices capable of detecting awide variety of agents than currentlypossible; 2, more rapid methods forisolation and identification of diseaseagents; 3, methods for active immunizationafter exposure; 4, antigens capableof immunizing against whole classes oforganisms rather than individual speciesor strains; 5, mass immunization procedurewhich would permit immunizationby inhalation of antigens by largenumbers of people simultaneously; 6,procedures for sterilization of large airmasses; 7, information on optimal dosageof disease agents and on infectionrates after exposure to know dosages;8, measures for arresting infections duringthe incubation period by adequateyet economical treatment; 9, specifictreatment for diseases caused by smallerviruses.Once an attack has occurred, civil defensemust be directed toward minimizingthe effects of an attack, he said."This would include limiting the numberof casualties; shortening the periodof morbidity; reducing or preventingfatalities, and preventing developmentof secondary cases (spread of the diseasethrough personal contact)."One of the first steps in control of diseaseis the ability to recognize its presence.This ability, according to Dr.Haas, "can be developed to a greaterstate of efficiency than is usually considerednecessary for peacetime communicabledisease control."For example, influenza, typhus, Qfever, typhoid and cholera are a few ofthe germs believed to be possible biologicwarfare agents. The doctor, by knowingwhat constitutes the usual incidence ofcertain diseases in a particular localityat various seasons, can quickly recognizeany unusual illnesses or familiar illnessesoccurring in unexpected numbers.Any suspicious circumstances should beimmediately investigated to determinewhether or not the outbreak occurredas a result of biologic attack.Absenteeism from schools or certainindustries, overloading of hospitals andclinics—evidence of outbreaks of communicabledisease in peacetime—shouldalert authorities that an attack mighthave taken place."Adequate preparation in advance and

14 The Health Bulletin April, 1951. .proper reaction after an attack," saidDr. Haas, "will . . . permit limitation ofnatural outbreaks and . may confidentlybe expected to achieve controlover infectious agents deliberately disseminated."In the same issue of the A.M.A. Journal,Dr. James C. Sargent, Milwaukee,Wis., chairman of the A.M.A. Councilon National Emergency Medical Service,viewed the prodigious role that healthand medical professions must play inthe civil defense picture as a whole.Dr. Sargent said:"Civil defense stands alongside militarydefense as a vital component ofour national security. This responsibilityfor national survival now rests onevery citizen . . ."It would be impossible to overestimatethe importance of the civil defensemedical and health services to the nation'ssurvival in this regard. The sickmust be cared for; enormous numbersof casualties must be treated, and allmust be protected from the communicablediseases that could accompany thedisruption of normal public health andsanitary safeguards . . ."Plans must be made in peacetime,since the opportunity for careful preparationand organization is irrevocablylost during the confusion and urgencythat is attendant on war. All trainedhealth personnel, including dentists,nurses, veterianarians, pharmacists,sanitary engineers, technicians of alltypes, as well as physicians, must participateand must cooperate wholeheartedlyand unselfishly with each otherand with those in authority . . ."There are numerous responsibilitiesthat devolve on the members of thehealth professions because of the possibilitiesinherent in the enemy's use ofthe newer weapons of warfare. The detectionof atomic, biologic or chemicalwarfare agents, as well as the treatmentof casualties from their effects,entails specialized knowledge and facilitiesthat should be supervised, for themost part, by the health professions . . ."The people of this nation must learnto live with rather than in fear of theatomic bomb, for its threat will remainwith them for a considerable time tocome. The public must be educated withrespect to the true potentials and limitationsof atomic warfare. Never beforehas there existed a weapon that permitssuch an opportunity for exploiting thepeople's fear of the unknown. The samemight be said of biologic and chemicalwarfare. This is not intended to dispargethe effects of these weapons, fortheir use could cause untold thousandsof casualties. But there is nothing newor mysterious in the effects of theseweapons . . ."The problem that confronts thehealth professions lies not in any lackof knowledge concerning these agentsbut in the lack of suitable plans andprograms for handling large numbers ofcasualties from them."* * * *SELECT PITTSBURGH FOR1952 CONGRESS ONINDUSTRIAL HEALTHThe Council on Industrial Health ofthe American Health Association hasselected Pittsburg for its twelfth annualCongress on Industrial Health, accordingto an announcement by Dr. Carl M.Peterson of Chicago, secretary of thecouncil.The dates for the congress have notbeen fixed. Dr. Peterson said, but areexpected to be sometime in February of1952. The eleventh annual meeting heldrecently in Atlanta, Ga., drew medicaland industrial leaders from all parts ofthe country for discussions of healthproblems in industry.Dr. Anthony J. Lanza, chairman ofthe Institute of Industrial Medicine,New York University-Bellevue MedicalCenter, New York, is chairman of theCouncil on Industrial Health.

April, 1951 The Health Bulletin 15//IMMUNIZATION AND CIVILBy William H. RichardsonRaleigh, N. C.DEFENSE//Throughout North Carolina, plans Both diphtheria and whooping coughare being made for civil defense. Those are extremely dangerous for small childrenand, although the death statisticsin charge of the program are thinkingabout air raid warning signals, emergencyfire fighting equipment, emer-we know that many children died offor 1950 have not yet been completed,gency medical services, and the many these diseases in North Carolina lastother services that are essential in disaster.It has been pointed out by those necessity, rest upon those parents whoyear. Responsibility for this must, ofactive in making our defense plans that failed to have their children immunized.Such parents could have spareddefinite responsibilities fall upon theshoulders of every man and woman in their children much suffering; theythe State. Adequate defense calls for could have saved, for themselves, manypreparation against many emergencies dollars and could have saved the valuabletime of attending physicians, re-which might arise in connection withall-out war. It means more than diggingair raid shelters, or studying how suffering from illnesses which couldleasing them for service to personsto defend ourselves against the dangers not have been prevented.of an atomic attack.A physician once wrote the NorthThe purpose of this article is to call Carolina State Health Officer that heattention to a definite measure that isfelt resentment every time he was calledupon to treat a child with diph-necessary in both war and peace, andwhich constitutes an important part of theria, because the disease is preventable.The loss in lives, money and time,our civil defense. Most parents defendtheir children against hunger, by providingadequate food; against cold, byin connection with preventable diseases,is bad enough in ordinary times, butproviding proper clothing; and against now, while we are trying to conserveignorance, by sending them to school.all of our resources, the need forThereimmunizingall children against everyare very few, if any, who woulddeliberately cause their children to undergoany physical suffering which before.preventable disease is greater than evermight be prevented. But, many are unwittinglydoing just that, by neglectingProtection Is SimpleItto have theirhaschildrenbeen pointed outimmunizedby a physicianat theagainst preventable Statediseases whichBoard of Health thatcause bothimmunizationsuffering andnow isdeath.so simple thatthere is almost no reason why everyImmunization Effectivesingle child should not be protectedReports received by the State Board against not only diphtheria and whoopingcough, but also against tetanus,of Health show that, in 1950, therewere 499 cases of diphtheria in North which is lock jaw, and smallpox. HeCarolina, practically every one of which went on to point out that many physiciansnow give diphtheria, tetanus andcould have been prevented, by meansof immunization. For more than a decadenow, there has been a law on our combined form. Only one injection awhooping cough immunizations in aStatue books, requiring the immunizationof babies against diphtheria, dur-months, will protect children againstmonth for four doses, starting at threeing the first year of life. Despite this, all three of these diseases for manywe continue to receive reports of diphtheriaamong our little children. There ed by each child at one year, threemonths. Additional protection is need-also occurred in North Carolina last years, and when he or she startsyear 3,552 cases of whooping cough. school. This additional protection is

16 The Health Bulletin April, 1951provided by means of what are calledbooster doses — one injection of thecombined immunizing agent is given atone year, three years, and at schooltime.This same physician went on to saythat these immunizations can be givenseparately. Your family physician willadvise you as to the best procedure foryour child. If you prefer, you may secureimmunizations at your local healthdepartment, without charge.Smallpox immunization should be administeredat the age of one year, orsoon thereafter. You may be interestedto know that smallpox now is presentin many countries, including England,which has socialized medicine, and nolaw requiring immunization against anydisease.The North Carolina State Board ofHealth, according to the physician incharge of Epidemiology, receives frequentreports of travelers who are comingto North Carolina, by air, fromcountries where smallpox exists. It isnecessary for these people not only tobe vaccinated, but to remain under observation,during the incubation period.Do Not Relax EffortsAll of this means that, although youmay not hear about smallpox, you cannotafford to become lax in the matterof vaccination against it. Therefore, itis highly desirable that every child bevaccinated, preferably at the age ofone year, and certainly before enteringschool.Diu-ing times of war or even mobilizationfor defense—as at present—thepopulation undergoes serious disruption.More people are traveling about. Housingconditions become overcrowded inmany areas, especially those adjacentto military establishments, or wheremunitions of war are manufacutred.We have examples of this in our ownState. Where there is actually wardamage, these conditions become muchworse and existing medical facilitiesare inadequate.In 1945 — just six years ago — diphtheriasuddenly became epidemic inthe wartorn areas of Germany. At thesame time, many of our service menbegan returning home. Apparently,some of these and other travelers fromthat part of the world became carriersof diphtheria. The result was that,here in the United States, diphtheriaalso increased. To bring this problemeven closer home, the 1945 diphtheriacases in North Carolina were more thandouble the number for 1944. We mustprotect ourselves from a recurrence ofthis unfortunate happening and, notonly that, we should take advantage ofall the immunizing agents, so thatevery child is protected as fully as possible,not only against diphtheria, butagainst all other preventable diseaseswhich might become epidemic duringperiods of great stress.The Epidemiologist for the StateBoard of Health has provided the followingsummary of this discussion. Hemakes five points, namely:(1) All children three months of age,and older, should be immunized immediatelyagainst diphtheria, tetanus,and whooping cough.(2) All children one year of age, orolder, should be vaccinated againstsmallpox.(3) Booster doses should be given tochildren at one year, three years, andbefore starting to school.(4) Protecting children in this way isessential in peace time, and is evenmore essential, as part of civil defense,in order to conserve our medical andhospital resources for use in time ofpossible war.(5) Contagious diseases follow war,so protect your family now.And so we have some very definiteadvice on immunization of our children,as a part of any well ordered programof civil defense. A parent who neglectsthe immimization of a helpless childagainst diseases which cripple and killmay not of necessity be a criminal, butsuch parent certainly is extremely negligent.

MEDICAL LIBRARYU. OF N. C .CHAPEL H ILL, N. C .(S^fel^iiI TKis BuUetin will be sent free to anij citizen of ri\e Stat^e upot\ request IPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912VoL 66 MAY, 1951 No. 5Lois Lee Barnes, Raft Swamp Township, Robeson County, bitten bya rabid dog. Photo by Penn Gray, Robersonlan.

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHuBEBT B. Haywood, M.D., Vice-President RaleighH. Lee Labge, M.D Rocky MountJohn LaBrucb Wahd, M.DAshevllleJasper C. Jackson, Ph.GLumbertonMes. James B. Hxjnt Lucama, Rt. 1John R. Bender, M.DWlnston-SalemBen J, Lawrence, M.D RaleighA. C. Current, D.D.S GastonlaEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OCQcerJohn H. Hamilton, M.D., Assistant State Health Officer and Director State Laboratoryof HygieneC. C. Applewhitk, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. JARRETT, B.S., Director Sanitary Engineering DivisionC. P. Stevick, M.D., M.P.H., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting It. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any inwhich you may be Interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitis Infantile Paralysis Typhus FeverCancer Influenza Venereal DiseasesConstipation Malaria Residential SewageDiabetes Measles Disposal PlantsDiphtheria Pellagra Sanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFlies Teeth Whooping CoughTuberculosisEpilepsy, Feeble-mlndedness, Mental Health and Habit TrainingRehaDllitation of Psychiatric PatientsThe National Mental Health Act.SPECL\L LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal Care.First Four Months.Prenatal Letters (series of nine Five and Six Months.monthly letters).Seven and Eight Months.The Expectant Mother.Nine Months to One Year.Infant Care.One to Two Years.The Prevention of InfantileTwo to Six Years.Diarrhea.Instructions for North CarolinaBreast Feeding.Midwlves.Table of Heights and Weights.Your Child From One to SixBaby's Dally Schedule.Your Child From Six to TwelveGuiding the AdolescentCONTENTSPageImmunization Policy 3Our Enemy—The Rat 5

^^ T^>TTiBl IPUBLI5MED BYTAE N^A CAROLINA STATE B'^ARD-zAEALTAl BVoL 66 MAY, 1951 No. 5J. W. R. NORTON, M.D., M.P.H., Sute Health Officer JOHN H. HAMILTON, M.D., EditorIMMUNIZATION POLICYBy a. H. Elliott, M.D., John H. Hamilton, M.D.,C. P. Stevick, M.D., AND Robert J. Murphy, M.D.State Board of Health, Raleigh, North CarolinaRecommendations first made severalyears ago for the immunization of infantsbefore the age of six monthsagainst pertussis have now been followedwith general agreement In thellteratvire on this subject. At the sametime there has also been widespreadacceptance of the principle of simultaneousadministration of diphtheriaand tetanus toxoids combined with pertussisvaccine. Earlier hesitancy to theuse of diphtheria toxoid before the ageof six months no longer appears toexist, to an important extent. The injectionof diphtheria and tetanus toxoidsearly in Infancy is necessary ifthey are to be used in combinationwith pertussis vaccine and the latteris to be administered at the age whenprotection against pertussis is mostneeded.The use of these combined antigensIs discussed in two articles appearingin the June 1950 issue of the Journalof the American Public Health Association.In a group of 189 Infants receivingthree injections of alum precipitateddiphtheria and tetanus toxoidscombined with pertussis vaccine atone, five, and nine weeks of age, respectively,di Sant'Agnese found thata rise In antibodies occurred in themajority. The dosage of the antigenused was O.Sc.c, Ic.c, and Ic.c, containinga total of 50 billion pertussisbacilli. The rise in antibodies was notas satisfactory in .these young infantsas in older children, however, and therecommendation was made that Immimizationnot be attempted before theage of three months.Sauer and Tucker found that fourdoses of the alvun precipitated tripleantigen administered at three, four,five, and six months, respectively, conferredprotection against diphtheria to86 per cent of the infants studied,against tetanus in 100 per cent, and topertussis in 98 per cent.Sauer used a product containing twicethe necessary amount of diphtheria andtetanus toxoids and 30 billion pertussisbacilli per c.c. Doses of 0.5c.c. were injected,giving a total dose of 60 millionpertvissis bacilli.In a round-table on Immimology InPediatric Practice, published in theJanuary 1951 Issue of the Journal ofPediatrics, Miller recommends the administrationof O.Sc.c. of alimi precipitateddiphtheria and tetanus toxoidswith pertussis vaccine (30 billionorganisms per c.c.) at four to eightweeks followed in one month by asecond Injection of 0.5c.c. and afterthree more months, by a third Injectionof 0.5C.C.All authors agree that recall or boosterdoses are essential at approximatelyone year and again before startingschool. It is important to note that thelevel of immimity after booster doses

.'The Health Bulletin May, 1951reaches approximately the same pointIn childi-en immunized early in infancyas in those immunized later.Reactions have not been found to beserious if care is taken to inject thematerial intramuscularly and to changethe needle after the syringe has beenfilled. Should a serious febrile reactionoccur, it is recormnended that the subsequentdose be reduced to O.lc.c. andthe patient's response again observed.At a meeting of State Epidemiologistsin Atlanta in April 1951, Dr. MyronWegman of the Louisiana State UniversityMedical School recommended aschedule of three doses of the alumprecipitated triple antigen at two, three,and four months with booster doses atone and six years.The use of tetanus toxoid routinely inInfant immunization is of special significancein relation to Civil Defense.A proposal has been made that tetanusImmunization of adults be included inthe nation-wide plans now being formulated.Some have felt that this procedureshould be delayed vmtil productionof the material to be usedcould be increased adequately to meetthe huge demand and imtil certainother more urgent civil defense needscould be met. In view of this situation,it appears to be a practical procedureto begin immediately the use of combinedalum precipitated diphtheria andtetanus toxoids with pertussis vaccinewhere this is not already the case, inorder that the infant popiilation nowundergoing immunization would notneed to be reinjected except for boosterdoses. This recommendation includesthe use of an alum precipitated tripleantigen containing not less than 30billion pertussis bacilli per c.c. and atotal minimum dose of at least 45bUlion.There is a considerable weight ofopinion that administration of tetanvistoxoid is important as a routine peacetimeprocedure because of the fact thatthe prophylactic use of antitoxin inhorse serum can be eliminated in mostcases that have been so inununized.In a child who has previously receivedtetanus toxoid and who has received aslight to moderately severe injury requiringtetanus prophylaxis. Miller recormnendsa booster dose of Ic.c. offluid toxoid. This preparation is advisedin lieu of alum precipitated toxoidsince it acts as a more promptstimulus of the patient's immunity. Insevere injuries such as compoimd fracturesor gross contamination of wounds,tetanus antitoxin is recommended byMiller at the same time as the toxoid.When early combined immunizationagainst diphtheria, tetanus and pertussisis carried out, there is adequatetime in the immunization schedule inwhich to administer smallpox vaccinebefore the age of one year. This resultsin fewer reactions and the child is lessapt to scratch the site of the vaccination.Six or seven months is a satisfactoryage.Early immimization has one otherpractical advantage from the publichealth standpoint, namely, that a higherpercentage of yoimg infants reach wellbabyclinics and physicians' offices thando children of an older age.Typhoid immunization is no longerrecommended by public health authoritiesfor routine vise on a mass scale.In rural areas where typhoid fever stillocciirs, selected groups of the populationshould be immunized. It is alsoessential that all persons in contactwith a known carrier or persons whoanticipate exposure to vmsanitary conditionsreceive typhoid immimization.Rocky Mountain spotted fever vaccineis recommended for immunizingpersons who are routinely exposed towooded areas. Present incidence of thisdisease does not justify the administrationof the vaccine to the entire population.An outline summary of the aboverecommendations is as follows:Recommended ImmimizationSchedule1 month—Examination and conferencewith mother.2 months—Conference. First injectionof alum precipitated diphtheria andtetanus toxoids with pertussis vac-

May, 1951The Health Bulletincine (should Include 15 billion pertussisorganisms).3 months—Conference. Second injectionD-T-P.4 months—Conference. Third injectionD-T-P.5 months—Conference. Vaccinationagainst smallpox.6 months—Conference and examination.Record result of smallpox vaccinationand revaccinate if necessary.7% months—Conference.9 months—Conference.12-18 months—Conference and examination.Booster dose D-T-P.School entrance—Examination. Boosterdose D-T-P. Revaccinate againstsmallpox.If the intervals between injections exceedthe one specified, continue theimmunization schedule xmchanged.When typhoid vaccine is administered,the following dosage is recommendedfor adults: 0.5c.c. weekly for threedoses. This should be reduced proportionatelyfor infants and children. Annualbooster doses of O.lc.c. intradermaUyshould follow the primary immimlzation.The booster injection may begiven subcutaneously, if preferred, usinga dose of 0.5c.c. for adults and less forchildren.OUR ENEMY — THE RATBy Charles M. WhitePrincipal Sanitary EngineerDivision of Sanitary EngineeringState Board of Health, Raleigh, North CarolinaHow Rats Destroy UsAs far back into antiquity as recordsgo, mankind and rats have waged anever-ceasing war. During some periodsof this struggle the rats have, in somecountries, been on the verge of completevictory by the total annihilationof their adversaries. Yet, there hasnever been a time when the exterminationof rats has been regarded as apossibility by the most hopeful.Nature endowed both rats and manwith powers of adaptability not possessedby any other living things. Bothhave manifested the ability to surviveand reproduce their kind in almost anyearthly clime. Each is omnivorous, ferocious,and completely destructive of naturalresources including all forms oflife. The life span of man Is longerbut in rats this is compensated for bya far more rapid rate of reproduction.In spite of aU oiu- efforts toward rateradication or reduction, the populationof these rodents keeps pace with that ofman. Experts estimate the number ofrats in the United States to be approximatelythe same as that of the humanpopulation.The black death, or bubonic plague,which swept across Europe in successiveepidemics from the fourteenth to theeighteenth century, was transmitted byrat fleas from rats to human beings.No greater calamity has occurred inhistory, including the world wars, the1917-18 influenza epidemic and othermajor disasters. It is estimated thatone-fourth of the European populationor at least 25,000,000 people died of thedisease. Mass hysteria and other psychologicaleffects, as well as generaldisorder and social disintegration, causedeconomic, moral and political degradationto follow. While this diseasehas never become widespread In theUnited States, there have been recorded505 cases during the present century.Of these 318 died. None of them occurredin North Carolina.Endemic typhus fever, another maladywhich is transmitted from rats tohuman beings by rat fleas, does occurin North Carolina. From 1929 through

6 The Health Bulletin May, 19511950 there were 1,487 cases of this diseasereported to the North CarolinaState Board of Health. The case fatalityrate Is very low. About 2% of thosewho have the disease die of it.Salmonellosis, a food infection disease,is often transmitted to man fromfood contaminated with infected raturine or feces. The case fatality rateof this disease is about one per cent.Hemorrhagic jaundice, or Weil's disease,is usually acquired by man fromfood or water contaminated by rat excretaor from handling infected rats.In dififerent outbreaks of this diseasemortality has varied from 4 to 48 percent.Rat-bite fever, which has a casefatality rate of about 10% in imtreatedcases, is caused, as its name signifies,by the bite of infected rats. In a studymade in Baltimore of 93 persons bittenby rats seven developed this disease.Trichinosis, a disease acquired by eatingInfected pork, has a mortality rateof about 5%. Normally, the rat playsno part in the transmission of this diseaseas we do not eat rats, but sometimeshogs become infected by eatingrats which have obtained the causativeorganisms by feeding on raw or improperlycooked pork and pass the diseaseon to us when we eat the hogs.Human beings are killed by all ofthese diseases with transmission cyclesInvolving the rat; hence their abilityto spread pathagenic organisms is probablythe most formidable weapon employedby rats in their never-endingstruggle against humanity. Yet, asidefrom their role as disease bearers, thereare other ways In which these rodentsadversely affect mankind, in some casescausing only minor annoyance, but attimes creating major catastrophes.Hordes of rats have been known tobring on starvation and famine by thedestruction of growing as well as storedfood crops. Vast quantities of food arealso rendered unfit for human consumptionupon being polluted by rats.The U. S. Department of Agricultureestimates that the average rat consumesor otherwise destroys $22.00worth of food in a year. If this be true,they cost North Carolina about $88,-000,000 annually. These destructive rodentseat eggs, kill poultry and otherdomestic animals and destroy largequantities of wild life. Structural damageto buildings and auxiliary facilities,such as plumbing and electric wiring.Is often caused by rats. They are alsoresponsible for many fires started bytheir gnawing on or dragging matches.Know the EnemyBefore successfully waging war. It Isnecessary to have knowledge of thehabits and characteristics of the enemy.In rat control, effectiveness is determinedby tiie use which is made ofbasic knowledge of the rat.There are two species of domesticrats In North Carolina, both of whichare known by several names. The Norwayrat, which is also known as thebrown, house, bam, burrowing, sewerand wharf rat, is the larger of the twospecies. The roof rat, which is frequentlyknown as the Alex, grey, black orclimbing rat, as its name implies, Ismost commonly foimd at higher levels.Being a better climber than the Norwayrat, this rodent Is usually the onefoimd In the upper stories and atticsof buildings.The reproduction potential of the ratis enormous. The gestation period Isonly 25 days, and litters range from 6to 14. Mature rats remain fertile regardlessof the season and diiring ayear produce several litters, the numberdepending on such things as food,warmth, and shelter. Studies In Baltimoredisclosed from five to seven littersannually. Heaviest breeding takes placeduring the svmimer months under normalconditions. For this reason, theeffects of poisoning campaigns in thefall last longer than those conductedIn the spring.The behavior of rats is influenced bythe same things which motivate humans,such as hunger, thirst, sex, fear,curiosity and maternal instinct. Hunger,thirst and the requirement for placesto hide from danger are factors mostutilized in rat control.The rat has a highly developed senseof smell. Its taste is somewhat less

May, 1951The Health Bulletinsensative than man's. Many authoritiessay rats are color blind. The sensesof hearing and touch are both veryacute. Its agility and excellent senseof balance makes control operationstedious and difficult. A rat can jumpnearly two feet high from a standingposition and slightly over three feetwith a running start. In jumping downward,a rat can cover a horizontal distanceof 8 feet while dropping 15 feetby jumping outward from a standstill.By being able to reach 18 inches, theycan scale a vertical wall if toe holdsare available at that spacing or closer.They can cross the street on a telephonewire or climb a vertical 3-inch pipe ifit is rusty. Palls seldom prove injuriousto them. Norway rats will burrow intothe ground as much as 5 to 6 feet toget under the foimdation of buildingswhere food is available but they seldomgo down over 18 inches for shelter ornesting. Sometimes their undergroundtunnels are several himdred feet long.Bodies of water are no barriers as ratshave been known to swim a half mUeIn open water. They dive and swimunder water without hesitation. Theywill gnaw through almost any materialthat is not as hard as their teeth.While rats tend to remain close totheir harborage as long as the foodsupply and living conditions are adequate,they will travel long distanceswhen necessary. In rural commimitiesthey frequently leave buildings in thespring and live in the fields imtil thescarcity of food or search for warmthdrives them back Indoors. Mass migrationshave been reported to occur whencrops failed or other disasters tookplace.The existence of rats in any area isdependent on food, water and harborage,and their density is usually Inproportion to the availability of thesenecessities. These items must be maintainedin any community for the benefitof mankind. If this could be doneand at the same time make them inaccessibleto rats, their control wouldnot present a very difficult problem.The habits of both rats and humansprevent such an ideal solution. Theperserverence of the rat combined withits resourcefulness and physical characteristicsmakes it hard to erect andmaintain barriers between it and food.Our careless habits and innate indifferencetoo frequently result in abountiful supply of everything the ratneeds being readily available.Ratproofing BuildingsRatprooftng of buildings in whichfoodstuffs are stored has been provedto be both effective and practical. Muchof this work has been and is still beingdone in North Carolina on a community-widebasis vmder the supervisionof local health departments incooperation with the N. C. State Boardof Health. Unfortimately, this activityis slow in achieving its goal due to thecost, lack of community organization,public indifference and individual opposition,as well as the need for continuedInspection and maintenance.While rat-proofing is strongly recommendedby us as one of the effectiveweapons against rats, cognizance mustbe taken of its limitations.Don't Feed the Enemy orProvide Him ShelterEven if all buildings in which foodstuffsare stored were to be completelyratproofed, our careless habits wouldstill furnish room and board for them.When garbage Is thrown out on theground or left in open containers, weare giving succor to the enemy. As mostdwellings can be entered by rats, thehousewife Is encouraging their residencyby providing a happy home in whichthey can hve and raise large familieswhen she leaves scraps or other foodat any place they can get to or allowsaccumulations of trash to form in whichthey can build nests.Foods should be treated as potentialsustenance for rats from the momentthey are brought into town tmtil finaldisposal of the garbage by adhering tothe following practices:1. Prior to preparation or serving, allfoods should be stored in ratproofcontainers.2. Foods for chickens, hogs or other

8 The Health Bulletin May, 1951animals should be stored in ratproofbiilldings or containers.3. Scraps of food should not be lefton the table, sink, drainboard, flooror any other place.4. Garbage should be kept in metalcontainers at all times. Neverthrow it out on the ground.5. The garbage can lid should be tightfitting and kept on at all timesexcept when its removal is necessaryin order to deposit garbage,clean the can or remove garbage.6. Cafes and other cormnercial establishmentswhich produce organicwastes should store garbage cansin rat-proof, fly-proof garbage containerhouses.7. Garbage should be collected atleast twice a week.8. Garbage should be disposed of bysanitary land fills or incineration.Never use an open dump.Harborage Is almost as essential asfood to rats. For this reason, collectionsof trash should not be allowed in dwellings,business establishments, backyards, alleys, vacant lots or any otherplaces.Prom the foregoing, it can be seenthat If food and harborage are notmade available to rats, there will be norats. Even though much progress is beingmade in that direction, the time isnot In sight when we will cease to feedand provide homes for them. ManyNorth Carolina towns have stringentlaws regarding the storage and collectionof garbage, the ratproofing ofbuildings and keeping premises free ofrat harborage. Some have providedsanitary land fills and modern incinerators.Through education programsand clean-up campaigns, conducted bylocal health departments, much hasbeen done to teach the housewife aswell as owners of bvisiness establishmentsthe importance of not feedingand housing rats. Yet, a peep into thealleys and back yards of almost anytown will disclose piles of valuelesstrash, waste foodstuffs on the groimd,uncovered garbage cans, open ventsthrough which rats can enter and leaveat will, and other conditions highlyfavorable to the happiness and wellbeingof rats. A stroll around the averagegarbage dmnp reveals a conglomeratecollection of the discards of moderncivilization, in all stages of disarray,destruction and putrefaction,providing a rat Utopia. A herd of hogsis sometimes observed feeding on topand around the edges but leaving allthe food needed by the rats. The porkfrom such hogs is almost always infectedwith Trichinella aspiralis, theorganism which causes trichinosis. Thehogs become infected from eating scrapsof vmcooked pork or dead rats.Killing RatsUntil we stop raising rats, it will benecessary to employ means for killingthem In order to keep their numbersdown to the bearable limit. This canbe done by violent means, such asshooting or clubbing, which, thoughconsidered good sport by some. Is notvery effective in reducing the population.Predators, such as cats, dogs andferrets, do very little good. Rats can beeffectively destroyed in their burrowsby several means, the most commonmethod being that of pimiping cyanidegas into the burrow. By attaching ahose to the exhaust pipe of a car andsticking the other end into the burrow,rats can be killed with carbon monoxidegas. Water forced into the burrow vmderpressure with a garden hose will drownrats. Several types of traps are on themarket which are widely used in ratreduction, ranging from the simple snaptrap to highly complicated, electricallyoperated traps.Poisoned bait or water is the mostwidely used means for killing rats. Anumber of poisons used for this purposeare available, but most of themare so highly toxic to human beings anddomestic animals that their use byother than highly trained experts isnot recommended. Red Squill, the safestof all rat poisons, has been in generaluse for years. Until recently it was theonly such poison recommended by theN. C. State Board of Health for publicuse. This material has been very satisfactoryin bringing about temporary re-

May, 1951 The Health Bulletin 9ductions In the nvunber of rats in anarea. Bait shyness is quickly developedby rats after receiving a dose too smallto kill or after seeing other rats becomeill and die soon after eating it.The result is prompt enough to causethe illness to be associated with thebait. This poison, regardless of its disadvantages,has a place on a rat controlprogram and is still recommended bythe N. C. State Board of Health inareas where extreme caution must beobserved against the possible ingestionby children or domestic animals, andfor the campaign-type rat control activitywhere no follow-up work Is to bedone.WarfarinA new rodenticide has been developedand released for public use which Iscomparatively safe and highly effective.This material, now called warfarin, wasfor a short period called Compound 42or WARP-42, and is sold imder severalcommercial names such as Dethmore,Rax Powder, etc.Warfarin, which is usually sold Inpowder form of 0.5% concentration, isentirely odorless and tasteless to bothrats and man. When this concentrationIs mixed with yellow corn meal or otherbait In the proportion of one part to 19parts of the bait, it is readily eaten byrats. Bait shyness does not develop aswith Red Squill. For this reason a continuouspoisoning program can be keptin operation.Warfarin is very slow in its physiologicalaction on the rat and severalfeedings are usually necessary before itproves fatal. A single dose is rarelyfatal. For several days after feeding noappreciable change is noticed in therat's appearance or activity. On thethird or fourth day subcutaneous hemorrhagesare often noticed, while Internalhemorrhages are occuring due tothe anti-coagulating effect of the chemical.By this time the rat walks slowlyand tends to drag its hind feet. Deathis caused by suffocation resulting fromlimg hemorrhage or the want of sufBcientblood to supply the tissues withfood. Little or no blood is observed externallyunless the rat has been injured.Death comes so peacefully andquietly that the other rats do not connectIt with food which has been eaten.The hazards to humans and domesticanimals are small but are consideredgreater than those with Red Squill.When baits poisoned with Warfarinare put out aroimd children or domesticanimals, bait stations should be used.The stations most commonly used arewooden boxes with holes to permit theentry of rats and inside containers tohold the bait. Your local health departmentwill be glad to supply informationregarding the design, constructionand placing of bait boxes.Dead and dying rats poisoned withWarfarin should be burned up or buriedto a depth of at least two feet to preventsecondary poisoning to domesticanimals.Your local health department will beglad to advise you regarding the use ofWarfarin and places where it can beobtained.In conducting an effective war againstrats several methods of attack are essentialas in other forms of warfare.Building barriers between rats and theirfood and harborage by ratproofing isboth practical and necessary In orderto conduct a successful campaign butby itself this method Is not sufBcent.Good hoxisekeeplng, premise cleanliness,proper handling of garbage, and otheradherence to basic principles of sanitationIs by far the best approach, butthe Impossibility of achievement on acomplete scale Is recognized. We willhave rats to kill for a long time.By the combined practices of ratproofing,cleanliness and rat killings,we can have satisfactory control.NEED MORE PHYSICIANEXAMINATIONS OF VIOLENTAND SUDDEN DEATHSOnly 13 per cent of the people in theUnited States are protected by adequateinvestigation of violent or suddendeaths, according to Dr. Richard Fordof Boston.In most states, Dr. Ford points outin the Journal of the American Medical

10 The Health Bulletin May, 1951Association, the coroner is not requiredby law to be a physician nor are thereadequate facilities for thorough investigationof such deaths. Dr. Ford estimatesthat 300,000 (29 per cent) of alldeaths annually are from violent orobscure causes.If medical examination is not a definitepart of the investigation in thesecases, he said, the true cause and mannerof death in many instances maynever be established.How does such medical investigationserve society?Its most important function is toexonerate the innocent, Dr. Ford believes.But disclosing murders, providingevidence for civil and criminal courts,recognizing fa.tal contagious diseases,exposing industrial health and safetyhazards are also important.Too often, he continued, the driverof a vehicle involved in an accident Isgiven full blame for killing or injuringa pedestrian whereas the victim—becauseof drunkenness, disease, or medication—isoften equally at fault.He also pointed out that there aresound medical reasons for many accidents.He described the case of a driverwho was seen to "struggle" with thewheel of his car while driving througha downtown section. The car went outof control, turned over and killed thedriver. An expense notation for a drugwhich was fovmd on the body and asubsequent medical investigation establishedthe man as an epileptic, a seizurehaving occurred while he was drivingthe car.Nonrecognition of mvirder is common.Dr. Ford said. In New York City alonethe medical examiner service disclosesapproximately 50 deaths annually whichare due to violence not noticeable externally.To demonstrate the role of medicalexaminers in establishing the iiuiocenceof a person, he cited the case of a smallgirl who died suddenly In a drugstore.The druggist was immediately suspectedof leaving poisonous drugs withinreach. A medical examination disclosed,however, that a red rubber toy balloonwas lodged in the child's windpipe. Sheprobably had been chewing on theballoon, it was explained, and, throughforced inspiration in sneezing or coughing,the balloon was drawn into thewindpipe and prevented her frombreathing.If this death had not been investigatedby thorough autopsy, to this daythe druggist would lie under the shadowof suspicion, even though tests showedthat the child had not been poisoned,Dr. Ford explained.Massachusetts, Maryland and Virginiawere the only three states namedby Dr. Ford as being served by centralizedlaboratories for medicolegal investigationof deaths. These togetherwith Maine, New Hampshire, Connecticut,Rhode Island and several citiesand counties of other states comprise atotal of 20,000,000 citizens served bysystems in which the investigator is atleast a physician, he said.Commenting on this problem in thesame issue of the Journal, Dr. Louis J.Regan of Los Angeles said:"When death takes place at work orin a trafiBc crash, it is readily assimiedthat it is an instance of accidentaldeath, while a medicolegal investigationmay reveal a natural cause and therebyplace the seemingly violent death Inits true causal relation. . . ,"Since, in many localities, the investigationof violent or obscure deathsis insxifBcient, the number of murdersthat actually takes place or the numberof deaths due to accident, suicide ornatural causes that are erroneouslyattributed to murder cannot be estimated."• • * *RECOMMENDED USE OFPENICILLIN OINTMENT INEYES OF NEWBORNSilver nitrate solution, the preparationnow being used in the eyes ofnewborn babies to prevent infection,may be replaced by penicillin ointment,as the result of a recent study. (Silvernitrate is required by law in manystates.)Drs. H. H. Davidson and N. J. Eastmanand Sanitarian Justina H. Hill of

May, 1951 The Health Bulletin 11Baltimore, writing in the Journal ofthe American Medical Association, recommendthat penicillin ointment beused in the eyes of newborn infants inpreference to silver nitrate because, intheir opinion, it is "the most eflacacious,the safest and least irritative agent"for this purpose.Dr, Davidson is on the staff of JohnsHopkins University and Hospital andis also senior assistant surgeon. UnitedStates Public Health Service. JustinaHill is also with the United States PublicHealth Service.Laws requiring the use of silver nitrateare a precautionary measure toprotect newborn babies from gonococcuseye infection. Such an infection—whichcan easily be transmitted at birth toan infant by a gonorrhea-infected mother—couldresult in serious eye damageor blindness.The doctors expressed the opinionthat, where necessary, regulations governingthe us» of silver nitrate shouldbe changed "to permit the use of penicillinoinment in hospital practice whenthe physician prefers it to silver nitrate."These recommendations come as aresult of their study of three differentmethods of eye care at Johns HopkinsHospital—penicillin ointment, penicillinintramuscular Injections, and silver nitrate.Each method was used in rotationfor a week at a time. During a twoyear period, 4,163 infants were treatedwith one of the three methods.All three methods proved equally effectivein preventing gonococcal infection,they reported, but the incidenceof eye irritation varied greatly.Only 10.6 per cent of the penicillinointment treated babies showed anysigns of inflammation such as redness,swelling or discharge. The Incidence ofirritation in silver nitrate treated babieswas 48.7 per cent. Irritation fromthe intramuscular treatment of penicillinwas recorded as 13.8 per cent."This observation," they said, "is inkeeping with the general experiencethat silver nitrate produces chemicalconjunctivitis (eye inflammation) In ahigh proportion of cases. (This inflammationdoes not cause serious or permanentinjury to the eye.)"Two other points in favor of thechange to penicillin ointment, accordingto the article, were that the costis approximately the same as that ofsilver nitrate and it Is easier to use.USE STREPTOMYCIN TO TREATTUBERCULOSIS IN CHILDRENStreptomycin has proved valuable intreating tuberculosis in children vmder12, according to an article in the Journalof the American Medical Association.Drs. William Berenberg, Charles D.Cook and Claire W. Twinam of Boston,authors of the article, tested the drugon 27 children between the ages of 7weeks and 17 years.They reported the following results:the disease was arrested in five, 18were improved, three were unimprovedand one was worse. The patient whobecame worse was a 7 weeks old Infantwho developed tuberculous meningitis.All three of the patients who did notimprove were over 12 years of age.Eight patients over 12 received the drugbut only two appeared to derive anylasting benefit from it, the doctors said.They explained that tuberculosis inchildren under 12 is somewhat differentfrom the type encountered in adultsand children over 12. Most children,they continued, between the ages of 3and 12 do well without specific treatment.The 27 children who received the drugwere selected because they failed toimprove with the usual treatment.Streptomycin may be expected to"supplement but not replace" the timetestedmeasures of prevention of reinfection,hygienic regulation, dietarysupervision, adequate rest and nursingcare in the treatment of tuberculosisin children, they said.

12 The Health Bulletin May, 1951PRECAUTIONS HELPGUARD CHILDRENAGAINST POLIOMYELITISThe National Foundation for InfantileParalysis lists these precautions forparents to follow in guarding childrenagainst poliomyelitis, according to anarticle in Today's Health, publishedby the American Medical Association:1. Keep children with their ownfriends. Keep them away from peoplethey have not been with, especially inclose daily living. Many people havea polio Infection without showing signsof sickness and can pass the infectionon to others.2. Try not to get overtired by work,hard play or travel. If you already havepolio In your body, getting very tiredmay bring on serious polio.3. Avoid getting chilled. Don't batheor swim too long in cold water. Takeoff wet clothes at once. Chilling canlessen your body's natural protectionagainst polio.4. Keep clean. Wash your hands carefullybefore eating and always afterusing toilet. Hands may carry polio infectionInto the body through themouth. Keep all food clean and covered.5. Watch for early signs of sickness.Polio starts in different ways—with aheadache, sore throat, upset stomach,sore muscles or fever. Persons comingdown with polio may feel nervous, crossor di2zy. They may have trouble swallowingor breathing. Often there is astiff neck and back.6. Call yoiu- doctor at once. Until hecomes, keep the patient quiet and inbed, away from others. Don't let thepatient know you are worried.7. Call your own chapter of the NationalFoundation for Infantile Paralysisif you need help. Look for thenumber in the telephone book or callyoiu* health department for the address.Polio is a very expensive disease totreat, but no patient need go withoutcare. You pay what you can afford,and your chapter pays the remainderof the cost of care. It is not a loan.Quarantine for polio is unwarrantedand medical experts agree that DDTspraying has no value in controllingthe disease, the article points out.Neither is there any scientific evidenceto condemn swimming pools as a sourceof infection. No one has been knownto contact the disease from water,* « * *AVOID EXTREIVEES INSUNBATHING TO SECUREATTRACTIVE TANFor maximum benefits and minimvraidangers in sunbathing, these suggestionsare offered in an article in Today'sHealth, published by the AmericanMedical Association.1. Start with 10 minutes of exposureto sun on the first day. By increasingexposure time 50 per cent each day, acoat of tan should be acquired safely.2. It is advisable to continue simbathingall summer, for the beneficialeffects of the ultraviolet rays will continuedespite the deepened color of theskin,3. Morning hours have been foimdmost effective for acquiring sun tan.The hours between 11 a.m. and 2 p.m.are most dangerous.4. Ultraviolet light may be as intenseon misty or cloudy days as indirect simlight. It can cause severeburning.5. The notion that skin burns morereadily when wet is a mistaken one.Stmba thing in shallow water or on theshore of a lake or the ocean is morelikely to produce a burn than svmbath-Ing away from the water, however. TheSim's rays are reflected from the water,which intensifies their strength. Reflectionsfrom snow or ice are evenmore potent,6. Lasting injury may be done if theeyes are not protected from the sim'srays. Dark glasses made of grotmd glassor several thicknesses of cloth over theeyes may be used.7. Drinking plenty of water or otherliquid when sunbathing is essential.Simstroke is due to dehydration. Salttablets are valuable, for salt tends tohold water in the tissues.8. After a sunbath, be sure to cooloff completely before plvmging Into cold

May, 1951 The Health Bulletin 13water. Heart attacks sometime resultfrom such sudden changes, which puttoo great a strain of adjustment on thecirculatory system.9. Children's skins are more tenderthan those of adults. Naps and planneddiversions in the shade or indoors areexcellent for youngsters who tend toplay too long in the hot sun.* * * *FIND 'TUSH-PULL"TECHNIQUE MOST EFFECTIVEIN RESUSCITATIONAn artificial respiration techniqueusing a "push and pull" maneuver isthe most effective of the manual methods,according to a report to the Cotmcilon Physical Medicine and Rehabilitationof the American Medical Association.The report also pointed outcertain advantages of mechanical resuscitatorsbut added that mechanicaldevices should be considered as adjunctsto and not substitutes for manualmethods.Drs. Archer S. Gordon, David C.Painer and A. C. Ivy of the Universityof Illinois College of Medicine, Chicago,made a study of various methods ofartificial respiration, both manual andmechanical. The study made by theChicago doctors was to determine themost effective methods of artificial respiration,a procediure which saves manylives.For their study they used 109 personswho had died less than a hour beforethe tests were performed, and nine livesubjects who were taught to "voluntarilysuspend their respiration."For most of the tests, the doctorsused a recently deceased person because,they said, such a subject is morecomparable to a person requiring artificialrespiration, except perhaps thedeeply anesthetized person where thereIs a temporary cessation of breathing.The effectiveness of artificial respirationdepends on several things but thisstudy was concerned mainly with theamount of air that could be broughtInto the lungs by various manvial andmechanical means.The doctors measured the minutevolume of air exchange with manualmethods by having the body inspireand exspire into a carefully balancedgraphically recording instrument calleda spirometer.With the mechanical methods, theyused a very sensitive and accurate flowmeter to record the volume of air exchange.A record could be made of theamoimt of air exchanged in the lungswith each respiratory movement.According to the report a comparisonof the findings shows that the resultsof the living subjects and recently deceasedones were "essentially in agreement"except that the volimie of airexchange in the living men was fourtimes greater. The doctors explained:"Either the volunteers unconsciouslyaided the artificial maneuvers or thereis less resistence in the conscious personto respiratory exchange. We areinclined to place much more weight onthe results from the corpses and toconsider them applicable in resuscitation(restoration of consciousness) ofnear-dead asphyctic (suffocated) subjects."The report continued:"Our results reaflBrm the fact thatno one method of artificial respirationcan be offered as completely satisfactory.However, there can be no doubtregarding the observation that thosemanual methods which utilize both a'push and pull' maneuver are superior."The mechanical resuscitators employedin this study are not more effectivethan a properly porformed 'pushand pull' manual method. . . . Exceptfor the armamentarium (equipment) ofthe anesthetist and of the fire or policeemergency crew, all mechanical devicesmust always be considered as adjunctsto and not substitutes for manualmethods."The doctors, however, pointed outseveral advantages to a mechanical resuscitator.Some of the advantages are:less skill is required; it is not fatiguing;it can deliver pure oxygen; It can beused where physical manipulation ofthe body is impossible or would beharmful as during major surgical procedures,in accidents with extensive

14 The Health Bulletin May, 1951burns, broken vertebrae, ribs and arms,for victims trapped under debris andduring transportation to a hospital;and it signals when the airway to thelungs is obstructed and provides anaspirator.At present the Schafer prone, or"push," method is used by more peoplethan any other. A newer but less knowntechnique employing a "pull" maneuver,involving lifting of the body at the hips,is the Emerson method, the doctorssuggested:"Those who are now indoctrinatedwith the Schafer prone pressure methodcan double the ventilating efBciency ofthe method by lifting the hips fourInches 12 times each minute, alternatingwith a 'push' on the lower part of thechest. Lifting the hips is fatiguing and,after the crucial first several minutes,may be employed after every second orthird 'push' on the lower part of thechest."• • • •EAR INJURIES ARE THREATOF NOISE IN INDUSTRYThe control of ear injuries due to excessivesound—the most frequent threatto the ears of workers today—^is a majorresponsibility of Industrial medicine,according to Raymond Carhart, Ph.D.,of Evanston, HI. Dr. Carhart is associatedwith Northwestern UniversitySchool of Speech and Department ofOtolaryngology.Auditory impairment due to excessivesound, known as coustic trauma, damagesthe ears without doing other physiologicalharm, he pointed out in theArchives of Industrial Hygiene and OccupationalMedicine, published by theAmerican Medical Association.Dr. Carhart said that acoustic traumacan be caused by a number of things:continuous noise, steady soimd at highIntensities, soimd of percussive and explosivevarieties, and pulsating noises,especially when unexpected and irregular.He cited the pneiunatic hammeras a good example of "a dangerouslystrong percussion soimd."A full program for protecting the"ears of industry," he said, can be effectiveonly if endorsed by both managementand labor. This Is his proposedthree-point program:1. Noises should be controlled withsound absorbing materials, by mutingdevices, or, if possible, by replacementwith new, noiseless machines. If noisecannot be controlled by these methods,workers should be required to wear eardefenders.2. A program of ear and hearingexamination—for the protection of boththe worker and his employer—shouldbe carefully planned.3. Analysis of each individual caseshould be the basis for appropriate joballocation. Workers with hearing lossesor those susceptible to acoustic traumashould not be placed in situations wheretheir impairment might constitute ahazard to themselves or others.* • * *TRANSCRIPTION OF TEEN-AGEHEALTH PROBLEMS RELEASEDThe Bureau of Health Education ofthe American Medical Association announcedthe release of 13 electricaltranscriptions of Interviews with highschool pupils on teen-age health problems.The subjects, together with the citiesin which the recordings were made,are as follows:Detroit, "Youth at the Wheel;" Pittsburgh,"How to Be Popular;" SanFrancisco, "Looking Your Best;" Colxunbus,C, "Extra-Curricular Activities;"Phoenix, "Dope, Drugs andSmoke;" Lake Mills, Wis., "Food andYour Health;" Portland, Oregon, andChicago, "Sports and Recreation;"Madison, Wis., "Date With the Doctor;"Cleveland, "Out-of-School Jobs;" Indianapolis,"Big and Beautiful;" St.Paul, "Choose Your Partner;" Austin,Tex., "First Offender;" Brooklyn, "Fearsand Fancies."The series, known as "Hi-Forum,"comprises interviews made by tape recordingswithout scripts. They werebased on suggested questions and topicheadings sent to the students In advance.The students were selected byschool superintendents.

May, 1951 The Health Bulletin 15Each program includes a summarizationby Dr. W. W. Bauer of Chicago,director of the B^ireau of Health Education,who supervised the production.Mrs. Harriet Hester of New York, radiocoordinator for the bureau, conductedthe Interviews. The programs were announcedby Cy Harrice of New York.The transcriptions will be distributedthrough state and local medical societiesto radio stations. About 700 stationsuse A.M.A. transcriptions, one halfof these regularly.* * * *SAYS CURB ON UNDULANTFEVER DEPENDS ONCURE IN ANIMALSEradication of brucellosis, or undulantfever, in human beings depends on itselimination in animals, says the Journalof the American Medical Associationeditorially.Brucellosis, the editorial points out,is not transmitted from person to personand the prevention of human infectiontherefore is dependent on thecontrol and elimination of the diseasein animals.According to the Journal, the numberof cases of brucellosis has been increasingsteadily. It says:"In 1927 there were reported only 217new cases; in 1937, 2,497, and in 1947,6,073 cases. The states that have thelargest number of cases are Iowa, Illinois,Texas and Wisconsin. The totalnumber reported for the past decadehas averaged about 4,000 annually.Chronic infections outnumber the acuteby a ratio of at least 10 to one, andthe chronic infections very frequentlyare not diagnosed. It is probable that40,000 to 100,000 infections occur annually."Brucellosis in animals causes abortionor premature birth, decreased milkflow and temporary or permanent infertility,the editorial continues. It estimatesthat about five per cent of alladult female cattle in the United Stateshave the disease."Therefore, at least 1.300,000 dairyand 800,000 beef cows are involved.Prom these figures it was estimated thatthe total annual loss of decreased milkproduction, fewer veal calves and necessaryreplacement of dairy cows is about$92,000,000."According to the editorial, when vigorouscampaigns against the disease inanimals have been carried out, greatsavings to the national economy haveresulted. It is estimated that the reductionof the incidence of bruc^osisby one half has resulted in savings tothe livestock industry of $50,000,000 annually.For control of the disease In animals,the Journal named these three methodsas available at present: (1) eliminationof infected animals based on the standardserum agglutination test, (2) vaccinationand (3) combination of thetwo."The evolution of treatment of brucellosisin human beings will probablybe along the lines of combination ofthe known antibiotics," according to theJournal.* * * •SURGICAL TECHNIQUEAIDS HEARING ABILITYA surgical procedure known as fenestrationhas brought increased hearingability to 70 per cent of a group ofdeafened patients, two doctors reportin the current issue of Archives ofOtolaryngology, published by the AmericanMedical Association.The patients were suffering from aprogressive type of deafness calledotosclerosis, according to Drs. Louis E.Adin, Jr. of Dallas and George E.Shambaugh, Jr. of Chicago, authors ofthe article. Dr. Shambaugh is associatedwith Northwestern University MedicalSchool, Chicago.Otosclerosis is caused by bony growthin the passageway which carries soxmdto the inner ear. Fenestration createsa substitute channel through whichsound can enter the ear.The operation was performed on aseries of 390 patients from 1940 to1945 and results have now been observedfrom five to 10 years.

16 The Health Bulletin May, 1951LIVE BIRTHS, INFANT DEATHS, AND MATERNAL DEATHS WITHRATES PER, 1,000 LIVE BIRTHS: NORTH CAROLINAAND EACH COUNTY, 1950*(Place of Residence)COUNTYLIVEBIRTHSINFANTDEATHSMATERNALDEATHSN. Carolina..AlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswick....Buncombe...BurkeCabarrus......CaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberland.CurrituckDareDavidsonDavieDuplinDurhamEdgecombe..ForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHenderson ..HertfordHokeHydeIredellJacksonNo.104,2481,6433461297865303581,0378288875352,7541,0281,4701,2301326215571,6745833743361311,7171,4161,4883,3981291111,0233421,1092,3051,5993,6528142,6852271798395264,4871,8681,2349137386014151561,428417No.I3,622411233122650284720942236293212740201484535140106634811685578118377686252113990372423251276612Rate | No.34.7|Rate

MEDICAL LIBRARYU. OF N. CCHAPEL HILL, N. CK4^I TKis BuLletm will be sent free to drvn cifizen of tKe 5kii^e upon request IPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 66 JUNE, 1951 No. 6STATE HEALTH OFFICER REPORTS FOR 1950

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-President RaleighH. Lee Large, M.D Rocky MountMrs. James B. Hunt Lucama, Rt. 1John R. Bender, M.DWinston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaH. C. LuTz, Ph.G. HickoryGeo. Curtis Crump, M.D.AshevilleEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S. , Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health "^DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionC. P. Stevick, M.D., M.P.H., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any inwhich you may be interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitis Infantile Paralysis Typhus FeverCancer Influenza Venereal DiseasesConstipation Malaria Residential SewageDiabetes Measles Disposal PlantsDiphtheria Pellagra Sanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFlies Teeth Whooping CoughTuberculosisEpilepsy. Feeble-mindedness, Mental Health and Habit TrainingRehabilitation of Psychiatric PatientsThe National Mental Health ActSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CareFirst Four MonthsPrenatal Letters (series of nine Five and Six Monthsmonthly letters)Seven and Eight MonthsThe- Expectant Mother Nine Months to One YearInfant CareOne to Two YearsThe Prevention of Infantile Two to Six YearsDiarrhea Instructions for North CarolinaBreast FeedingMidwivesTable of Heights and WeightsBaby's Daily ScheduleYour Child From One to SixYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageJoint Responsibilities Of Public Health And Private Practice 3Departmental Reports 7

PUBLI5AED BYTAE N^RTA CAROLINA STATE B'^ARD-^AEALTAIVol. 66 JUNE, 1951 No. 6J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorJOINT RESPONSIBILITIES OF PUBLIC HEALTHAND PRIVATE PRACTICE*J. W. R. Norton, M.D., F.A.C.P.Raleigh,North CarolinaThe customary detailed report hasbeen submitted for this Conjoint Sessionas has been done previously. It is felt,however, that instead of an annual reviewof activities at this time, it wouldbe more helpful to mention, and commenton, some of the opportunities forconstructive joint action by privatepractitioners and public health workers.Let us go into consultation regardingour North Carolina and our communitypatient just as we might determine theessential findings, make a diagnosis andwork out a plan of treatment for anindividual patient.We are often faced with unreasoningand undeserved criticism and with openattempts to make immediate radicalchanges by those with selfish motivesor by some with sincere intentions butlacking in basic understanding of thetotal problem. It is essential that wewho have dedicated our lives to medicaland health care understand eachother and give intensive study to currentproblems and the best methods fortheir solution. We must resist all attemptsto drive wedges between thosephysicians who work for salaries andthose reimbursed on a fee for servicebasis. Clinicians, researchers, laboratoryRead before the Conjoint Session of State Board ofHealth and the Medical Society of the State of NorthCarolina. May 9, 1951.*SecreUry of the State Board of Health and StateHealth Officer.workers, teachers, and public healthphysicians seek alike the goal of constantlyimproving health for NorthCarolina. Specialists and general practitionersbenefit themselves and theirpatients when similarities are emphasized,rather than differences. In providingmodern medical and health care,it is required that we work in harmonywith each and all of the others. Thebest treatment includes attention to prevention.Desirable public health methodsassist, and never interfere withethical private practice.Our embarrassment and disappointmentat unfair criticism and selfish attemptsat regimentation must not beallowed to induce a persecution complexwith a resulting tendency toward superficialand emotional striking out blindlyat foe and friend alike. Careful analysisshould enable us to determine basicmotives and it should prove helpful todiscuss all medical and health planningwith co-workers and with those who paythe bill. Either private practitioners,public health workers or the publicoperate under a distinct handicapwhen one group assumes that the othergroups are not equally unselfish andare working in opposition. All soundpublic health programs have been initiated,and are maintained, under theleadership of public spirited privatepractitioners. The few short-sighted

The Health Bulletin June, 1951personalities who would interfere witha continuation of this sound long-rangeplan fortunately are decreasing. Strifeand distrust must be replaced everywhereby constructive and patient understanding.A year ago attention was invited tothe rising toll from diseases of theheart and blood vessels, cancer, nephritis,diabetes, mental disease and accidents.Again, there is basis for the confidentbelief that we can work out aprogram in the control of these healthproblems in the non-communicable fieldthat will be ethical, acceptable andeffective, encroaching upon the prerogativesof none. All public health programsdirected against these problemswill have but one objective, that is, topromote early private medical care forthe patient and to insure the successof that care by providing to every physician,where needed, the services oftrained personnel in case-finding, follow-up,and rehabilitation. We canmake full use of lessons learned indeveloping dependable control techniquesagainst communicable diseasesand attack health hazards in the noncommunicablefield with the same vigor,tenacity and freedom from emotionalor personal consideration. Neither thepublic health armamentarium nor thatof the private practitioner can remainstatic. We must make progress together.The community patient and the individualpatient have each received increasinglyprompt, effective and adequatecare. Public Health procedureshave successively emphasized quarantineand fumigation, regulatory sanitation,isolation and immunization,chlorination and pasteurization, epidemiologicalinvestigation, nutrition andhealth education, prenatal care andfamily planning, case-finding and workingout arrangements for early treatmentby private physicians. There isalways resistance to change and thetimid have predicted dire calamity asprocedures acceptable in former dayshave become obsolete or the emphasishas been shifted. Private practitionerswill have happier and better work wheneach and every cancer, heart disease,diabetes and mental disease are foundearly just as they did when childrenbecame immunized against smallpox,typhoid, diphtheria, whooping coughand tetanus, and tuberculosis and syphiliswere detected earlier. Prompt eliminationof reservoirs of infection andof influences that undermine individualor community health has become a recognizednecessity.The field of opportunity for cooperationbetween public health and privatepractice is neither limited to communicabledisease control nor to services forthe indigent. Whatever proves mostbeneficial to the conservation, promotion,or recovery of health for the individualor the community patient hasbeen observed to be good for the doctor.There are no exceptions of consequenceto this rule. When we prevent the preventable,provide for universal earlycase-finding and arrange jointly forprompt and adequate treatment, no onesuffers. The private practitioner is aidedand the public benefited by state andlocal health departments that work towardprevention of disease, assist incase-finding and help to provide expensiveequipment and facilities fortreatment. Your public health departmentsare striving wholeheartedly forimprovement of working conditions forprivate practitioners and for the developmentof voluntary prepaymenthospital and medical care plans.As individuals and as a profession,we must continuously strive to makegood with the public who pay the billnot only for public health but for privatepractice as well. Better trainingin public relations and in our civic responsibilitiesis needed for our professionwhich must be alert to the continuingnecessity for current internalcorrections and long-range planning.This remains the biggest gap in medicaleducation. It has been said that, "thepublic is down on what they are notup on." As individuals and as a professionwe must have said of us thatwe are earnestly striving to make goodand better, not that we appear as if wethink we have arrived. In some casesprivate practitioners, while alert to the

June, 1951The Health Bulletinneed for improvements in the care ofindividual illnesses and injuries, haveoverlooked their opportunity and dutyfor leadership in planning the provisionof efficient local health departmentsand hospital and medical careservices for their community to assureprevention, early case-finding and adequatetreatment promptly available. Itis desirable that our grievance committeesaim toward a basis for long-rangeconstructive planning as well as delayedcorrections. If physicians fail to leadin community health planning throughboards of health, formation of healthcouncils, rural health conferences, andthrough all other means, those whotake over this function may even omitmedical consultation during the planningstage of their activity.The public is not fully informed onits part in adjustment to some of om*modern changes. With good roads, electricityand telephones and desirable developmentsin clinics and hospitals thereis no more need for a physician atevery crossroad than for a general store.A doctor ten miles away may be morereadily available now than the one whoa generation ago was in walking distance.A well-informed public can alsoconserve the doctor's time and saveconsiderable expense by office insteadof home visits, day rather than nightcalls, and by more prompt but shorterhospitalization. In former generationsthe doctor and hospital were used onlyin extreme emergencies. Medical costsare less when the physician is consultedearly for the "ounce of prevention" orthe "stitch in time."Perhaps the glamor of the medicalspecialist and the specialized or categoricalpublic health worker has beendisproportionately emphasized; certainlytoo little is associated with the generalpractitioner and the generalizedservice of the local health department.Medical students fear lack of prestigein general practice and the public andappropriating bodies get exaggeratedviews of individual diseases and otherhealth problems rather than an enthusiasticappreciation of the value of thebest generalized medical and health servicefitted to the needs of each individualand cpmpiunity.Constructive suggestions for improvementof public health practices are alwayswelcome from individuals andfrom the county and state medicalsocieties. These should be made to localboards, or the state board, of health,however, and not handled so as to leavethe impression that we in medical andhealth work are a house divided againstourselves. County medical societies areurged to furnish leadership and guidancein medical and health planning.Local health departments are relativelyfree and should be responsive to theirlocal medical societies and the peoplethey serve. State Board of Health ruleson policy are general and flexible.Where we fall short in uniformity wegain in freedom and utmost accomplishmentin school health and other servicesas we appreciate more fully ourlocal health departments. Your healthofficer, local or state, welcome the kindof relationship each of you would wishif you were a health officer.Two misconceptions that I would liketo speak against have been encountered.One is that the use of tax fundsinevitably leads to bureaucratic controland loss of individual freedom. The selectiveand wise use of tax money mayhave the opposite effect. Federal appropriationsto our State Board of Healthand state and federal monies used byour local health departments aid andassist, but have not interfered with,our complete state and local freedom.The same can be said, so far, with regardto Hill-Burton funds in the constructionperiod. Hospital maintenanceproblems are becoming complicated anddeserve careful long-range planning.Another misconception is the ideathat North Carolina public health workinfringes upon the field of private practiceand leads to increasing governmentalcontrols. Each and every oneof you are invited to analyze the workof your State Board of Health and yourlocal health department with care andyou will convince yourself otherwise.Which of these services would you asprivate practitioners eliminate or be

The Health Bulletin June, 1951able, or wish, to do altogether by yourselves,—environmentalsanitation; controlof sewage, water and food; communicabledisease epidemiology; maternaland child health; health education;vital statistics; diagnostic and centrallaboratory; oral hygiene; industrial hygiene;mental health; organizing forcancer case-finding; planning schoolhealth services; making arrangementsfor crippled children's work; nutritioneducation; accident prevention education.Physicians on our State and localboards of health have a major share inplanning and in guiding policies in thisState. North Carolina physicians, dentists,pharmacists and other leaders cantake real pride and reassurance of continuedfreedom from medical regimentationin the excellent public relationscreated by these health services.A matter worthy of mention, even ina brief report, is that some who takethe shorter, easier, cheaper training forthe care of the sick are increasing theirinsistence that no distinction be madebetween them and those with morethorough preparation. In the 1951 Legislaturethere were introduced five billsas follows: chiropodist to be defined asthe physician and surgeon of the footand leg; naturopaths to have a specialboard; chiropractors to sign death certificates;drug clerks to become assistantpharmacists; optometrists not to bedistinguished from ophthalmologists inreferrals by public agencies. A commonthought is seen in all five bills;— "Doless, but demand as much recognitionas the one who does more. Scream'discrimination!' when a distinction onthe basis of qualification is attempted."Does the plan of salvation operate"without discrimination" when it promisesa crown only to those who bearthe cross? Ability to select and beingable to make a distinction—being discriminating—amongthose who rendermedical and health services are basicnecessities for progress. Remove thisfreedom from public agencies and theloss of individual freedom may soonfollow.Other items of interest from the 1951General Assembly are: $50,000 for acancer hospital for indigent patients inthe terminal stage of the disease; $86,-500 for crippled children; a streamsanitation law to be administered by acommittee under the State Board ofHealth; a rewritten tuberculosis controllaw; setting up a board for registrationof physical therapists; and slight a-mendments to our laws relating tovital statistics; retirement of publichealth workers; diphtheria immunization;and sanitary districts. The newState Health Department B'uilding isto be officially known as the "CooperHealth Building."It seems appropriate to close by referenceto one whose life was devotedto increasing joint action by privatepractitioners and public health workersthrough which everyone has been benefited.After forty-five years in privatepractice, local and state health work,Dr. George Marion Cooper was gatheredto his fathers on December 18, 1950.His and succeeding generations reverentlygive thanks to our Creator andcall him blessed. For many, his unselfishand devoted service adds years tolife and also life to years. His life isproof that public health and privatepractice can advance hand in hand andthat the health of each and all is therebymade better. He led us far along theroad we should follow. He proved thatas we overcome or divest ourselves ofhandicaps that beset us as an individualor as a profession our hold onthose things we would like most to keepis strengthened.

June, 1951The Health BulletinDEPARTMENTAL REPORTSNorth Carolina State Board of HealthJanuary 1, 1950 - December 31, 1950CENTRAL ADMINISTRATION— J. W.R. Norton, M. D., State Health Offiver.When the State Board of Health wasreorganized, effective February 1, thestaff of the Central Administration remainedpractically intact; that is tosay, Public Relations, Budgets, Files andPersonnel remained in this Division,under the direct supervision of theSecretary and State Health OfHcer. Thework of those in charge of printing andmailing was transferred to this Division.We will now take up the above, inthe order named on the ofRcial organizationchart:During 1950, the Senior PublicitySpecialist delivered fifty-two broadcasts,in person, over Station WPTP,in Raleigh. He also cleared all statementsfor the press authorized by theState Health Officer, in addition toroutine news releases. Incidentally, itmight be stated here that the radioprogram later was enlarged to includethree stations, instead of one. In additionto WPTP, the State Board ofHealth program is now heard eachSaturday over WBT in Charlotte andWWNC inAsheville. During the periodcovered in this report, the Senior PublicitySpecialist attended the meetingof the Southern Branch of the AmericanPublic Health Association in Birminghamand the meeting of theAmerican Public Health Association inSaint Louis. He also assisted the StateMedical Society in giving publicity toits annual meeting in Pinehurst, as hehas done since 1938.Next in order we find Budgets. Thetotal amount budgeted for all purposeswas $5,068,141. Included in this totalwere: State funds, $2,081,166; Federalfunds. $2,927,369; Special Accounts,$59,606. The total number of vouchersissued was 17,209. A breakdown of thesevarious funds appears in the officialrecords of the Budget Officer.The Personnel Office made 105 appointmentswithin the State Board ofHealth, of which 38 were in professionalclassification. Separations totaled 108,of which 45 were in professional classifications.There were 47 reclassifications,the majority of these bearing onsalary increases. Salary increments weregranted to 209 employees and increasesto 15. Forty-five employees were certifiedas permanent. As of December 31,1950, there were 336 budgeted positionsin the State Board of Health, 37 ofwhich were vacant. In the local healthdepartments, there were 320 appointmentsand 336 separations; reclassifications,119; salary increases, 548; certifiedas permanent, 267; as of December31, 1950, there were 1,083 budgetedpositions in local health departments,of which 59 were vacant.During the year, the mailing roomdistributed the following pieces of literature:health education, 1,584,646; Maternity,44,848; child health, 93,247; miscellaneoussupplies, 48,492; midwife supplies,5,804. During the year, 3,273,175multilith forms were printed. This workalso is in Central Administration.Central Filing has continued to expand.This office receives, classifies,files and makes available for use copiesof all official letters, reports and writtentransactions from the State HealthDepartment. During 1950, approximately155,076 pieces of material werereceived for filing; 37,626 individualsearches for material were made. Thelibrary is maintained primarily for theconvenience of em.ployees of the StateBoard of Health. One hundred twentysixnew medical and Public Healthbooks were received during 1950; 59journals were subscribed for, and fifteenjournals were bound in volumes.

8 The Health Bulletin June, 1951PERSONAL HEALTH DIVISION — A.H. Elliot, M. D., Director.Before attempting a report on theactivities of the Division of PersonalHealth, it should be stated that theDivision suffered an irreparable loss inthe death of its Director, Dr. G. M.Cooper. Dr. Cooper had developed allof the different branches of the Divisionfrom their very beginning to theirpresent position of rendering an unlimitedand invaluable service to thewhole State of North Carolina andmost especially to mothers, infants andchildren. May we hope that his influencefor the truth and for better healthwill live on in the efforts of the presentand future employees of this Division.Sections of the Division of PersonalHealthMaternal and Child Health(Including Premature Program)Crippled Children's ProgramNutritionCancer ControlHeart DiseaseMaternal and Child Health: During thepast year, 6102 prenatal and well babyclinics were held with the followingattendance records:Maternity 29,644Well baby and preschool 48,812Booklets, leaflets, etc., on prenatalcare and care of infants and childrenwere distributed to the following extent:Maternity 44,848Child Health 93,2471950 was the second whole year ofoperation of the premature program.Two new centers were opened (Rexand James Walker Memorial) makinga total of six centers. There are alsofour secondary centers (our help: specialtraining for nurse—2 incubators).Special refresher courses for publichealth and hospital nurses are availableat Duke. All except eight county healthdepartments have been supplied withtransportation incubators for gettingprematures to the centers or to somehospital. 629 premature infants receivedcare under this program last year.Crippled Children: During the yearthere were 307 clinics held serving 5,501new and 5,724 old cases. Seven hundredand twenty were admitted to hospitalsand 201 appliances were paid for. 1950opened with 20,831 on the register(many polio cases). This load so nearlyexhausted the appropriated funds thatmany non-emergency cases had to bepostponed and the hospital stay ofacute cases had to be shortened.Two special features of the year were(1) the operation of a three-weekssummer camp for crippled children onthe Pamlico River. Forty-two childrenattended. This camp was without costto the Crippled Children's Program orto the children. It was supported bycommunity contributions. (2) One ofthe department's nurses was invited toattend the White House Conference inWashington, December 3-7. This conferencewas concerned with child developmentin the fields of health, religion,recreation and social service.Since then this nurse has had conferencesthroughout the State on the subjectmatter of the Washington Conference.Nutrition: The director and ten veryspecially trained nutritionists and dietitianscover most of the State throughhealth departments, hospitals, institutions,clinics, communities and schools.The importance of nutrition in all agesand under all conditions is being taught.Special service is given State institutionsin kitchen arrangement, foodpurchase and preparation, food habits,etc.Teaching nutrition to public healthnurses—school teachers receive specialattention. Diet habits of school childrenare surveyed and in many schools animalfeeding demonstrations are conducted.Special diets for low incomegroups are stressed.Most of the time of the two dietitiansis spent in the various State institutions,by invitation, advising andconsulting with the persons in chargeof feeding the inmates. Special attentionis given to construction, arrangementand equipment in new and reconditionedkitchens. Planning of meals,selection and purchase of food mate-

June, 1951The Health Bulletinrials are given careful consideration.Some of the special projects duringthe year were with welfare departmentson feeding ADC children, with trainingcenters connected with UNO and theschool lunch program.Cancer Control: During the year eightDetection and Diagnostic-Managementand three Detection Centers were operated.On Jime 30 the Winston-SalemCenter was closed and the members ofthe Forsyth County Medical Societyelected to do the work in their individualoffices. During the year 472 clinicsessions were held; 11,775 examinationswere made in the detection centers,4,579 of them were referred to theirfamily physicians, 3,287 were referredto the Diagnostic-Management Centersand then on to their family physicians.This shows that 7,866 patients were referredto private physicians. 259 newcases of cancer were diagnosed and 52already known cases were reviewed.579 biopsy examinations were reportedto this office. Approximately 2,500 casesof cancer were reported during theyear. The 1949 Legislature appropriated$50,000 for the treatment of indigentcancer cases. This is confined to casesoffering hope of cure or arrest.Mobile Gastric Cancer Detection:This unit is being operated on an experimentalbasis. It is planned to doabout 10,000 cases and then evaluatethe procedure to determine whether ornot the procedure is practical. This unithas served only in Durham and Wilmingtonand has done slightly overhalf the proposed ten thousand cases.The cancer detection and diagnosticcenters have the approval of the CancerCommittee of the State Medical Societyand during the year a representative ofthe American College of Surgeons visitedeach of the centers and after athorough investigation recommended tohis board that they be considered forapproval.Free examinations of cervical smearsby the Papanicolaou method is availableto all the centers. Four of thecenters are using this as a rountinescreening method. 4514 smears were examined.Most of the centers are expectedto use this method soon.Heart Disease: Very little has beendone in heart disease control. Part ofthe salary ($6000) of one of the teachersat the University is paid out ofthis appropriation. The full salary ofan EKG technician at one of the teachinginstitutions is also paid out of thisfund. A certain amount of equipmentand supplies are also provided theteaching center.It is planned to make this a muchmore active program this year.MATERNAL AND CHILD HEALTHSECTION—Robert J. Murphy, Jr., M.D.,Pediatric ConsultantIn the past year two additional prematureinfant centers have been opened.They are Rex Hospital in Raleighand James Walker Memorial Hospitalin Wilmington, making a total of sixcenters with a capacity of eighty-fivepremature beds. The increase in hospitalcosts has made it necessary forus to limit our financial participationin these centers to two-thirds of thecenters' capacities. Despite this cut inour financial participation we have beeninterested in keeping the centers fullto capacity and have accomplished thisby enlisting the aid of the county welfaredepartments and the parents toparticipate in sharing the expenses. Thesix premature infant centers can onlytake care of a fraction of the prematureload and are therefore reserved in mostpart for the smallest of the prematurebabies. We have tried to improve themedical care of premature babies inthe local hospitals by the establishmentof secondary centers. These centersare those who have a pediatricianon the staff and a nurse in charge whohas been trained in premature carethrough a scholarship offered by thisdepartment. The hospitals are alsoloaned two Gordon Armstrong incubators.Four of these secondary centershave been set up in the past year atElizabeth City, Rocky Mount, Concordand Goldsboro. Through cooperationwith Duke University we have establisheda refresher course in premature

10 The Health Bulletin June, 1951care for Public Health Nurses and hospitalnurses. Thus, we have a trainingcenter within the State and do nothave to send our trainees out of theState, as has been done previously. Allof the counties in the State with theexception of 8 are equipped with prematureinfant carriers to transportthese premature infants to the localhospitals or our centers. Since the startof the Program in 1948 we have financiallyaided 1300 prematurely born babies.We have seen a drop in the prematuremortality and on increased interestin the premature problems amongnurses and physicians, particularly pediatriciansand obstetricians.CRIPPLED CHILDREN'S SECTION—Ruth Council, R. N., ChiefDuring the summer of 1950, a campfor crippled children was an addedactivity to the program. The camp waslocated on the Pamlico River nearWashington, N. C. and was operatedfor three weeks. The children were selectedin the clinics by the orthopedistson the basis of those who would benefitmost from the physical and social aspect.All of these were from the countieseast of Raleigh. The counselors•were selected through the State HomeDemonstration Agent. Nurses fromcounty health departments staggeredtheir services and other workers weresecured from nearby vicinities. Nutritionistsfrom the State Board of Healthwere also present for supervision ofplanning of meals and kitchen activities.There were forty-two children whoattended this camp during the summer.Funds were raised through local resources,in the counties from whichthe children came.One of the nurses from this sectionwas invited to attend the White HouseConference which was held in Washington,December 3rd through December7th. This conference, known as theMid-Century White House Conferencewas based on personality developmentof children and youth through health,religion, recreation, and social service.There were approximately 4,000 delegateswho attended.Since the conference, the nurse hasgiven a number of reports throughoutthe state in the interest of the followupprogram which includes the recommendationsmade the last day, December7th.During the year there were 307 clinicsheld throughout the state. Each ofthese clinics is within a distance of approximatelyfifty to sixty miles of everychild. There were 5,501 new cases admittedto these clinics and 5,724 oldcases re-examined during the clinicsessions. There were 720 admitted togeneral hospitals, 115 extensions authorizedand 201 appliances purchased.As of January 1950 there were 20,831on the state register. During the firstthree months of the year the fundswere depleted to such an extent thatthe department was unable to take careof any cases except emergencies. However,it is definitely felt that none ofthe cases recommended for surgerywere neglected because each child wasreferred to another agency when necessary.On December 18th, we lost our Director,Dr. G. M. Cooper. He had startedthe North Carolina Crippled Children'sProgram in 1936, following theSocial Security Act of 1935.NUTRITION SECTION—BertlynBosley,Ph.D., ChiefThe work of the Nutrition Section,one of the more recent activities of theState Board of Health, is increasing inimportance with each passing monthas more knowledge is secured about thepart food plays in some of the majorhealth problems. Insistence upon properuse of foods to maintain goodhealth has heretofore been urged forthe younger generation. It is now recognizedthat it is of major importancefor the aged and particularly for thosewith chronic diseasesThe Nutrition Section is staffed bywell-trained nutritionists and dietitianswho work with all official and somenon-ofRcial agencies in the state. Alarger number of these well-qualifiedworkers is needed. It is hoped that the

June, 1951 The Health Bulletin 11number of field consultants can be increasedto ten for service in the 100counties of the state since no countiesare now employing nutritionists. Whenthis number is secured health departments,hospitals, institutions, clinics,communities and schools in all parts ofthe state will have an opportunity toreceive the assistance which is beingrequested and is needed in bringing a-bout better nutrition practices andconsequently better health.GeneralThe amount and quality of workaccomplished during 1950 was greaterthan in any previous year. This wasdue to an increase in the number ofstaff which was made possible, in part,by the appropriation of the 1949 Legislatureto the Section. Funds in largeramounts are still greatly needed if theSection is to be able to give adequateattention to the many requests whichare coming from all sections of thestate.The work was conducted through *53county and city health departments,through state and county institutions,and through hospitals, communities,and schools.StaffAs of the 31st of December the staffwas as follows:Dr. Bertlyn B'osley, DirectorMiss Mary Brice Deaver, PrincipalNutritionistMiss Sallie J. Mooring, ConsultingDietitianMiss Mabel B. Gladin, ConsultingDietitianMiss Nina L. Corbett, Senior NutritionistMiss Gladys Strawn, Senior NutritionistMiss Winston Osborn, Senior Nutritionist*Alamance. .Alleghany. Ashe, Buncombe, Asheville,Burke. Caldwell. Caswell, Chatham. Cherokee, Concord,Duplin, Durham, Edgecombe, Rocky Mount,Greene, Guilford, Greensboro, High Point, Halifax,Haywood, Canton, Henderson, Hendersonville, Hoke,Iredell, Mecklenburg, Charlotte, Moore, New Hanover,Wilmington, Orange, Pender, Polk, Richmond, Hamlet,Rockingham, Robeson, Lumberton, Rockingham(county), Leaksville, Spray, Reidsville, Rutherford,Surry, Swain, Transylvanijj, Wake, Raleigh, Wayne,Goldsboro, Watauga, Boone.Miss Emma Clinkscales, SeniorNutritionistMiss Carolyn Flewellen, JuniorNutritionistMiss Marie Pfunder, Junior NutritionistMrs. Rose Wischkaemper, JuniorNutritionistThere were three resignations: MissJana Jones, Principal Nutritionist, Mrs.P. C. Stott, Senior Nutritionist, andMiss Dorothy Kiely, Senior Nutritionist.The vacancies were filled by advancingMiss Deaver from Senior Nutritionistto Principal Nutritionist and by fillingthe other vacancies with new staff. Sixmembers of the staff joined the Sectionin the latter half of the year, but beingwell trained, were soon assigned to theirrespective areas.One scholarship candidate. MissPfunder, completed her studies at SimmonsCollege in August and is now employed.Another scholarship candidateentered Simmons in September. She willbe available for employment upon thecompletion of one year of study.On December 31, 1950 the staff numberedeleven; on the corresponding datein 1949 the staff was eight. To do satisfactorywork the minimum numbershould be not less than fourteen.ActivitiesThe plan of work remains as in precedingyears. The state is divided intoeight districts, with one field consultantin each of six of the districts. Each hasan office in the local health departmentand coordinates her work with that ofthe health department staff in theirregular program through the health departmentsand the schools. The dietitiansgive consultation service to thefood service departments of state andcounty institutions as well as to the administratorsof these institutions in renovatingold kitchens or in planning fornew kitchen construction and equipment.They also review all kitchen plansfor new hospitals,submitted to the MedicalCare Commission. There are somespecial activities with other state agencies,in addition to the above work.

12 The Health Bulletin June, 1951Work With NursesContinuous staff education of nursesat state and local level, at quarterlyconferences is provided. The subjectsdiscussed depends upon the needs of thenurses in each area. Requests have beenfor basic nutrition information; foodhabits and nutrition practices in thestate for adults and children; adequatediets for the low income group; specialdiets for those suffering from specificdiseases; fifty-five of these conferenceswere held attended by 697 public healthnurses.Work in ClinicsThe six district nutritionists are ableto provide some service to the regularclinics held by some of the health departmentsin their districts. An attempthas been made to demonstrate the kindof nutrition instruction which nursesmight give. These demonstrations andservices have been given in prenatal,well-baby and pre-school clinics. Patientswith special nutrition problemsare referred by doctors or nurse for individualconferences. There were 21group discussions and 1262 individualconferences held with those attendingclinics.Survey WorkFundamental information which canbe secured regarding the food habits ofany group is essential for preparing aprogram for improvement of healththrough good nutrition practices. Thisinformation is used by health officersand the nurses in their work and byteachers for planning the nutrition instructionwhich is needed in the classroom.The procedure for collecting surveyinformation has been described inreports of previous years. This past yearsurveys have been made in 39 schools;and 1053 children have been interviewed.Work in SchoolsAssistance in the School Health Programis one of the most frequent requestsmade of nutritionists. In responseto these requests the consultantgives refresher courses to teachers.Afterwards she gives specific help tothose teachers planning nutrition instructionfor the students in their healthprogram. The number of teachers receivingthis instruction during 1950 was3550 in 115 schools. Of these 311 teachersrequested help and included nutritioninstruction as a part of their healthprogram. Animal feeding experiments,using white rats and guinea pigs, werecarried out in the upper grades by teacherswho wished to make the best useof the instruction received.Work of the Consulting DietitiansSince the dietary consultant servicebegan in 1948 there has been an increasingdemand for this type of work andas a consequence a second dietitian wasadded to the staff in September 1950.This service includes assistance in reviewingarchitects' plans for new kitchenconstruction or renovation in hospitalsand state institutions and those constructedunder the direction of theMedical Care Commission. In additionthe dietitians assisted in the establishmentof specifications for food serviceequipment for state institutions; inevaluating dietary practices in state andcounty institutions, when requested; inproviding menu guides, and in cooperatingin food handlers' courses. Duringthe year the above service has beenrendered to 52 state and county institutions,1 orphange, 4 colleges. Fifty-foursets of plans and 37 sets of specificationshave been reviewed for the MedicalCare Commission.Special Work(a) Joint work has been carried onwith the Department of Public Welfarein respect to dietary needs of familiesreceiving Aid to Dependent Children'sFunds. This activity is still in progress.(b) A demonstration project for wellchildconferences has been set up cooperativelywith the School of PublicHealth and the District Health Officeof Orange-Person-Chatham-Lee Counties.It was requested that a nutritionistbe assigned to this district so that acomplete health department staff couldwork on the project. A nutritionist wassecured in October. The work has beenstarted.(c) The cooperative demonstration

June, 1951 The Health Bulletin 13program with the School Lunch Program,begun in 1949, has been continuedthroughout the year.(d) As in previous years consultantswere made available for special summerschool work relating to health. Nutritionistsserved as consultants for educationworkshops. One served as instructorin the Health Education Workshop atThe North Carolina College.One met with the Institute on Prematuresheld for nurses at North CarolinaCollege. Another served as consultantfor the Institute on Maternity, also,The activities of the Nutrition Sectionare increasing each year. Since nutritionis now considered to be of greaterand greater importance in promotinggood health at all ages it is essentialthat more emphasis be placed on bringingabout an understanding of the valueof good nutrition practices for people ofall ages. For many years nutrition hasbeen accepted as being of great importanceto the young; it is now realizedthat it is of even greater value to theaged and to the diseased.The practice of good nutritionthroughout life will help prevent someof the health problems now existing. Tobring about these practices is the majorproblem of the Section. An adequatestaff will enable the Section to aid inestablishing better food practices, andthereby assure better health benefits tothe people in all sections of North Caro-for Nurses at North Carolina College.One nutritionist served as consultant tothe supervisors workshop at The Woman'sCollege. A nutritionist also metwith the Resource-Use Education Workshopat The North Carolina College.lina.Another cooperated with the School-Cancer SectionHealth Coordinating Service at The In February, 1950, the State Board ofUniversity of North Carolina.Health was reorganized and the DivisionOne nutritionist served as consultant of Cancer Control was merged within the lunchroom workshop in the BiltmoreSchool for one week. She, also, sonal Health Services. Dr. G. M. Cooperother groups imder the Division of Per-served one week in the school lunchroomworkshop in Cullowhee.sion, and Dr. Mildred Schram continuedwas appointed Director of the new Divi-One nutritionist attended the CommunityNutrition Institute held at Syra-Section untU her resignation on Augustto serve as Field Director of the Cancercuse University for two weeks. This instituteis held each year to provide On March 7 the Gastric Cancer De-22, 1950.postgraduate training for consultants tection MobUe which is equipped withfrom all over the United States.a Schmidt-Helm camera and accompanyingx-ray equipment began opera-One consulting dietitian and one nutritionistvisited the Crippled Children's tion in Durham. The Schmidt-HelmSummer Camp in Washington, North camera in this Unit is one of five In theCarolina, to supervise the food service United States and is the first to ever bewhich had been planned by the NutritionSection.the cancer program is an experiment inplaced in a mobile unit. This phase ofOne consultant was on the program in screening apparently well people forthe school lunch workshop at North stomach cancer. Seven 70 mm. films ofCarolina College in Durham.the stomach and esophagus are made ofPour graduate students in Nutrition each examinee and can be done in approximatelyseven minutes. Mr. Walterwere assigned to North Carolina for fieldtraining; two were students from the Lee Horton, Jr., who had received specialtraining at Johns Hopkins Univer-Philippines assigned by the PublicHealth Service; two were from the Universityof Tennessee.od originated was employed as Seniorsity where the photofluorographic meth-Technician toConclusiontake and develop thefilms. Dr. W. W. Vaughan and Dr. RobertJ. Reeves, Radiologists in Durham,study the films; and any person whosefilm shows any suspicious condition isreferred to a practicing radiologist for

14 The Health Bulletin June, 1951more complete study. The Mobile Unitoperated in Durham until October whenit was moved to Wilmington at the invitationof the New Hanover CountyMedical Society. During the year approximately4,000 citizens were x-rayedunder this experimental program. When10,000 cases have been completed, aneffort will be made to evaluate theeffectiveness of this survey.During the State Medical SocietyMeeting at Pinehurst in May, the MobileUnit was on the grounds of theCarolina Hotel and open for inspectionby the members of the Society. Also, anexhibit was set up in the building whichincluded the continuous showing of thefilm "Breast: Self Examination". Byspecial invitation. Dr. Schram gave atalk on "Method and Results in theState-County Cancer Centers" beforethe Section on Obstetrics and Gynecology.During the annual meeting at Pinehurstthe Cancer Committee of the StateMedical Society went on record as approvingthe work of the State Board ofHealth Cancer Centers and recommendedthat county medical societies whichdid not have Cancer Centers affiliatewith one or arrange to organize theirown. (Adopted by House of DelegatesMay 1)At the International Cancer Congressin Paris, July 17-21, Dr. Schram read apaper, "An Experiment in Mass Screeningof a Population for Cancer."The taking of cervical smears to bestudied by the Papanicolaou methodwhich was initiated in the Cancer Centersin 1949 as a part of a "screening"program was extended to four clinics.In these four Centers 4,514 smears weretaken and studied. This phase of theprogram will be instituted in other CancerCenters as it is requested by thelocal Staffs.During 1950 approximately 2,500 cancercases were reported to the StateBoard of Health by physicians, hospitals,and clinics in the State in accordancewith the law which made cancer a reportabledisease as of July 1, 1949.Early in 1950 a program for the careof Indigent Cancer Patients was inaugurated.The State Legislature in1949 made this program possible by appropriating$50,000 for each year of thebiennium for this purpose. Due to thesmall amount of money available (nopart of the Federal appropriation canbe used for treatment of cancer i, theplan has been limited to cases offeringa hope for cure or arrest of the disease,and does not cover terminal cases. Hospitalizationfor any one person is limitedto thirty day in any one year. The participatinghospitals are paid on thebasis of Cost Analysis Statements submittedto the State Hoard of Health.Surgery and x-ray and radium therapyare paid for in accordance with a feeschedule which was prepared by a Sub-Committee of the Cancer Committee ofthe North Carolina State Medical Society.Prior to December 31, 335 cancerpatients were treated under this programat a cost of approximately $49,000.The operation of the Cancer Detectionand Diagnostic - Management Centerscontinued under the original policiesduring the year. Two new Centers wereopened, bringing the total to be organizedto eleven. The Edgecombe-NashCounties Cancer Center in Rocky Mountbegan operation on January 25, and theWayne County Cancer Center was openedin Goldsboro on May 12.The Forsyth County Cancer Centerwhich was opened on July 21, 1948, inWinston-Salem ceased operation onJune 30, as the Forsyth County MedicalSociety decided to carry on its cancerwork in accordance with the HillsdalePlan.The Cancer Centers operating during1950 were:Detection and Diagnostic-ManagementBuncombe County Cancer CenterAsheville, North CarolinaDurham-Orange Counties Cancer CenterDurham, North CarolinaEdgecombe-Nash Counties CancerCenterRocky Mount, North CarolinaForsyth County Cancer CenterWinston-Salem, North Carolina(Closed June 30, 1950)Guilford County Cancer CenterGreensboro, North Carolina

June, 1951 The Health Bulletin 15> DuringLenoir County Cancer CenterKinston, North CarolinaNew Hanover County Cancer CenterWilmington, North CarolinaWayne County Cancer CenterGoldsboro, North CarolinaDetection CentersJackson-Swain Counties Cancer CenterSylva, North CarolinaNortheastern Carolina Cancer CenterElizabeth City, North CarolinaWilkes-Alleghany Counties CancerCenterWilkesboro, North CarolinaThe Centers meet once a week for atwo-hour period with the exception ofone Detection Center which is held twicemonthly. In the Major Centers (Detection& Diagnostic-Management > theDiagnostic clinic is held following theDetection clinic.During 1950, 472 clinic sessions wereheld, with a total of 11,775 examinationsbeing made in the Detection clinics. Ofthis number 4,579 examinees were referreddirectly from the Detection Centersto their personal physicians fortreatment of conditions found in theCenters. A total of 3,287 examinees werereferred to the Diagnostic-ManagementCenters for consultation by the DiagnosticStaff of the clinic and then totheir physicians for treatment, makinga total of 7,866 individuals who were referredto their physicians from theclinics. A total of 311 cancers were seenin the clinics, 259 being diagnosed bythe Center Staffs. The remaining 52cancers had been diagnosed as such beforethe examinee visited the clinic. Ofthese cancers 232 reexaminations weremade. The Cancer Section of the StateBoard of Health received 579 pathologicreports on Cancer Center examinees onwhom biopsies were taken to determinethe presence of cancer. It is interestingto note that approximately 1 of every 38examinees seen proved cancerous.the year a representative ofthe American College of Surgeons visitedeach of the State-County CancerCenters in North Carolina and after athorough investigation of each recommendedto his board that they be consideredfor approval.LOCAL HEALTH DIVISION—C, C.Applewhite, M.D., DirectorOn February 1, 1950, the State Boardof Health transferred the section onvenereal disease control from this divisionto the Division of Epidemiology, andplaced in this division a section onmental heatlh and the State Board ofHealth portion of the school health program.During the year there was only onemedical officer in this division, theDirector, who was responsible for thegeneral administrative supervision of allthe sections in this division along withthe administrative duties incident to thesuccessful operation of all of the fulltimelocal health departments withinthe state.During the past year the director hasfocused his attention on the programdesigned to improve the domiciliary facilitiesof the personnel in the localhealth departments by working closelywith the Medical Care Commission andthe county commissioners in the state.During the year contracts were let foreleven local health centers. At presentthe county commissioners of the samenumber of counties have indicated akeen interest in this program.During the year the director has visiteda good percentage of the local healthdepartments where an opportunity wasafforded to discuss with the local personnelthe important role which theyare playing in the total public healthprogram. An honest effort is being madeto cause all the personnel in the localhealth departments to feel that theyare an integral and important part ofthe state health organization and thatthe proper execution of the duties assignedto each one will aid and abetthe on-going of the public health movementin North Carolina.At the end of the calendar year 1950,more than 4,000,000 men, women andchildren in the one hundred counties ofNorth Carolina were receiving some typeof local health service in the sixty-seven

16 The Health Bulletin June, 1951organized health departments, forty of local health departments, with 59 vacwhichwere county units, twenty-four ancies. Of this nvunber ten were fulldistrictvmits, and three city health de- time health officer vacancies and twentypartments. In order to supply medical vacancies were in the public health nurssupervisionto all of the counties, it has ing persormel. This shortage of qualifiedbeen necessary to attach a niunber of personnel, particularly physicians andthe smaller counties to larger counties nurses, continues to be a major problem,having the services of a full-time health Trainingr: During 1950 the followingofficer. In practically aU instances this personnel received, or were in the proprocedvirehas been very satisfactory. cess of receiving special training underAs of December 31, 1950, there were the varied programs sponsored by the1,083 full-time budgeted positions in State Board of Health:Health Officers—scholarships University of North Carolina 3Health Officers—orientation in various field training centers 4Health Officers—attending radiological health conference 3Health Officer—attending Duke Psychosomatic Clinic 1Health Officers Division Directors, and other public health personnelattending Mental Health Seminar 29Physician on staff State Board of Health—tuition at University 1Public Health Nurses—scholarships 12Public Health Nurses—orientation at various field training centers 40Public Health Nurses—attending special Extension Courses 27Public Health Nurses—taking special quarter's work 20Public Health Nurses—special courses in tuberculosis, geriatrics, cancercontrol, mental health, child growth and development, prematureinfant care and maternity, cardiovascular diseases 157Public Health Nurses—attending Psychosomatic Clinic, Duke University— 26Hospital Nurses—course in care of premature infants 2Sanitary Engineers—scholarships University of North Carolina 2Sanitarians—special 8-week courses at various field training centers 36Sanitarians and Engineers—special Milk courses 27Sanitarians—course in Insect and Rodent control 36V. D. Investigators—special training 8P. H. Educators—scholarships ^^Nutritionist—scholarships^Lab. technician—scholarships1Bacteriologist—scholarshipsMental Health Trainees—scholarships 3Personnel in various categories of public health attending workshops, etc.— 9Industrial Hygiene Engineers—special courses 3Chief Industrial Hygiene Engineer—special course at RadiologicalMonitor School, Chicago — ^Apprentice Trainees—assigned to local health departments:Health OfficersPublic Health NursesHealth EducatorSanitarians and P. H. Engineers :^*^5Total 469

June, 1951 The Health Bulletin 17In addition to the routine services ofthe Field Representatives such as consultationto the local health units inregard to records and reports, reviewingand editing reports to and from theState Board of Health, it is felt thatprogress has been made in three respects.As was stated in the conjoint reportfor 1949, a new report form was to beused by the local health units beginningJanuary 1, 1950. This annual report wasa drastic change from the quarterlystatistical. The Field Representativesspent a considerable amount of timereaching every department in the stateto give interpretation and explanation ofitems and assistance in compilation ofdata. One of the strong points of thenew report is that the cooperation ofthe entire staff is needed for its completion,and the interpretation of the datais of interest to all the personnel. Forthis reason, and also to expedite coverageof the entire state, the new reportwas discussed in many places at generalstaff meetings. This report form is beingused in 1950 and 1951 on a trialbasis. It is planned to have a committeecomposed primarily of local personnelto study suggestions for changes andadditions, and revamp the trial forminto one that will be satisfactory forseveral years.During the summer of 1950, theOrange-Person-Chatham-Lee DistrictHealth Department asked the RecordsAnalyst of the Department of FieldTraining of the School of Public Healthand the Field Representatives of theLocal Health Division to assist in developingrecords which would simplifythe present forms and procedures usedin recording their activities. After severalconferences with the medical, nursing,and clerical staff, three experimentalforms were designed and proceduresoutlined. An experiment in theuse of these was begun in September,1950, and will continue into the springof 1951. From this it is hoped that somerecommendations may be made forsimplification of records throughout thestate.For some time in-service training forclerks has been contemplated but thefiscal year 1950-51 is the first time thatfunds have been included in the budgetfor this purpose. This followed the employmentof Miss Alpha Kenny, EducationalDirector, Public Health Recordsand Statistics in the Department ofField Training in the School of PublicHealth, who will be mainly responsiblefor this training. Having money andpersonnel for the first time, definiteplans have been made for two twoweeks'courses in the spring of 1951.PUBLIC HEALTH NURSING SEC-TION—Amy L. Fisher, R.N., ChiefBeginning in January, 1950, a Quarter'sTraining Program for Selected RegisteredNurses in Public Health wasgiven to twenty nurses in order to improvetheir service and make them eligiblefor reclassification as Junior PublicHealth Nurse. This was a cooperativeproject with the Department of FieldTraining, School of Public Health, Universityof North Carolina, and was underthe guidance of Miss Evelyn Johnson,Education Director. All of these nurseshave passed the Merit Examination andare now working as Junior Public HealthNurses.Prom January until September, fivepublic health nurses made consultantvisits to local health departments. InSeptember Miss Dorothy Boone wasgranted leave of absence to take theMental Health Course at the Universityof Minnesota.Continued emphasis has been placedon the development of the PrematureInfant Program with Miss Mabel Pattonassigned practically full time to thisprogram. School Health Service wasgiven special emphasis because of thefunds available for correction of defectsand also because of some regional planningconferences (which are describedunder School Health Coordinating Service.)On April 10, 1950, Miss Florence Burnettwas employed as Public HealthNursing Consultant, PsychosomaticClinic, Duke Hospital. Her salary is paidby the State Board of Health from Men-

18 The Health Bulletin June, 1951tal Health funds. Miss Burnett is nowplanning the program of Training inMental Health for Public Health Nurses.In addition to the four week-end groups,a ten-day course is offered for nursesfrom the distant parts of the state. MissBurnett is also available on requestthrough the State Board of Health forstaff conferences in departments whereone of the nurses has been to Duke forthis experience.In the interest of recruitment of publichealth nui'ses, an apprenticeship planhas been started whereby nurses may begiven experience in field training centers.Three nurses were granted stipendson this program early in the year, twoof them were granted scholarships forthe Program of Study in Public HealthNursing in September. Five additionalnurses began apprenticeship experiencein the fall.HEALTH EDUCATION SECTION —Elizabeth Lovell, ChiefAs in years past, the keynote in publichealth education in 1950 was the recruitment,training and employment ofhealth educators on the local level. Atthe present time, twenty-six trainedpublic health educators are working inlocal health departments in North Carolina.Two of the health educators wereemployed in 1940 to develop a demonstrationin venereal disease investigationand general health education. These twohealth educators were employed withUSPHS funds, and in 1950 the localhealth departments assumed the responsibilityfor the salaries.Ruth Thompson was employed asSupervisor of Public Health Educationand loaned to Wake County Health Departmenton a part-time basis to developa local health education programand to supervise the local health educatorsin the eastern section of NorthCarolina. A public health educator,jointly employed by the State Board ofHealth and Appalachian State TeachersCollege, has continued her work as Professorof Health Education, AppalachianState Teachers College, as well as workingpart-time with the district healthdepartment in Boone.Two public health educators havecontinued working with the TuberculosisSection of the State Board of Health.Even though the time allotted for theeducational program preceding the massX-ray has been limited, these workershave done an excellent job of preparingcommunities for the mass surveys.In 1950 ten public health educatorswho received their training at the Universityof North Carolina and NorthCarolina College were employed in localhealth departments or colleges inNorth Carolina.The State Board of Health awardedfive training scholarships in September,1950. The first public health educationapprentice is now receiving her graduatetraining at North Carolina College.One apprenticeship trainee is receivinghis training at Wake County Health Departmentat the present time.The local health educators carried ona planned recruitment program throughand local communities andthe collegesscreened the applicants for scholarship.This year for the first time, a deliberateeffort was made by the local health educatorsto interview the references givenby each applicant. In addition, each applicantwas asked to submit an autobiographyas a part of the applicationforscholarship.In 1950 the local public health educatorshave assisted public health personnelin developing health educationprograms to meet the needs in localcommunities. These programs includesuch activities as organization of healthcouncils; foodhandlers and milkhandlerscourses; adult study courses; and planninghealth programs with civic clubs,home demonstration clubs, voluntaryhealth agencies and other groups.With the increased emphasis on theschool health program, the local healtheducators have continued emphasis onthe organization of school health councils;in-service-training programs forteachers, providing materials to schools;assisting in planning school health programs;and working with Parent-Tea-

June, 1951 The Health Bulletin 19Cher Association groups on health educationprograms.The health educators have assisted inpreparing, producing and distributingpamphlets, posters and exhibits andhave utilized films, radio programs andnewspaper articles in the local healtheducation programs.In July and December statewide conferencesfor health educators were heldat the State Board of Health in Raleigh.In addition, the local health educatorsattended the March Working Conferencein Chapel Hill, and a school healthconference sponsored by the SchoolHealth Coordinating Service in October.In two areas of North Carolina thehealth educators participated in themeetings of District Public Health Associations.The Supervisor of Public Health Educationattended the workshop on "Supervision"conducted by Charlotte Towleat the University of North Carolina.Field visits were made to local healtheducators by the Supervisor and Chiefof Public Health Education.The health educators attended andparticipated in the meetings of the N.C. Public Health Association. A numberof the health educators attended theSouthern Branch APHA meeting inBirmingham. Several of the health educatorsattended and participated in theAmerican Public Health Associationmeeting in Saint Louis.Members of the Public Health EducationSection Staff have taken anactive part in committee work of state,regional and national organizations concernedwith health education.The Public Health Education Sectionworked with other Divisions of the StateBoard of Health and allied agencies andorganizations on health education materials;orientation and training coursesfor personnel and in planning and developinghealth education programs.In cooperation with North CarolinaCollege, exhibits were prepared forSouthern Branch APHA and the NorthCarolina Medical Society meeting. Anexhibit was prepared in cooperation withHealth Publications Institute for theNorth Carolina Public Health Association.An exhibit was developed for theN. C. State Fair in cooperation with theCancer Society and the Cancer Sectionof the State Board of Health.Two special activities of note havebeen developed during the year. A seriesof study courses on health subjects isbeing conducted for the prisoners atWomen's Prison. With the increasedactivity in civil defense, the PublicHealth Education Section has been assistingin developing the health servicesprogram of civil defense in Asheville.Upon request, the section has assistedlocal health departments in planningand developing health education programsin the counties where there areno local health educators.MENTAL HEALTH SECTION— M.Frances Johnson, Acting ChiefIn July, 1950, Miss Dorothea L. Dolan,Psychiatric Social Work Consultant,USPHS, was transferred to Chicago,Illinois, Region 5. The staff now consistsof Miss M. Frances Johnson, ChiefPsychiatric Social Worker; Miss AlmaLee Draper, Secretary; and Mrs. DennacelleKiger, Librarian. The MentalHealth Consultants to act in lieu of astaff psychiatrist are: Dr. J. W. R. Norton,State Health Office; Dr. C. C.Applewhite, Director, Local Health Division;Dr. Mabel Ross, Region 3, USPHS;Dr. David A. Young, Spt. North CarolinaHospitals Board of Control; Dr.Maurice H. Greenhill, Associate Directorof Neuropsychiatry, Duke UniversitySchool of Medicine; and Dr. Lloyd J.Thompson, Professor, Bowman GraySchool of Medicine.The following clinics provide servicesin local communities. Approximately3,000 cases were handled and 2,069 wereclosed during the year.Mental Hygiene Clinics — Asheville,Charlotte, Raleigh, and Mount AiryChild Guidance Clinics — Durham,Duke HospitalPsychosomatic Clinic—Duke HospitalNeuropsychiatric Clinics— BaptistHospital in Winston-SalemCharlotte City Health Departmentand Duke Psychosomatic Clinic each

20 The Health Bulletin June, 1951have a Mental Health Nurse and Winston-SalemCity Schools have a SocialWorker. The Surry County Clinic atMount Airy and the Durham ChildGuidance Clinic are under the auspicesof the local health department. Thisplan seems to be working very nicelyand it is hoped that in the near future,all clinics will be under the direction ofthe local health officer, thereby decentralizingadministration of mentalhealth funds.Mental health stipends in psychiatricsocial work were awarded to Miss MarthaFaison who attended Tulane Universityand is now employed at theState Hospital and Mr. Sidney Talismanwho attended the New York School ofSocial Work. A suitable assignment hasnot been found for Mr. Talisman sincethe completion of his training.A Professional Circulating Library isavailable to all professional people. Thiscontains approximately 320 books onpsychiatry and mental health. Twohimdred and fifty were circulated thisyear. Pierre the Pelican messages, aseries of twelve monthly printed lettersto parents of first-born children, aredistributed through the state—24,180series being issued this year. Services ofthe psychiatric social worker are available,and many field trips were madein this period in addition to a heavycorrespondence. A set of three mentalhealth posters were issued to health departments,pediatricians and otheragencies throughout the state. Films forlay education and professional stafftraining were lent on request. Pamphletsand reprints were issued to keypeople throughout the state. An instituteon mental health was held atWrightsville Beach in June. This wasvery successful, being attended by healthofficers, psychiatrists, resource people, apublic health educator, a public healthnurse, a clinic psychologist, a mentalhealth nurse, and two psychiatric socialworkers.Recruitment efforts are continued inthe hope that it may become possibleto make available to every county notonly mental health training opportunitiesand mental health informationalmaterials, but also mental hygiene clinicservices which are needed in a wellbalancedprogram. Our objective is toprevent mental illness and promote positivemental health of all North Carolinians.SCHOOL HEALTH COORDINATINGSERVICE—Charles E. Spencer CoordinatorThe North Carolina School HealthCoordinating Service which is sponsoredby the State Department of Public Instructionand the State Board of Health,officially represented both agencies inthe school health and physical educationprograms in North Carolina duringthe period January 1, 1950, to December31, 1950.In carrying out this responsibility, thestaff members worked with schoolsuperintendents, principals, and teachers,with public health department personnel,and with representatives of otheragencies interested in the health ofchildren, youth and adults.Major Activities of the YearCurriculum Study and ImprovementProject Continued.The health and physical educationcurriculum project, described in detailin the 1940 Annual Report, was continuedduring 1950. By December 31,1950, the Physical Education Bulletinproofwas completed except for editing,reading and writing directions to printers.During the year, tentative sectionsof the Health Guide were completed anddistributed to many county and cityschools for experimental use. Recommendationsfor revision have been made,many of which will be incorporated inthe new material.Administration and Supervision of theSchool Health FundThe School Health Coordinating Servicecontinued to represent the StateDepartment of Public Instruction andthe State Board of Health in the administrationand supervision of theschool health program, including planningand administering the expenditure

June, 1951 The Health Bulletin 21of school health funds in the amountof $550,000 annually, appropriated by the1949 General Assembly to be allocatedby the State Board of Education asgrants in aid to city and county schooladministrative units. The plan for allocatingthe funds the first year of thebiennium July 1, 1949 to June 30, 1950,was continued the second year of thebiennium, namely:A. Each county and city school administrativeunit was allotted an amountequal to 50(* per pupil based on theAverage Daily Membership for the firstseven months of the previous schoolyear.B. In addition, the sum of $1,000 wasallotted to each county regardless ofsize. Each school administrative unitwithin the county receives a portion ofthe $1,000 allotment based on its percentageof the total students in thecounty.The policies approved by the StateBoard of Health and the State Board ofEducation in 1949, governing the expenditureof these funds, were continuedfor the second year of the biennium.Also, the State B'oard of Health continuedthe plan of earmarking anamount equal to 40(J per pupil for schoolhealth work.Expenditures of State Board of Educationschool health funds for the periodJuly 1, 1940 to June 30, 1950, were asindicated below:Salaries: Health Educators ^ $ 25,809.29Nurses 55,540.54Physicians 8,399.22Technicians 10,111.91Travel: Health Educators^ 3,156.23Nurses 12,682.59Physicians 251.10Technicians 1,981.76Clinic Fees 46,554.57Correction of Defects 272,033.07Supplies 25,078.04Equipment 55,983.11In-service Training 3,295.10$520,876.44State and Local Planning for SchoolHealthA. A state Advisory School HealthCommittee was approved by the StateHealth Officer and the State Superintendentof Public Instruction. The functionsof the committee are to study theover-all school health program and tomake recommendations to the StateHealth Officer and State Superintendent.The Committee is composed of thefollowing members:Dr. Clyde A. Erwin, State Superintendentof Public InstructionDr. J. W. R. Norton, State Health OfficerDr. C. C. Applewhite, Local Health Administration,State Board of Health,Raleigh, N. C.Mr. J. E. MUler, State Department ofPublic Instruction, Raleigh, N. C.Dr. Clyde Minges, State Dental Society,Rocky Mount, N. C.Dr. Roscoe McMillan, State Medical Society,Red Springs, N. C.Dr. J. Henry Highsmith, Divisional ofInstructional Service, State Departmentof Public Instruction, Raleigh,N. C.Mrs. Anne Maley, Lunchroom Program,State Department of Public Instruction,Raleigh, N. C.Miss Catherine Dennis, Division of InstructionalService, State Departmentof Public Instruction, Raleigh, N. C.Miss Ada McRacken, State Departmentof Public Welfare, Raleigh, N. C.Dr. E. A. Branch, Division of Oral Hygiene,State Board of HealthMr. John L. Cameron, Division of SchoolBuildings and Surveys, State Departmentof Public Instruction, Raleigh,N. C.Mr. Robert L. Caviness, Division ofSanitary Engineering, State Board ofHealth, Raleigh, N. C.Miss Amy L. Fisher, Supervisor ofNurses, State Board of HealthMrs. H. A. Helms, 1001 W. Peace Street,Raleigh, N. C. (P.T.A.)Mr. Felix Barker, Division of SpecialEducation, State Department of PublicInstruction, Raleigh, N. C.Miss Frances Johnson, Mental HealthAuthority, State Board of HealthMiss Elizabeth Lovell, Local Health Administration.State Board of Health;Raleigh, N. C.

22 The Health Bulletin June, 1951Dr. Bertlyn Bosley, Nutrition Section,State Board of HealthMr. Charles E. Spencer, Director, SchoolHealth Coordinating ServiceMrs. Annie Ray Moore, Health Educator,School Health Coordinating Service.B. Ten Regional Planning Conferences.The staff of the School HealthCoordinating Service, with the cooperationof other divisions of the State Departmentof Public Instruction and theState Board of Health, the Welfare Department,the Parent-Teachers Associationand the State Medical and DentalSocieties conducted ten Regional SchoolHealth Conferences, to promote and assistwith planning for better schoolhealth programs on the local level.Many planning conferences in individualcounties were held after the regionalmeetings upon request of local healthofficer and school superintendent.Health EducationWorkshopA Health Education Workshop wassponsored by the School Health CoordinatingService and the University ofNorth Carolina at Chapel Hill from June13 to July 20, 1950.The purpose of the Workshop was toprovide opportunities for teachers, schooladministrators and health workers (1)to study the major health problems ofchildren and adults, (2) to assist themin planning functional programs to meetthe needs of their own particular schoolcommunitysituations, and (3) to gainbasic information and a mastery ofskills and techniques essential to thebest implementation of such programs.Six semester hours of graduate orundergraduate credit was given by theUniversity to those who completed thework.Financial aid in the amount of $750was given by the North Carolina Divisionof the American Cancer Society tothe University of North Carolina to beused toward general expenses of theWorkshop. Local Tuberculosis Associationprovided scholarships to individualparticipants from their respective countiesand cities. The State TuberculosisAssociation made a grant of $250.00 forgeneral expenses of the Workshop.Other Service of the Staff of the SchoolHealth Coordinating ServiceState planning and promotional workand services to school and health departmentpersonnel through consultativeservices, field visits, planning andcarrying on in-service education, productionof certain materials, reviewingand recommending use of materials, locateand recommend use of local, stateand national resources, evaluative procedures,joint state conferences andcommittees, state and national organizations.A. Health Services. This involvesworking with school and health departmentpersonnel in teacher screening andobservation of children with obvious deviationsfrom normal. Audiometer testing,physical and psychological examinationsare done and follow-up workwith parents carried on to get neededcorrections of defects. Consultant andpromotional and advisory services arealso given to promote better records andreports, and a promotion of activities isdirected towards making educational experiencesout of health services.B. Health Instruction. This involvesworking with teachers and administratorsin identifying and solving childhealth needs through experiences directedtowards improvement of habits, attitudesand knowledges. It involvesdirecting work with teachers in preparationof materials of instruction andevaluation in such areas as mental hygiene,community health, family lifeeducation, communicable disease controland sanitation, safety and personalhealth problems such as nutrition, dentalhygiene, rest and sleep, and care ofthe eye, ear, nose and throat and educationwith reference to harmful effectsof alcohol and narcotics.C. Healthful School Living. "The EnvironmentalAspects of Health." Thisinvolves assisting administrators inselecting and improving environmentalfacilities and in the care and use ofsuch facilities. It also involves work withadministrators in the organization ofthe total school health program to pre-

June, 1951 The Health Bulletin 23vent over-crowding, over-work, or anunbalanced program.D. Physical Education. This involvesgiving assistance to administrators inorganization, scheduling, selecting andcare of facilities and equipment; personnel;and the program of physicaleducation including the required credit,instruction, recreation activities, intramuralactivities and varsity athletics.E. Mental Hygiene. The consultant inmental hygiene worked with school andhealth departments to make mental hygienean integral part of the entireschool health program. Mental hygienewas emphasized from the position approachedas:1. An area in health instruction asshown in 5B above.2. A sensible way of living for teachers,pupils and parents in whateveractivity they are engaged.Cooperation and CoordinationIn carrying on the above listed activities,the School Health CoordinatingService was particularly aware of itsresponsibilities to:A. Cooperate with other divisions ofthe State Health and Education Departmentsand with other agencies and organizationsin worthwhile school healthprojects.B. Work toward coordination of allschool health activities to avoid duplicationand omission of services.Demonstration Work in Negro SchoolsA. The Negro staff members workedextensively in the following counties:Hoke CountyRandolph CountyMoore CountyGranville CountyAsheville CityB. The Negro staff assisted with theHealth Education Workshop for teachersat North Carolina College at Durham.They also participated in theFamily Life Education Workshop heldat the same institution.EPIDEMIOLOGY DIVISION— C. P.Stevick, M.D., DirectorSince February 1, 1950, the Division ofEpidemiology has been comprised of thefollowing sections: Acute CommunicableDisease Control, Tuberculosis Control,Venereal Disease Control, Public HealthStatistics, Industrial Hygiene, and AccidentPrevention. A separate report followsfor each of these Sections.Acute Communicable Disease ControlThe duties of the Chief of this Sectionare being performed by the DivisionDirector. These consist of the analysisof morbidity data, consultation with localhealth departments, investigation ofcommunicable disease problems in thefield, preparation of educational materials,and general administration.Two communicable diseases reachedlow records in 1950, according to morbidityreports. These were lymphogranulomavenereum with a total of 91 cases,and malaria 35 cases. In addition, therewere no smallpox cases reported for thesecond consecutive year, and diphtheriareports were fewer in number than inany year except 1948.Record high totals were established byamebic dysentery with 132 reports,encephalitis with 9 reports, and tuberculosiswith 3,653. Sufficient facilitieshave not been available to adequatelyinvestigate the first two of these problems.The amebiasis increase is believedto be due merely to the increased recognitionof endemic cases. Encephalitis isa problem that needs careful observationin coming months. The wide extent ofcertain types of this disease in the fareast and other parts of the world andthe known existence of certain insectvectors in this and other states representa definite hazard. Steps are being takento more fully utilize newly developedvirus identification facilities of theUnited States Public Health Service.Tuberculosis case-finding by mass x-raysurvey techniques has been at a highlevel for the past several years. Theratio of cases per death in 1948 was 4.2,in 1949 3.6, and, according to provisionaldeath totals, for 1950 it was 4.7. Thisappears to indicate that there has beenno real increase in tuberculosis incidence;however, the possibility cannotbe completely discounted that an increasein cases may have occured re-

24 The Health Bulletin June, 1951cently without sufficient time havingelapsed for the deaths to have increasedproportionately.Substantial improvement was made inthe reported incidence of the followingdiseases: gonorrhea, syphilis, and murinetyphus fever. Gonorrhea reached arecord high in 1949 with 16,173 reports.The 1950 total of 14,930 reports is slightlylower than the 1948 total and may besignificant in view of the increased casefindingefforts being made throughoutthe state. Syphilis reports are at thelowest level since 1933 and the declinehas now been continuous since 1939except for one post-war year. Earlysyphilis declined approximately 40% andlate syphilis 20% in 1950 as comparedto 1949. Typhus fever has declined withoutinterruption from a high of 236 reportsin 1944 to 12 in 1950; DDT dustingin endemic areas apparently has beenhighly effective in achieving this result.Poliomyelitis reports total 756. Thesecases were widely distributed throughoutthe state so that no clear cut epidemicfocus appeared as in other years havingan equally high attack rate.Whooping cough cases, which hadreached a record low number in 1949,were more than doubled in 1950. Thetotal of 3,552 cases is larger than wasreported in the preceding four years,and indicates a need for renewed emphasison pertussis immunization of infants.The change in incidence of other communicablediseases is not noteworthy.The animal diseases of importance tohumans, such as tularemia, undulantfever, and Rocky Mountain spottedfever, have remained at approximatelythe same level. Resolutions have beenadopted recently by the North CarolinaVeterinary Medical Association and certainlocal veterinarian associations recommendingthat a veterinarian trainedin public health be added to the staffof the State Board of Health to assistin the control of those animal diseasesof importance to public health. The needfor this service has been emphasized,particularly with respect to rabies.The typhoid carrier register maintainedby this Section held the namesof 76 individuals as of the close of theyear 1950 as compared to 78 the yearprevious.TUBERCULOSIS CONTROL SECTION—William A. Smith, M.D., ChiefThe principal function of the TuberculosisSection is case-finding by community-wideand special x-ray surveys.Home follow-up and immediate followupof cases found during mass surveysis continually emphasized to health departments.To that end, the Sectionmaintains follow-up personnel in thecounty or district after the departure ofthe mass x-ray personnel. The duty ofthis personnel is to reexamine those personswho were definitely or tentativelydiagnosed as having tuberculosis duringthe regular survey. The final resultsof follow-up activities in fourteen county-communitysurveys made in 1950showed that 92% of those persons whorequire reexamination responded by returningto the Health Department forsuch examination.Health education and publicity inconnection particularly with communitywidesurveys is another responsibility.This work is performed by two healtheducators. This health education beginsprior to the beginning of a survey andcontinues during the survey.Other responsibilities and activitiesinclude liaison with:State institutions (for better casefinding)The Director, State SanatoriaState Tuberculosis AssociationN. C. Division of Vocational RehabilitationState Department of Public WelfareLocal health departments (for casefindingand other measures pertainingto tuberculosis control)Cooperation with Duke UniversityHospital (pertaining to x-ray ofhospital admissions and other personsby furnishing the hospital aGeneral Electric 4x5 x-ray apparatus)Interpretation of 4 x 5 film for onecountyFurnishing funds to purchase x-ray

IJune, 1951 The Health Bulletin 25equipment for county health departmentsAllotment of $75,000 to counties to beused in tuberculosis controlOn occasion, furnishing minor equipmenton loan to county health departmentsPersonnel and EquipmentThere are twenty-two persons employedby the Section. Personnel consistsof two doctors, two health educators(one white and one Negro, both ofwhom are female), one part-time consultantnurse, one chief clerk, ten x-raytechnicians, and six other persons.Equipments consists of:Eight mobile x-ray units with tractorsOne portable 14 x 17 WestinghouseunitOne generatorOne 4x5 x-ray unit located in theReviewing Section at Duke HospitalOne Chevrolet carry-all.Activities during 1950Special surveys were conducted inthirty-eight communities and includedstate institutions, colleges and schools,the general public, industry, and specialgroups selected by health oflBcers. Someschools, colleges, and state institutionswere surveyed by special request. Theseare generally routinely surveyed duringmass surveys of an area. Those surveyedby special request in 1950 were:Schools and Colleges:Wake Forest College Wake ForestWashington High School RaleighEastern Carolina Teachers CollegeGreenvilleGreene County High SchoolSnow HillJohnston County Teachers- SmithfieldMethodist OrphanageRaleighUnion County Teachers MonroeState CollegeRaleighUniversity of North CarolinaChapel HillCommunity-wide sui'veys were completedin health department jurisdictionsnamed below:Hertford-GatesWashington-TyrrellLenoir-JonesOnslow-PenderRobesonColumbusBladenBrunswickNashFranklinWilsonCaswell County Teachers -YanceyvilleCity of Rocky Mount SchoolsRocky MountPeace InstituteRaleighMeredith CollegeRaleighShaw UniversityRaleighSaint Augustine College RaleighState Institutions:State School for Blind RaleighState HospitalGoldsboroState HospitalRaleighWomen's PrisonRaleighNumber of X-Ray Plates MadeDuring the year over 300,000 x-rayplates were made. The type and numbertaken is listed below:70 mm. plates madeduring mass andspecial surveys 298,3004x5 plates madeat Duke UniversityHospital 15,24614 X 17 plates madeduring followupclinics9,000 (estimated)Findings322,546Findings are recorded according torate per 10,000 persons examined andinclude community-wide surveys only inwhich follow-up activities were carriedout by our personnel. Persons who werereexamined represented 92% of thosewho actually were in need of reexaminationand our figures are based on thisgroup.During 1950, 15 counties were surveyedand the results tabulated below include14 of these counties. The survey inWilson County was completed December23 and the final results have not beentabulated as of this date.Findings are:Rate per 10,000 persons examinedPulmonary scars 144.6

26 The Health Bulletin June, 1951Minimal, moderate, and far advancedtuberculosis 34.2Suspected tuberculosis 25.0Diagnosis reserved 16.0Cardiovascular 63.3VENEREAL DISEASE CONTROL SEC-TION—Maurice Kamp, M.D., ChiefSatisfactory progress in venereal diseasecontrol, especially syphilis, has beenmade during 1950. There has been agratifying drop in the early or infectiouscases of syphilis reported. The decreasein reported cases of congenital syphilisis not as marked. Morbidity data andother pertinent figures reveal the following:I. Cases reported for the first time:Syphilis Gonorrhea1949 6,699 16,1771950 5,168 14,934II. A comparative study over a threeyearperiod of primary, secondary, andcongenital cases showing the percentagethey comprise of the total cases reported:Number Cases Percent Number Per CentYear Primary and Primary and Con- Con-Secondary Secondary genital genital1949 2,093 31.2% 416 6.6%1950 1,196 23.1 346 6.6III. Total admissions to the two VenerealDisease Centers at Durham andCharlotte1949 6,7911950 5,232Total admissions in both Centers sinceopening in 1943, through December 31,1950: 53,413.During the report period the Sectioncontinued a special case-finding projectin cooperation with the United StatesPublic Health Service whereby trainedvenereal disease investigators were employedby the State Board of Health andassigned to local health departments inareas of high incidence. At the end of1950 there were 20 of these individualsserving 41 counties. In 18 other countiesthere were locally employed investigators.In those counties not having investigatorspublic health nurses providedsimilar service. The functions ofthis group included careful interviewingof all new patients by using special interviewingtechniques and the investigationof the contacts named by the patients.The following table illustrates the effectivenessof this program and at thesame time emphasizes the need for continuationof the control program inorder not only to make possible a furtherreduction in the incidence ofsyphilis but also to prevent an actualincrease in incidence from the reservoirof undetected cases. The extent of thisreservoir is probably considerable, inview of the increase in infected contactsfound by means of increased effort.A comparative three-months study ofepidemiological activity is shown below:Infectious Syphilis Contacts Number NumberYear Number of Named per of InpatientsPatient Contacts fected1949 1,080 .79 853 2971950 777 3.01 2,339 748This clearly shows that it is possibleto secure a great number of infectedpeople, even though the number of patientsin a comparative period decreases.Contacts interviewing and investigationof contacts has been emphasized duringthe calendar year. Although it ismore difficult to find infected people,this study shows that they do exist.Increased effort was made in cooperationwith the prison system. Because ofexcellent cooperation on the part of thechief prison physician, our local investigatorswere permitted to interview infectedinmates in the 92 state- operatedprison installations. In addition, the prison-wideadoption of penicillin therapyfor the treatment of syphilis effectedbetter over-all control, including thatof short-term prisoners.Due to the decline in the number ofcases of syphilis and the consequent risein cost per patient day, the RapidTreatment Center at Charlotte wasclosed December 31, 1950. The encouragementof the local health departmentsand private physicians to treat cases ofvenereal disease locally also contributedto the decreased number of Rapid TreatmentCenter admissions. Gonorrhea istreated almost exclusively on a localbasis by private physicians and localhealth departments with the one injectiontreatment of penicillin.

June, 1951 The Health Bulletin 27A primary objective of the StateBoard of Health, so far as venereal diseasecontrol is concerned, is for themanagement of venereal disease by theprivate physicians and the local healthdepartments. To implement this objectivethe development of adequate localhealth department facilities has beenencouraged. To provide proper technicalbackground, refresher courses for physicians,health officers, public health andgraduate nurses have been given duringthe year. Intensification of this programhas occurred during the last half of1950 so that classes are being held twoto three times a month for the variousprofessional groups. The response tothese short-term courses, averagingthree days in duration, has been verygood. For this reason, this phase of theprogram will be continued indefinitelyand will include courses for Negro physiciansand nurses.The clinical facilities of the VenerealDisease Center at Durham are in constantuse by the Syphilology Departmentof Duke University Medical Schoolto teach the medical students thevarious aspects of venereal disease management.The School of Public Healthat Chapel Hill, too, utilizes some phasesof the program at this Center.It is planned to emphasize venerealdisease control in the military and defenseareas of the state. Concentrationof effort in these areas will anticipateand manage any increased prevalenceof venereal disease as a result of the defenseeffort.A research project under the directionof Dr. John J. Wright, School of PublicHealth, known as the North CarolinaSyphilis Studies was set in 1940 to followthe trends in syphilis over a longperiod of time. The project is located atthe School of Public Health in ChapelHill and is under the administration ofthe Division of Epidemiology of theState Board of Health. Funds are derivedfrom the University and from federalgrant-in-aid allocations to theState Board of Health.Basic data on all stages of syphilisoccurring in the area have been accumulatedsince 1941 in the form of registerof serologic tests and a register of allbirths in the area. These data are beingused for evaluating venereal diseasecontrol programs.During 1950 the following studies werepublished1. Greenberg, B. G., Wright, J. J., andSheps, C. G.: "A TECHNIQUE FORANALYZING SOME FACTORSAFFECTING THE INCIDENCEAmer-OF SYPHILIS", Journal ofican Statistical Association, September1950, Vol. 45, pp. 373-399.2. Wright, J. J., and Sheps, C. G.:ROLE OF CASE FINDING CON-TROL TODAY", American Journalof Public Health and The Nation'sHealth, July 1950, Vol. 40. No. 7.3. Wright, J. J., Sheps, C. G., and"REPORTS OF THEGilford, A. E.:NORTH CAROLINA SYPHILISSTUDIES: V. Indices in the Measurementof Congenital Syphilis",American Journal of Syphilis, Gonorrheaand Venereal Diseases. InPress.Since July 1950 the staff have beenengaged in three studies relating to theproblem of congenital syphilis:1. A retrograde epidemiologic study isbeing completed of a series of cases ofcongenital syphilis reported during thepast few years in the area surroundingChapel Hill. By interviews with familiesand physicians, and review of all availablemedical and health records on thefamilies, an attempt is being made tofind why congenital syphilis is still aproblem despite seemingly adequatemeans of prevention.2. A series of cases of maternal syphilisare being studied to determine themost efficient case-finding methods.3. A study of 14,000 pregnancies occurringin the area in the past nineyears is being made to determine towhat extent serologic tests are beingdone during pregnancy as a routinepractice.Members of the staff have also takenpart in the teaching of venereal diseasecontrol methods at the School of

28 The Health Bulletin June, 1951Public Health and at the North Caro- sponsored by the Public Health ServiceUna College at Durham and have par- in Phoenix, Arizona; Chicago; Illinois;ticipated in venereal disease seminars and Roanoke, Virginia.INDUSTRIAL HYGIENE SECTION—O. J. Swisher, Jr., M.D., ChiefMedical ServiceI. Number plants surveyed (industries with silica and asbestos hazards) 116Physical examinations and x-rays 3,603Number issued work cards 3,492,,Number rejectedIHDiagnoses of rejects:23 silicosis, first stage.32 silicosis, second stage.14 silicosis, third stage.11 with no dust pathology but recommended to have sanatroium studydue to other pathology.3 asbestosis, first stage.3 asbestosis, third stage.22 recommended to have sanatorium study due to questionable tuberculosis.1 cardiac enlargement.2 cystic disease of lungs.Industries surveyed included the following:14 marble and granite.3 asbestos.44 machine works and iron foundries.14 monumental works.16 quarries and stone companies.8 feldspar.10 mica.1 tungsten.1 vermiculite.1 pottery.1 ilmenite.3 pyrophyllite or kaolin.X-rays taken in non-dusty trades 465Non-dusty trades included:Carolina Mirror CorporationSanford Tobacco Refining CompanyState Highway DepartmentII. Medical case histories submitted to Industrial Commission 60Supplementary medical case histories submitted to Industrial Commission 8Special physical examinations and x-rays as requestedby Industrial Commission 70Diagnoses of special examinations and x-rays:13 silicosis, first stage23 silicosis, second stage12 silicisos, third stage7 asbestosis, first stage3 asbestosis, second stage3 asbestosis, third stage1 with no dust pathology but emphysematous blebs4 for further sanatorium study4 essentially negative

June, 1951 The Health Bulletin 29III. Court hearings 3329 hearings testified by Dr. Swisher4 hearings testified by Dr. DavisThese court hearings included employees from the following plants:Asheville Mica Carpenter & Phillips Mica English MicaD. T. Vance Mica Carolina Marble & Granite Feldspar ProducingCole-Willard Stone Bradley Mining Union AsbestosHarris Clay Glascock Stove Works Wysong-Miles FoundryThe following diagnoses were given in these court hearings:3 silicosis, first stage19 silicosis, second stage (one with questionable tuberculosis).7 silicosis, third stage (one with questionable tuberculosis).3 asbestosis, second stage1 essentially negativeSuperior Court cases(employee of Palmer Stone Works, with diagnosis of silicosis,first stage with old healed tuberculosis lesions, inactive in bothapices).Cases settled out of court 5Cases continued , 3Cases postponed^IV. Pre-employment x-rays and statements submitted 133Number re-takes (x-ray) made during year 9V. Conferences with Medical Advisory Committee 11Since the adoption of the new policy especially true of the asbestos industry)for more rapid x-raying of employees in Permission is granted only after carefiilthe dusty trades, there has been a little study of the employee's physical andmore than double the number of exami- medical findings by the Advisory Medinationsand x-rays made by this Sec- cal Committee. Employees whose physitionduring the year 1950 over that of cal findings indicate progression of thethe previous year. Under the new policy, disease are not permitted to return tothe field work is handled directly by work in the dusty trades.Dr. C. B. Davis, Senior Public Health a Hewson Clinitron was purchasedPhysician, the employees of the dusty and installed in our mobile x-ray unittrades x-rayed, occupational histories during the month of December. Thistaken, and the x-rays processed at this equipment is used for rapid processingoffice. Those employees found to have of employees for determination of diadustpathology are called in to this betes and is coupled with dusty andoffice for a complete physical examina- non-dusty trade surveys carried out bytion after which the findings are again this Section. As this Section does notreviewed by the Advisory Medical Com- employ the necessary personnel to opermitteeand the advisability of their con- ate the Clinitron, the local health detinuingtheir employment in a dusty partment in the county in which intradedetermined. dustry is under survey takes charge ofEmployees with a first or second stage the program. To date, there have beenasbestosis or silicosis are permitted to approximately 12 cases of diabetescontinue their employment in a dusty foimd. These have been referred to theirtrade under the following circumstances: physicians for medical care.1 ) No progression is shown in path- During the year a senior general clerkology over a period of years; (2) No was employed by this Section and provedclinical findings or symptoms that to be very proficient in helping with thewould warrant their removal from dust; x-ray work on the mobile unit after the(3) the individuals agree to wear a res- resignation of our senior photofluoropiratorwhile exposed to dust (this is graphic operator.^

30 The Health Bulletin June, 1951Engineering ServiceThe present emergency has imposedupon industry of North Carolina theburden of increasing production of materialsrequired in a program of nationaldefense. This has resulted in expansionof already existing productionfacilities and the establishment of newones. Associated with this expansion hasbeen the introduction of new processes,new materials, and personnel. These alwayscontribute to the problems of industrialhealth. These problems are beingstudied, in so far as resources ofthis Section permit. Many plants haveshown their interest in these problemsby calling on engineers of this Sectionfor assistance towards evaluating andcontrolling hazards which might impairthe worker's health. A staff of threeengineers was engaged in this work untilDecember 1950, when one memberwas recalled to military service. Due tolimited number of people with industrialhygiene engineering training andexperience, possibility of replacementappears remote.In July, the State Board of Healthcooperated with North Carolina Councilof Civil Defense by sending an industrialhygiene engineer to a five-weekscourse on radiological warfare, sponsoredby the Atomic Energy Commission,and held at Illinois Institute ofTechnology, Chicago.Following a plan to decentralize engineeringactivities of this Section, twomembers of the staff moved their headquartersto Charlotte where the City ofCharlotte furnished required office space.One engineer remained in Raleigh untilhis recall to military service. The plan,designed to better serve industry, isproving its value in having the advantageof an office more centrally locatedwith respect to the industrialized Piedmontsection of the state.A statistical summary of industrialhygiene engineering activities during theperiod covered by this report is presented.Industrial Hygiene EngineeringActivities for 1950I. FieldA. Plants visits 2701. Routine inspection 862. Special IndustrialHygiene surveys 126a. Samples atmosphericContaminants collected 283(1) Dust 243(2) Other 403. Number workers involved 5,7494. Field determinations 142I. LaboratoryA. Analyses 2041. Dust 182a. Particle count 137b. Particle size .c. Petrographic 92. Other contaminants 16III. MiscellaneousA. Reports 1261. Routine inspections 162. Special IndustrialHygiene surveys 1103. Monthly 124. Annual __ 1PUBLIC HEALTH STATISTICS—C. R.Council, ChiefThe Public Health Statistics Sectionhad its beginning with the reorganizationof the State Board of Health in-February 1950. The primary purpose inestablishing such a section was to centralize,in so far as practical, all statisticalactivities relating to the state publichealth program. As of the close ofthe year 1950, all or part of the PublicHealth Statistics Section performedstatistical activities for the followingsections:Maternal and Child HealthTuberculosis ControlCancerHeart DiseaseVenereal Disease ControlMental HealthAcute Communicable DiseaseAccident PreventionControl

June, 1951 The Health Bulletin 31Special ProjectsSpecial projects undertaken duringthe year are described below:1. Birth Registration Test.This project is being conducted on acooperative basis by the Bureau of theCensus, the National Office of VitalStatistics, and each State Registrar. Theprimary purpose of this test, from ourstandpoint, is to obtain measures ofregistration completeness in local areasof the state on a comparable basis. TheBureau of the Census can use the test tomeasure the extent of under-enumerationof the infant population for the nation,and for various geographic andpopulation subdivisions. It may be usedto help ascertain reasons for failure toenumerate infants in the population.The test will also make available correctionfactors for vital statistics basedon registered births and provide datafor special analytical studies.2. Prematurity Death Study.Death due to infants born prematurelyis one of the ten leading causes ofdeath in the over-all population in spiteof the fact that such deaths are relatedto that segment of the population underone year of age. Because of this relativelyhigh loss of life, and because effortsare always being made to improvethe general health of the child, a statisticalstudy was begun in early 1950 todetermine the basic problems associatedwith this subject.It was necessary to know if the prematureproblem was general; if it wasgreater among the mothers in the ruralor urban areas: if it was higher in oneage group of mothers than in another;if race, attendant, or institution of birthaffected the number of premature deathsin any unusual manner. Some knowledgewas also needed of birth order asto which child had the best chance ofsurvival: the first born, second born,third born, etc.These factors, plus others that mightinfluence the premature death rate, werestudied in the hope of obtaining answersthat might emphasize the salient reasonsfor premature births that terminatedfatally, thereby doing the mostgood, from a life-saving standpoint, witha minimum of services rendered.3. General Accident Fatality Report.Accidents are one of the most importantleading causes of death. Detailedinformation about the circumstancesof fatal accidents has been needed fora long time in order to develop programsof accident prevention. The State Boardof Health, with the cooperation of thecity and county health departments,adopted the program of following upeach fatal non-motor vehicle accidentby use of a special report form. This reportform furnished additional facts associatedwith the death but not availableon the death certificate. The formswere processed and worthwhile datasuch as nature and manner of injury,agent or object associated with the accident,type of place, time, and how accidentoccurred, were studied in approachingthe problem with the intent ofavoiding future accidents.4. Other Special Studies.The Section in continuing other specialstudies begun in former years. Thespecial maternal mortality survey begunseveral years ago under the sponsorshipof the North Carolina Medical SocietyCommittee on Maternal Welfarewas carried on in 1950 in the same manneras in former years.A program to improve the promptnessand completeness of birth and deathregistration was begun in June 1947 andis being continued with very good results.The per cent of births and deathsfiled late since that time has been reducedby over 35 per cent.The motor vehicle accident fatalitysurvey was continued in 1950 in cooperationwith the State Department ofMotor Vehicles. The increase in deathsfrom this cause was anticipated due tothe increased road miles traveled and tothe additional number of motor vehiclesusing the highways. In this survey, asin the General Accident Fatality survey,more detailed factors associated withdeath are collected, tabulated, and analyzedthan are available on the deathcertificate.Personnel and tabulating machinefacilities of the Section have been utilizedin continuing the program of edu-

32 The Health Bulletin June, 1951eating parents of first-born children asto caring for the child in its first twelvemonths of life. A series of twelve mentalhygiene pamphlets are sent to the parentson a monthly basis. Approximately30,000 sets of twelve pamphlets eachwere addressed and mailed monthlyduring the year.Further selected statistical studies onthe prevalence of tuberculosis in differentsections of the state, by age, color,sex, and occupation were carried on duringthe year.Routine ActivitiesOn a comparable basis, more work ofa statistical nature has been done onwhat is generally thought of as vitalstatistics — births, deaths, stillbirths,population—than for any of the sectionsnamed.During the year, approximately 122,-000 current and delayed births were recorded,32,000 deaths, and 3,000 stillbirths.Recording these certificatesmeant editing for promptness, completeness,and accuracy, authorizing for paymentby each county treasurer, coding,microfilming, preparing punch cards,verifying, tabulating, printing, binding,indexing, and a host of other operationsnecessary to process efficiently such avolume of certificates.From this routine of activities, severalinvaluable indices of the state's progressin health were derived.There were 34.6 infant deaths per1000 live births (provisional figure) in1950. This compares favorably with recentyears and resumes a downwardtrend interrupted in 1948 and again in1949.The provisional maternal mortalityrate was 1.2, the same as in 1949.Birth and death certificates receivedthrough December 1950 indicate thatthe official crude birth and death rateswill be slightly lower than in 1949. Theprovisional rates based on all certificatesof residents received in 1950, with noregard to year of occurrence, are 26.4live births per 1000 population and 7.7deaths. The official rates will be slightlylower since the final figures will include1950 occurrences received through March1951. Approximately two per cent of ourcertificates are received too late to beincluded in the ofiBcial figures.Since 1925, diseases of the heart havebeen the leading cause of death in thisstate and each year a greater proportionof all deaths are claimed by this cause.In 1925, the heart disease death rate was123.5 per 100,000 population; in 1950,the provisional rate was 239.1. Statedanother way, 11 per cent of all deathsin 1925 were due to diseases of the heart,whereas 31 per cent were due to thiscause in 1950.Certain other leading causes of death,with provisional rates were 100,000 population,are as follows: JCause Number RateVascular lesions 3,855 95.4Cancer 3,115 77.1Influenza and pneumonia__l,383 34.2Non-motor vehicleaccidents 1,251 31.0Motor vehicle accidents 1,089 27.QImmaturity (unqualified) __ 880 21.8Due to the revised method of assigningcauses of death begun in 1949,nephritis dropped out of the seven leadingcauses of death.The program to improve registrationwas intensified in 1950. A full-time fieldrepresentative continued to visit personsresponsible for filing certificates and toinvestigate cases of unusual delay in registration.Teaching periods were continuedfor midwives to improve theirknowledge of correct birth registration.The outbreak in Korea resulted in anincreased demand for certificates neededfor wartime reasons. More certifiedcopies of births and deaths and verificationswere issued in 1950 than in anyyear since World War II.Two more county health departmentsassumed the responsibility of registeringall certificates in 1950. Local city andtownship registrars still serve in 59counties. There are approximately 600such registrars at present. At one timethere were 1,500 local' registrars. Thenumber of local registrars is decreasedevery time a local health officer is appointedlocal registrar for an entirecounty. This simplifies the whole registrationprocess, and is being insti-

June, 1951 The Health Bulletin 33tuted as rapidly as health department planning of activities to be institutedfacilities are developed. when funds are provided.„, „ ^.. , ,, , , Non-motor vehicle and non-indvistrialThe Section mcreased the amount of^^^.^^^^^ ^^^ ^^^^ ^^ ^^^ ^^^^ ^^statistical service m 1950. More special^^^^^ ^^ ^^^^^ .^ ^^^^^ Carolina. Therequests from physicians, other m-^^ ^^^^^ accidents are in thedividuals, and various agencies were re-^^^^ ^^^ ^^ ^^^ ^^^^^^ ^^ communiceivedand information provided than^^^^^ ^.^^^^^^ .^ childhood, and thein previous yeais.continuation of accidents as an increas-SectionAccident Preventioning cause of death among individuals'^^ hazard, accidents are now the lead-This Section is in the process of form- between the ages of one and twenty-fiveation. Funds have not yet become avail- years. The most numerous accidents areable for personnel or operating expenses, falls of elderly persons.Up to the present, activities have con- The following table presents a sumsistedof exploration of the problem by mary of the accident deaths for the yearthe Division Director and preliminary 1949:Leading Causes of Accidental Deaths, by Place ofOccurrence, by Age, North CarolinaCause of Death Number Under 1 year 1-14 yrs. 15 & overAll accidents 2,241 157 343 1,741Motor Vehicle 965 6 134 825Traffic 939 5 120 814Non-Traffic 26 1 14 11All Other Accidents 1,276 151 209 916Falls 258 1 10 247Drowning 121 — 37 84Conflagration 116 5 41 70Mechanical Suffocation 112 103 3 6Burjis (other than conflagration) 98 4 28 66Firearms 89 — 24 65Poisonings by solids and liquids 70 3 20 47Water Transports 56 — 8 48Other Road Vehicles 19—81134Railway 51 — 2 49Aircraft 46 — — 46Blow from Palling Object 39—5Other Accidents 192 35 23 134Late Effects of Injury and Poisoning __ 9 — — 9The activities of this Section will be accident prevention. This importantdirected primarily at home accident problem, which together with otherprevention. Local health department non-motor vehicle accidents in 1949staff members will be given training to caused over twice as many deaths asacquaint them with the nature and motor vehicle and industrial accidentsscope of the problem as well as the combined, is appropriately of concern tobasic techniques of prevention. Where- the public health organization of thever possible, support will be given to the state.industrial safety program of the In-;dustrial Commission and Labor Depart- SANITARY ENGINEERmG DIVISONment as well as to the highway safety —J. M. Jarrett, B.S., Directorprogram of the Motor Vehicle Bureau.There is within the state government The following is a very brief summaryno centralized effort in the fleld of home of the numerous activities engaged in

The Health Bulletin June, 1951by the personnel of this Division duringthe calendar year, 1950. Only the highlightsof the year's program and accomplishmentsare enumerated here,since detailed monthly reports of theactivities have been submitted to theState Health Officer and members of theState Board of Health.AdministrationOur program of cooperation and assistanceto Federal, State, municipal andcounty officials, and agencies concernedwith mutual problems relating to sanitaryengineering or sanitation, has continuedduring the year. Special assistancewas given to the Budget Bureau,Department of Public Instruction, Departmentof Public Welfare, State Highwayand Public Works Commission,Hospitals Boai'd of Control, State Departmentof Conservation and Development,School of Public Health, Universityof North Carolina, N. C. State College,State Department of Agriculture,architects, consulting engineers, municipalofficials, and local health departments.The administration of the work withinthe Division was improved during theyear, and was expanded to provide betterservice to those requesting assistance.A unit designated as the Insect andRodent Control Section was created inthe Division, following the reorganizationof the State Board of Health, whenMalaria Control was transferred to thisoffice from the Division of Epidemiology.Personnel changes were the lowest wehave had in recent years, only two secretariesbeing replaced. Four new personswere added to our staff: one engineeron industrial waste studies, onejionior engineer as a district engineer,one district sanitarian, and one secretary.At the end of the year, the personnelemployed consisted of 12 engineers,13 sanitarians, 1 entomologist, 6 secretaries,in addition to the Director, makinga total of 33 employees. This doesnot include those persons paid directlyby the U. S. Public Health Service andassigned to Malaria and Typhus Controlactivities.SANITARY ENGINEERING SECTION— E. C. Hubbard, ChiefConsiderable time was devoted duringthe year to assisting the operators ofmunicipal water and sewage treatmentplants in connection with operationalproblems. Assistance was also given theoperators through schools conducted forthem at the University of North Carolinaand Duke University. A great numberof conferences were also held withprivate consulting engineers and architectsrelative to planning and designingwater and sewerage facilities. We assisteda number of towns with the locationof new well sites, this work beingcarried on in cooperation with the StateGeologist's office. Many improvementswere accomplished in connection withmunicipal water and sewage treatment,although they will not be listed here indetail. Projects completed, or under contract,amounted to an estimated cost ofover $13,000,000. The number of projectsinvolved was 76.The industrial waste studies, begunlate in 1949 by virtue of the passage ofPublic Law 845 and the allocation ofspecial funds to the State Board ofHealth, got under way and work wascarried on at Winston-Salem, Thomasville,Statesville, Marion, Mt. Airy, andElkin. In connection with this activity,laboratory facilities were provided inthe State Laboratory of Hygiene for theexamination of sewage and industrialwastes. The addition of this laboratoryhas greatly augmented the work beingdone in this field. A special researchproject was also carried on in cooperationwith Professor Granstrom and theSchool of Public Health at the Universityof North Carolina on a study ofrendering plant wastes. The office al.socooperated with the State Stream Sanitationand Conservation Committee, ofwhich the Director is Chairman, and thework of this Committee was correlatedas much as possible with the regularactivities of the Division. Considerabletime was devoted to conferences andconsultations with representatives ofout-of-state industries that were consideringsites for the location of their

June, 1951 The Health Bulletin 35plants within the State. Technical problemsrelating to their waste disposal wereof primary importance and further emphasizedthe need for more adequatelaws relating to stream sanitation.The laboratory of the U. S. GeologicalSurvey, located in the State Laboratoryof Hygiene, continued to cooperatein supplying us with information regardingpublic and industrial watersupplies in the State as to their chemicalcontent. The work began last year inconnection with the State Highway andPublic Works Commission also continued.Fairly complete analyses of thewaters of the prison camps are nowavailable.Surveys and inspections were made ofall interstate carrier watering points andwater supplies, and reports were furnishedthe U. S. Public Health Service asone of our cooperative projects withthem. We also worked with the PubUcHealth Service and the National ParkService in connection with sanitationproblems created by the constructionand paving of the Blue Ridge Parkway,'because of its relation to some of ourmunicipal mountain water supplies.Continued efforts were put forth topromote the proper disposal of garbageand refuse through the sanitary landfillmethod. The most outstanding projectin this field was the establishment of asanitary landfill by Durham County, andthe provision of county-wide garbagecollection service. Landfills were also installedat Black Mountain, Fontana,Hendersonville, and Brevard.Considerable time was given by theEngineering Section to conferences withofficials of Sanitary Districts in connectionwith financing problems, developmentof plans, and other matters relatingto the establishment of proper sanitationfacilities within these areas. Preliminarywork was done toward thecreation of three new districts.The program of approving water andsewerage facilities at FHA insuredhomes is rapidly expanding, and the inspectionand approval of subdivisionswere continued. It is expected that housingproblems brought about in certaindefense and military areas will alsogreatly increase this activity during thecoming year.SANITATION SECTION—R. L. Caviness,ChiefA number of activities which we belivewill have considerable impact uponthe future development and progressof our sanitation activities were inaugurated,or further developed. One projectof considerable importance was carriedon in connection with the VocationalAgriculture teachers through the StateDepartment of Public Instruction. Thiswork consisted of demonstrations heldthroughout the State for teachers of vocationalagriculture in the proper constructionand installation of residentialtype septic tanks. Our engineers andsanitarians worked with these groups,and it is believed that better constructionand promotion of facilities at ruralhomes will be forthcoming. Considerableemphasis was also placed on maintenanceand construction of sanitary priviesin those areas where municipal waterand sewerage are not available. A largenumber of the local health departmentshave neglected this work during recentyears, and through the efforts of thisoffice more interest is being shown inrural sanitation activities by the localhealth departments.A cooperative project was also workedout with the Schoolhouse PlanningDivision of the Department of PublicInstruction whereby our engineers reviewand work with this group in theapproval of plans for new schoolhouses,water and sewerage for these schools,and in the design of proper facilities forcafeterias and lunchrooms. We beUevethat the program started this year willprove of considerable value, particularlyin view of the large schoolhouse constructionprogram underway throughoutthe State.As mentioned in my report last year,laboratory facilities for the examinationof shellfish were sorely needed. Thislaboratory was established this year incooperation with the Carteret County

36 The Health Bulletin June, 1951Health Department and the State Departmentof Conservation and Development,and should add materially to thework being done in connection withshellfish sanitation.workingRepresentatives of this office,in cooperation with the School CoordinatingUnit and Department of PublicInstruction, have also developed for useby the local health departments, a systemof grading and the score sheetswhich will be used by the Departmentof Public Instruction in their programof accrediting schools. Heretofore, wehave had no standard school inspectionalprocedure by local health departments.We also believe that this is aforward step in providing better sanitaryfacilities at our public schools.Milk work has continued as in previousyears, this work consisting primarilyof surveys and assistance to localhealth departments and the dairy industryin connection with the constructionof pasteurization plants and dairies.Two short courses have been worked outwith the N. C. State College and theSchool of Public Health at the Universityof North Carolina, in which localsanitarians are given a two-week'scourse in pasteurization plant operation.These courses have proved to be exceptionalypopular and helpful to thelocal sanitarians who are given practicalinstruction for a period of two weeks ina modern milk plant where they canstudy all types of equipment and itsoperation. Several special milk conferenceswere also held through the State,in order to instruct the local sanitarianson the proper interpretation of theStandard Milk Ordinance. These conferenceshave also gone a long way towardeliminating misunderstandings andbringing about better working relationshipsbetween the health departmentand the industry involved.As reported last year, special fieldtraining centers were established forthe training of sanitation personnel.Classes continued in connection withthis field training program, and duringthe year 43 sanitarians were given thiseight weeks' course of training. Plansare under way for the reorganization ofthese training programs, which we hopewill be brought about during the comingyear.Inspections and surveys were made ofall the State institutions, particularlythe hospitals and mental institutions.Reports were submitted to other Stateagencies involved, such as the Departmentof Public Welfare. Because of thework which has been going on for sometime in connection with the sanitationof State institutions, considerable improvementwas made during the pastyear in the physical facilities at theseinstitutions. The most notable improvementswere carried on at State Hospitalat Goldsboro, Colored Division of T. B.Hospital at McCain, White Division ofT. B. Hospital at McCain, State Hospitalat Raleigh, and Caswell TrainingSchool at Kinston, and the sanitationof these institutions, particularly withregard to food handling, is, in ouropinion, a credit to the State, and tothose responsible for the management^nd operation of these places.INSECT AND RODENT CONTROLSECTION—C. M. White, ChiefThe malaria control work, was carriedon in previous years through theDivision of Epidemiology, was transferredto the Sanitary Engineering Divisionon March 1. This program has beenfinanced for the past several years primarilyby the U. S. Public Health Service.Because of the nation-wide reductionin malaria, the Public Health Servicereduced our allocation for the fiscalyear beginning July 1, 1950. This hasnecessitated a complete revision of thetype of program which was formerlycarried on, in order that it might fitinto our general sanitation programs incooperation with local health departments.Consequently, the typhus controlwork and the malaria control work havebeen combined, and a section createdin the Division known as the "Insectand Rodent Control Section." For thefiscal year ending June 30, 1950, a totalallocation of $107,785 was received fromthe Public Health Service for malaria

June, 1951 The Health Bulletin 37and typhus control activities, while forthe current fiscal year this was reducedto $30,900.In reorganizing these programs, wehave adopted a new approach to thecontrol of arthropod-borne diseases, emphasisnow being placed on intensive,rather than extensive operations. Wherewell defined problems formerly existed,the abatement of which required theemployment of large forces of men, inaccordance with well established andproved methods or procedure, it is nowdifficult at time to determine whether ornot the diseases exist in a locality. Reportswere received during the yearfrom several areas, indicating that alarge number of cases of malaria existed.Upon detailed investigations, however,it was determined that the reports werebased on a faulty diagnosis. In cooperationwith the Public Health Service, thework of the laboratory technicians waschecked by a physician of the PublicHealth Service who made an evaluationof the laboratories in two hospitals andit was determined that the technicianshad mistaken blood platelets or artifactsfor the Plasmodia. We have also foundthat it is difficult to establish the typhusfever focci, since physicians frequentlyreport typhus and other Rickettsial diseases,in accordance with clinical diagnoses,before receiving laboratory reports.As a result, a number of cases oftyphus fever have been reported asRocky Mountain Spotted Fever, andvice-versa.In addition to this surveillance programon which every effort is made tocorrectly establish the existence and locationof these diseases, one of the principalactivities has been the preventionof new hazards, such as improperly constructedimpoundments which wouldbreed mosquitoes. Impounded water regulationsrequire that a permit be obtainedbefore a pond is built, and thebuilder agrees to maintain the pond insuch a manner that it will not breedmosquitoes. We have assisted the localhealth departments in connection withthis work, and have made a great numberof the inspections directly from thisoffice. During the year, 716 applicationsfor permits to build ponds were received.Conferences were held with the U. S.Public Health Service and the U. S.Corps of Engineers, as well as representativesof other states, relative toarmy regulations in connection with theconstruction of large power reservoirs.We were particularly concerned with the14,000 acres of Buggs Island Reservoirlocated in North Carolina. It has finallybeen agreed by the Corps of Engineersthat they would follow our regulationsin the construction of this impoundment,and have adopted mosquito controlplans which are agreeable to us.Other major impoundments which willprobably be built in the near future willalso require close supervision of controloperations.Even though the drastic reduction inFederal appropriations have reduced insectand rodent control activities inmany localities, considerable work isstill being carried on with local funds.During the year, 20 counties and 2 citiesconducted DDT residual spraying programson which 40,857 premises weresprayed. Fly control operations of sometype were carried out in most of thecounties. Five cities maintained ratproofingprograms. DDT dusting for ratectoparasites was done on a large scalein 5 cities, and regular rat-poisoningactivities were in operation in 13 cities.Emphasis is still being placed on properstorage, collection, and disposal of garbageand refuse as another phase of ourinsect and rodent control program.The entomologist with the Divisionassisted local health departments inconnection with the Identification ofrat ectoparasites, miscellaneous insects,such as ticks, lice, etc., and also carriedon the laboratory examination of bloodslides and made special investigations.During the year, 1438 blood slides weretaken at Roanoke Rapids and sent tothe U. S. Public Health Service at Atlantafor examination. Two thousandeight hundred and thirty-five bloodslides were examined by State andMalaria Control personnel. These bloodslides came from school surveys madein 1949, and also from those sent in by

38 The Health Bulletin June, 1951practicing physicians in 1950. ties that were carried on by the Sani-Attached to this report is a numerical tary Engineering Division during thetabulation of some of the major activi- year 1950.Numerical Summary of ActivitiesJanuary 1, 1950—December 31, 1950.Engineering:Public water supply inspections 525Well sites examined and approved 53Water samples collected and examined 66Special investigations conducted (water supplies) 38Suwerage system inspections 404Stream pollution problems investigated 25Plant site investigations 148Special investigations (.sewerage systems)Sand analyses5147Water supply plans approved 40Sewage works plans approved 60Swimming pool plans approved 4Sewage plant plans furnished 130Swimming pool plans furnished 15Outdoor bathing places investigated 11Sources of water supply examined for interstate carriers 15Watering points examined 49FHA developments investigated 30FHA cases processed 1,871Special conferences with engineers, city, and county officials 669Premises inspected for ratproofing and eradication 8,986Establishments ratproofed 565Cost to owners for ratproofing $35,075Premises treated (eradication) 3,698Premises inspected for DDT dusting 34,227Premises treated (DDT) 24.204Pounds of DDT dust used 32,884Premises treated (Poison) 23,820Local campaigns supervised ( ratpoisoning >13Sanitation:Milk Plant inspections 250Dairy farm inspections __ 1,254Milk surveys completed 49Milk plant plans reviewed 56Special investigations (milk) 32Milk samples collected __ 107Conferences regarding milk 312Foodhandling establishments inspected . 1,485School lunchroom inspections 332Abattoir and meat processing plant inspections 207Meat market inspections _•___ 444Frozen food locker plant inspections 60Poultry plant inspections 200Plans reviewed for foodhandling establishments 546Foodhandler schools held . 42Private water supply inspections 1,392Private sewage disposal inspections 530Privy inspections __ 3.934

June, 1951 The Health Bulletin 39Summer camp inspections 43Institutions inspected 249Hospital plans reviewed 138Hospital plans approved 33Public school inspections 154Swimming pool inspections 20Hotel and tourist camp inspections 171Complaints general sanitation 134Special investigations 78Special meetings 313Shellfish packing plants inspected 817Retail seafood markets inspected 70Patrol inspections of restricted waters 63Plans distributed 136Number of court cases 19Bedding:Retail places inspected 1,473Manufacturing plants inspected 4,115Pieces of bedding condemned 2,370LABORATORY OF HYGIENE DIVI- From the standpoint of the Labora-SION—J. H. Hamilton, M.D., Director tory, North Carolina is continuing tomake progress in its fight against ty-The State Laboratory of Hygiene con- phoid. We made more blood cultures fortinued in 1950 to render service to typhoid in 1950 than we did in 1949 andphysicians, hospitals, and Health De- recovered the typhoid organism in 34partments in their efforts to prolong instances during the past year. Greaterhuman life. The time-tested procedures diligence has been shown in 1950 in thehave been followed, improved methods search for typhoid carriers—3,659 examihavebeen developed when possible, and nations resulted in an even one hundrednew activities have been started. persons being demonstrated as harbor-Prom the standpoint of history, the ing the organism.State Laboratory of Hygiene had its be- Agglutination tests for typhoid wereginning with the examination of speci- smaller in number as were the numbermens of water from supplies offering of positive reactions,water for sale. During the past year the Agglutination tests for other diseases;laboratory examined 10,199 specimens such as Undulant Fever, the Rickettsiaof water. This is an increase of more Infections, and Tularemia were allthan 500 specimens over 1949. Part of smaller in number in 1950 than in 1949.this increase was due to the addition of There was also a reduction in thenew public water supplies.number of miscellaneous blood cultures.The Laboratory has provided funds, Slightly more than 1700 cultures werespace, and utilities for the study of examined for the gonococcus, which wasNorth Carolina water suppUes, conduct- recovered in only 24 specimens; whereedby the United States Geological Sur- as, a large number examined in 1949vey and the North Carolina Department yielded 247 positive isolations,of Conservation and Development. The There was also a decrease in the numfollowingpublications have resulted ber of animal heads examined for rabies,from this study: as well as in the number of animalsSurface Water Supplies in North found to have the disease. Notwith-Carolina standing this fact, practically the sameFlouride in Surface Water and Pub- number—865 persons received antirabiclie Water Supplies treatments prepared by the State Lab-Public Ground Water Supplies in oratory of Hygiene in 1950 as against 868North Carolina in 1949.

40 The Health Bulletin June, 1951Our physicians, as well as our healthdepartments, have been more active intheir fight against intestinal parasitesin 1950 than they have been for years.Of 16,660 examinations one or two parasiteswere found in 3,172 specimensthe percentage of infestation was considerablyhigher than in 1949 when 14,-352 specimens showed only 2,367 withparasites.For diphtheria a larger number ofexaminations was made in 1950 than in1949 but fewer typical organisms werefound.For two successive years now the laboratoryhas examined hundreds of bloodfilms for Malaria without finding asingle parasite in those specimens whichwere sent for diagnosis. In 1949—1019specimens were examined and in 1950662.The increased interest in tuberculosiswas reflected in the number of specimensof sputum sent for microscopicexaminations and for culture— 17,022such specimens xvere examined in 1950the tubercle bacillus being found in1,688 of these which is a smaller numberthan was found in 15,484 examinationswith 1,738 showing typical organisms.The number of specimens sent formiscellaneous examinations was greaterin 1950 than in 1949—3,519 as comparedto 2,924.North Carolina's interest in Vincent'sAngina is continuing to decrease, only2,007 specimens being received dui'ingthe past calendar year.Serological tests for syphilis continueto be one of the major activities of thelaboratory. There was an actual increasein the number of specimens of blood receivedduring the calendar year, 1950305,532 as compared with 293,905 in1949. The number of doubtful and positivereactions in 1950 were approximatelyone-third less than in 1949.The number of spinal fluids examinedin 1950 was only slightly greater thanin 1949.Other serological tests included complementfixation for Endemic Typhus981 specimens of blood from rats and13 specimens from humans. Complementfixation tests were performed on14 patients for Rocky Mountain SpottedFever, three specimens for RickettsialPox, two specimens for Eastern EquineEncephalomyelitis, and 2 specimens forQ Fever.One of the new activities of theLaboratory—that of Cytological examinationof smears, was increased markedlyduring 1950—a total of 5,191 examinationswere made. All of the specimensexcept 677 made on the female inmatesof the State Hospital in Raleigh, weresent from the various cancer clinicsconducted throughout the State. TheClinic in Durham contributed 1,440 ofthese and the Clinic in Wilmingtonbeing second, contributed 1,390. TheLaboratory hopes to extend this serviceas soon as competent cytologists can betrained.Another new activity of the Laboratoryis in the field of stream pollution.Chemical analyses were made on 387specimens.Of the biological products preparedand distributed by the Laboratory—thequantity of typhoid vaccine has showna marked decrease during 1950. The decreasedprevalence of the disease hasmade unnecessary many of the formerpopular immunization clinics. The diminisheddose used in immunization hasalso tended to reduce the volume of thevaccine.Smallpox vaccine was used in a smalleramount in 1950 than 1949, althougha sufficient amount of vaccine was distributedto vaccinate 228,257. Our improvedPertussis Vaccine, continuing toincrease in popularity each year sincethe Laboratory first offered it, has shownan increase over the previous year—1950is no exception, even though there is adefinite increase in the popularity ofthe multiple antigen immunizing agents.There seems to be an increased tendencytoward the immunization of otherchildren and adults to diphtheria. Therewas a sizeable increase in the amountof the Ramon or soluble diphtheriatoxoid during the past year. There wasalso an increase in the amount of AlumPrecipitated Diphtheria toxoid. Thecombinations of diphtheria toxoid withPertussis Vaccine, and with Tetanus

June, 1951 The Health Bulletin 41Toxoid; and Diphtheria Toxoid withTetanus Toxoid and Pertussis—the socalledtriple antigen, also showed markedincrease in 1950. Almost three timesas much triple antigens was used in1950 and in 1949. The demand for SchickTest and Schick Test Control materialwas almost unchanged.Notwithstanding the fact that a largenumber of children were immunizedagainst Tetanus with Tetanus Toxoidthere is still an increase in the amountof tetanus antitoxin distributed, bothfor prophylactic and therapeutic purposes.In spite of the increase in the amountof Scarlet Fever, there was a very smallamount of Dick Test material distributedby the Laboratory.From the administrative point ofview the first half of the year 1950 wasrelatively free from worry. There werefewer resignations than we had experiencedfor several years. The second halfof the year was a marked contrast. Presumablythe outbreak of the War inKorea, the increase in the number ofmen in uniform and the step-up in militarypreparations, resulted in a markedincrease in the number of resignations.We lost some experienced workers whichwe could ill afford to lose and some welltrained youngsters who showed promiseof developing into dependable bacteriologists.The workers who have beenwith us through the years have manifesteda commendable loyalty to ourInstitution and to the cause to whichit was dedicated. We feel confident thatthey—with the assistance of such recruitsas we may be able to attach toour staff, will continue to render dependableservice and make a commendablecontribution to the protection ofthe people of North Carolina.ORAL HYGIENE DIVISION — ErnestA. Branch, D.D.S., DirectorMore than 76,000 children in the elementaryschools of North Carolina hadan opportunity, during the year, 1950,to learn dental health facts throughclassroom instruction by the dentists onthe staff of the Oral Hygiene Division,while 165,000 children and teacherslearned about teeth from Little Jackand his dental health puppet show.The mouths of more than 81,000 childrenwere inspected. For 32,000 underprivilegedchildren the staff dentistsmade the necessary dental corrections,referring the privileged children to theirown dentists.The ten full-time State school dentistsvisited 522 elementary schools in 55counties.In addition to the children who receiveddental health instruction fromthe dentists and puppet show, manyother classroom groups have used thedental health educational materials preparedand distributed by the Oral HygieneDivision. A conservative estimatewould indicate that the mouth healthprogram has reached at least 250,000children, or about half of the enrollmentof the elementary grades duringthis one year.The record is not so good in respectto dental inspection and treatments, dueto the shortage of public health dentists.This time last year the prospects forrecruiting the staff were excellent. However,the Korean situation arose, practicallybarring us from the recruitmentfield. Because of the present nationalsituation a further reduction in the staffis imminent.The changing conditions and circumstancescall for new ventures and programs.Plans are now being worked outto try to meet this emergency. The dentistsin private practice are being calledon to supplement the services of thestaff dentists in making dental correctionsfor the underprivileged children.The Executive Committee of the NorthCarolina Dental Society and the DentalMembers of the County Boards ofHealth have endorsed in substance thefollowing basic principles as guides forthe proposed emergency program:1. Every dentist licensed to practicein the State will be given the opportunityto participate ,but no dentist willparticipate to the extent of devotingmore than six hours a week to this program.2. Payment to the dentists will be on

42 The Health Bulletin June, 1951an hourly basis, and the dentists willaccept a rate which will be less thantheir usual remuneration.3. Children who receive the service areto be certified by the welfare departmentas being financially unable to pay fordental service.4. The service is to consist only of thefollowing treatments: extractions, simplefillings, prophalaxes, silver nitrate treatments,and the topical application ofsodium flouride; with the relief of painand extractions having the priority.Trial programs have been inauguratedin several counties. Reports indicate thatthey are proving satisfactory. Dr.Branch, has, in the last few months,travelled from one end of the State tothe other, meeting with school, publichealth, and dental groups. He has beenmost successful in securing the interestand cooperation of the private practitionersin this emergency measure.Of necessity the setting up of this supplementarycorrective program has requiredtime and attention. Lest it appearthat there has been a change ofemphasis, we wish to reaffirm our adherenceto the principles that publichealth's sphere is in the field of preventionand that education is the most effectiveapproach to the problem of prevention.The Division of Oral Hygieneis endeavoring to attain its objective,the reduction of the incidence of dentaldefects and of systemic diseases of dentalorigin, by a program of dental healtheducation in the elementary schools ofthe State.VENEREAL DISEASE EXPERIMENT-AL LABORATORY—Harold J.Magnuson,Sr. Surgeon, Medical Officer inCharge, Chapel HUl, N. C.The Venereal Disease ExperimentalLaboratory, which functions as a fieldstation of the U. S. Public Health Serviceand as the Department of ExperimentalMedicine at the School of PublicHealth, University of North Carolina,as of May 15, 1950, was able to occupythe new quarters provided by act of theState Legislature, H. B*. 31, Chapter1248, 1949.As in the past, chief emphasis hasbeen upon basic research in the field ofvenereal diseases, with various membersof the staff providing institutional andconsultation services within the Schoolof Public Health, University of NorthCarolina. The type of work underway isbest summarized in the following listof publications by staff members duringthe past year.List Of Publications1. Magnuson, H. J., Thompson, F. A.,Jr., and Rosenau, B. J. The Effect ofSubcurative Penicillin Therapy Uponthe Rate of Development of AcquiredImmunity in ExperimentalSyphilis Am. J. of Syph., Gonor.,and Ven. Dis., Vol. 34, pp. 219-226,May, 1950.2. Tauber, H., Chymotrypsin Inhibitionby Human Serum in Health andDisease, Proc. Soc. for Exp. Biol, andMed., Vol. 74, pp. 486-489, July, 1950.3. Doak, G. O. and Jaffe, H. H., Disproportionationof Aromatic StibosoCompounds. II. Methods of Synthesis,J. Am. Chem. Soc, Vol. 72, pp.3025- 3027, July, 1950.4. Jaffe, H. H., and Doak, G. O., Disproportionationof Aromatic StibosoCompounds. III. Effect of Structure,J. Am. Chem. Soc, Vol. 72, pp. 3027-3029, July, 1950.5. Arnold, R. C, Wright, R. D., andMcLeod, C, Reinfection in ExperimentalSyphilis in Rabbits FollowingPenicillin Therapy. IV. The Developmentand Character of Immunityin Latent Syphilis, Am. J.of Syph., Gonor., and Ven. Dis., Vol.34, pp. 327-330, July, 1950. (Thiswork was done at the Venereal DiseaseResearch Laboratory, StatenIsland. Dr. McLeod was a memberof our staff at time of publication.)6. Doak, G. O., The Heterocyclic Derivativesof Phosphorus, Arsenic,Antimony, Bismuth and Silicon byGeorge Frederick Mann, J. Am.Chem. Soc, Vol. 72, p. 4335, September,1950. (Book review)7. Thompson, P. A., Jr., Greenberg, B.G., and Magnuson, H. J., The RelationshipBetween Immobilizing and

June, 1951 The Health Bulletin 43Spirocheticidal Antibodies AgainstTreponema pallidum, J. of Bact.,Vol. 60, pp. 473-480, October, 1950.8. Thompson, F. A., Jr. and Magnuson,H. J., Studies in Increasing the Sensitivityof the Ti-eponemal ImmobilizationTest for Syphilis, Am. J. ofSyph., Gonor., and Ven. Dis., Vol. 35,pp. 21-34, January, 1951.9. Bucca, M. A., Thayer, J. D., Roberts,H. B., and Tager, B., DehydrogenationsProduced by the Reiter Spirochete,J. V. D. I., Vol. 32, pp. 6-12,January, 1951 (Work done by VenerealDisease Research Laboratory,Staten Island. Dr. Thayer ismember of our staff.)now a10. Tauber, H., Biophysical ResearchMethods by Fred M. Uber, TheChemist, Vol. 28, p. 71, 1951. (Bookreview)11. Magnuson, H. J., Rosenau, B. J., andGreenberg, B. G., The Effects of Sex,Gastration and Testosterone Uponthe Susceptibility of Rabbits to ExperimentalSyphilis, Am. J. of Syph.,Gonor., and Ven. Dis., Vol. 35, pp.146-163, March, 1951.12. Tauber, H., Synthesis of High Molecular-weightProtein-like Substancesby Chymotrypsin, J. of Am. Chem.Soc, Vol. 73, pp. 1288-1290, March,1951.13. Doak, G. O., and Eagle, H., CorrelationBetween the Chemical Structureand Biological Activity of Arsenobenzenes.(In press — monographform)14. Tauber, H., The Enzymes by Sumnerand Myrbaeck, Chem. and EngineeringNews. (In press—Book review)15. Magnuson, H. J., and Thompson,F. A., Jr., Heterologous Strain Immunityin Experimental Syphilis, J.of Immunol. (In press)16. Magnuson, H. J., Thompson, P. A.,Jr., and McLeod, C. RelationshipBetween Treponemal ImmobilizingAntibodies and Acquired Immunityin Experimental Syphilis, J. of Immunol.(In press)HEALTH PUBLICATIONS INSTI-TUTE, INC.—Felix A. Grisette, ExecutiveDirectorAlthough an independent, non-profitcorporation, Health Publications Institute,formerly known as Venereal DiseaseEducation Institute, operates as adivision of the State Board of Health.The State of North Carolina makes noappropriation whatsoever to the budgetof the Institute except to provide quartersin the Old Armory Building. In exchangefor these quarters, the Institutemakes available a minimum of $5,000worth of its educational materials andstaff services to the State Board ofHealth without charge. As a generalrule .these education materials are passedon by the State Board of Health tolocal health offices throughout the State.The capital funds of the Institutehave been provided by grants from theZ. Smith Reynolds Foundation. Currentoperating expenses are derived from thesales of its education materials andservices. The State Health Officer is amember of its board of directors and itsexecutive committee.What The Institute Does1. The Institute develops, produces,publishes and distributes visual aidswhich are required by people engagedin every aspect of health work, such asbooks, leaflets, pamphlets, posters, displays,motion pictures, filmstrips andadvertising materials.2. A professional creative service suchas writing, artwork, layout, and consultationis available for the use ofhealth departments and related healthagencies requiring such services.3. Research and evaluation projects inall aspects of health education materialsare carried on, not only to the end thatits own materials may be adequatelytested but independently for otherhealth departments and agencies.Although charged for to an extentthat will make them financially selfsupporting,these services are madeavailable on a non-profit basis.Financial OperationsBecause the Institute during its early

44 The Health Bulletin June, 1951years was primarily a publishing arm ofthe Venereal Disease Division of theUnited States Public Health Service, itreceived a modest subsidy from thatsource until July 1, 1949. The NorthCarolina State Board of Health providedquarters and some financial assistanceuntil June 30, 1946.The Z. Smith Reynolds Foundation,because of its interest in health andmedical education, contributed annualgifts to the Institute until June 30, 1946.At this time, its annual gifts were terminatedand replaced by a more generousbut non-recurring capital revolvingfund. Since July 1, 1949, except for thecontinued availability of the ReynoldsFoundation capital revolving fund, theInstitute has relied entirely on the salesof its materials and services for its financialsupport.Some 1950 AccomplishmentsDuring the year 1950, the Institutebecame more firmly established andmore imiversally recognized as nationalheadquarters for health educational materials.Circulation of its various healtheducation media attained a total of 1,000-000 copies per month. These materialswere used by health departments inevery American state and more than adozen foreign countries. Approximately200 different types of media were involved.One especially noteworthy achievementduring 1950 is the extent to whichthe Institute has become recognized asa publisher of proceedings of medicalconferences. Notable illustrations ofthis publishing program are the NationConferences on Aging and the NationalConference on Chronic Illness.The Institute has been designated asthe official publisher of the proceedingsof both these groups. The papers, reportsand recommendations from thesetwo major medical gatherings will beused widely among the medical professionthroughout the United States.The Institute has also been designatedas the oflBcial publisher of the proceedingsand the other documents resultingfrom the Midcentury WhiteHouse Conference on Children andYouth held in Washington, D. C. inDecember.TOTAL PHYSICIANS IN U. S.AT ALL-TIME HIGH OF 209,040There were 209,040 physicians in continentalUnited States as of December15, 1950, an all-time high record, accordingto the annual medical licensurereport of the American MedicalAssociation.The report showed there were 6,002additions to the medical profession inthe United States and its possessionslast year. Against this there were 3,794deaths, making a net gain of 2,208 inthe physician population. This compareswith an addition of 5,866 physiciansin 1949, and a net gain of 2,266after allowing for 3,600 deaths.Made public in the Journal of thethe medicalA.M.A., the report detailedlicensure statistics for 1950. It was preparedby Dr. Donald G. Anderson ofChicago, secretary of the A.M.A. Councilon Medical Education and Hospitals,and Miss Anne Tipner, also of Chicago.The report presented evidence of thehigh medical training rating of themedical schools of the United States,all 72 of which now are approved bythe council.Of 4,955 graduates of the existingUnited States schools who last yeartook state board examinations to practicemedicine, 4,808 (97.1 per centt passed.The 1949 passing percentage was96.8 per cent.Against this record, only 673 of the1,248 graduates of other schools (53.9per cent) successfully passed their examinations.The percentage by othermedical schools was: Approved Canadianschools, 91.5; extinct schools, 93.3;foreign, 45.0; unapproved schools, nolonger existent, 37.8; schools of osteopathy,72.0. The overall passage was5,481 out of a total of 6,203 examined,or 88.4 per cent. The 1949 percentagewas 87.5.

[MEDICAL LIBRARYU. OF N. CCHAPEL HILL. N. C.^.(BsMp^mI TKis BiiUetin -will be sehtfree to

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. DtxoN, M.D., President AydenHubert B. Haywood, M.D., Vice-President RaleighH. Lee Laege, M.D Rocky MountMrs. James B. Hunt Lucama, Rt. 1John R. Bender, M.DWinston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaH. C. LuTZ, Ph.G HickoryGeo. Curtis Crump, M.D.AshevUleEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S. , Director of Oral Hygiene DivisionA. H. Elliot, M.D., Dirertor Personal Health DivisionJ M. Jarrett, B.S., Director Sanitary Engineering DivisionC. P. Stevick, M.D., M.P.H., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting It. The Board also has avaUable for distributionwithout charge special literature on the following subjects. Ask for any mwhich you may be interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitis InfantUe Paralysis Typhus FeyerCancer Influenza Venereal DiseasesConstipation Malaria Residential SewageDiabetes Measles Disposal PlantsDiphtheria Pellagra Sanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFlies Teeth Whooping CoughTuberculosisEpilepsy, Feeble-mhidedness, Mental Health and Habit TrahiingRehabilitation of Psychiatric PatientsThe National Mental Health ActSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below wUl be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CareFirst Four MonthsPrenatal Letters (series of nine Five and Six Monthsmonthly letters)Seven and Eight MonthsThe Expectant MotherNine Months to One YearInfant CareOne to TVo YearsThe Prevention of Infantile Two to Six YearsDiarrheaInstructions for North CarolinaBreast FeedingMidwivesTable of Heights and WeightsYour Child From One to SixBaby's DaUy ScheduleYour Child From Six to Twelve•'Gtiiding the AdolescentCONTENTSPageInto the HillsA Truly Great PhysicianWhat General Practice Is - ^^^^^

1PUBLI5AED 6YTAE N^RTA CAROLINA STATE B°A R D >/ AEALTAVol. 66 JULY, 1951 No. 7J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorINTO THE HILLS(Case Finding Services of the Official Agency)Robert F. Young, M.D., M.P.H., F.A.P.H.A.Halifax County Health DepartmentHalifax, North CarolinaCould it be that there is a need for achange in the attack against the ageold enemy, tuberculosis, from that of asweeping, motorized maneuver on the"vast plains" where tuberculosis at onetime rode rampant to that of a gorillatype of warfare fought In The Hills,where this clever enemy possibly hasretreated and where he must be foughtand literally dug out from every rockycrevice. If so, then this gorilla warfarewould require a new plan, new maneuversand new techniques along with amore dogged patience and perseverancethan has ever been demanded in thepast.Could it be that the once proud andhaughty "Captain of the Men of Death"has now degenerated into an outlaw.Could it be that the Giant who onceslew our stars of literatvire such asThoreau, Brown, Keats and many otherfamous men of history, is now contentto "bump off" his victims in the lowerincome brackets by sniper fixe, underthe cover of ignorance and from behindthe rocky crags of superstition andthereby to reduce himself to a cormnonrenegade who seeks refuge by retreatingInto The Hills.There was a time when there seemedto be no defense against this relentlessenemy, tuberculosis, imtil from out ofthe Harz Mountains of Germany, Godgave us Koch, and through him, revealedto us this redheaded killer, thetubercle bacillus, for the first time inhistory; until Roentgen gave us thex-ray and demonstrated to us directlythe deadly work of this bacillus in thelung tissue; until Trudeau gave us theLittle Red Cottage at Saranac andtaught the value of rest; and until themany other weapons against this marauderof the microscopic world hadbeen provided through the years withthe adding of the modern Sanatoria, thepresent surgical techniques and judgment,and now the armamentarium ofthe modern miracle drugs.It seems to the writer that the OfficialAgency in Halifax County has battledtuberculosis on the vast plains and nowInto The Hills through four rather distinctphases of case finding procedures:(1) Tuberculin testing or relatively smallgroups of the population followed byx-raying of the positive reactors; (2)The opening broad attack in 1946 whenthe first mass x-ray survey (the fourthin the state) was made available to us;(3) An epidemiological type of x-raysurvey of a selected group of the populationin a selected area of the county;(4) The recent mass x-ray survey ofJanuary, February and March, 1951, our

second within five years (the first massre-survey in the state), and from whichthe smoke of battle has hardly cleared.The first phase of case finding activitieswas carried out with the best facilitiesat the disposal of the agency atthe time and when tuberculosis waswide spread both as to population groupsand as to the geography of the county.The five year median tuberculosis deathrate in Halifax County during this firstphase (1941-1945) was 58 per 100,000population compared with a rate of 35for North Carolina as a whole. Duringthe early 1940's, there were many tuberculosisfamilies in the covmty and thedisease seemed to be more devastatingin its attack on the family than at thepresent time. It seemed to be the usualthing then to find secondary cases ofthe disease in families where active casesexisted. Thus, even though the diseasewas attacking on a broad front, out onthe plains, the Official Agency had tobe content with rather limited defensemaneuvers within limited groups of thespopulation.Then came the remarkable developmentof the photoflurographic x-rayunit and with it the mass x-ray surveytechnique. When the four mobile x-raybehemoths, furnished by the StateBoard of Health and the United StatesPublic Health Service, rumbled IntoHalifax County on that bleak day inDecember, 1946, together with the necessaryprofessional, technical and clericalpersonnel, we in the health department,and our loyal cooperating agencies, felta surge of confidence and felt, too, thatthe battle with tuberculosis had changedfrom a defensive to an all out offensivemaneuver—tank warfare on the plains,if you please.The intensive public health educationalphase which preceded the massx-ray survey of 1946 was planned toreach all groups of the population in allsections of the county—school children,industrial employees, agricultural workers—everyonefifteen years of age andolder. Tuberculosis at that time wasthought to be wide spread in most groupsand in most areas in the county and,therefore, this type of educational cam-The Health Bulletin July, 1951paign was geared for the time.Another important factor in connectionwith this first mass x-ray surveywas the setting up of as complete andaccurate a tuberculosis register as possible.The many records and files of thehealth department and in the physiciansoffices were searched dUigently vmtil allknown cases of tuberculosis and theircontacts were tabulated.When this first mass attack on tuberculosishad been completed, our tuberculosisregister groaned under the heavyaddition of two hundred and forty-fournew cases of significant tuberculosis inall stages; moreover, twenty new activecases were added to the county andstate sanatoria, resulting in a discoveryrate of .9 hospital cases per thousandcitizens x-rayed.Also, in connection with and immediatelyfollowing this first mass x-raysurvey, a weekly x-ray and fiuoroscopicclinic was organized and has operatedcontinuously since that time to whichall suspected cases and all contacts oftuberculous families have been referredas indicated.The back breaking work of visitingall of these tuberculous homes has beenfaithfully carried out by our nurses tomake certain that the necessary laboratorywork, tuberculin testing and othercase finding activities were done, inaddition to the x-ray diagnostic work.This first mass survey in HalifaxCounty resulted in the x-raying offifty-eight per cent of the x-ray population,but the question that reared itsugly head immediately and that hashaunted us until the present time hasbeen, "what of the forty-two per centwho did not report for x-ray."It has been our experience that thefollow-up activities of a mass x-raysiu-vey must be relentless, and the questionas to when a suspected case orapparently arrested case of tuberculosiscan be ultimately closed is certainlyone most difficult to answer. We havefollowed many of these suspected casessince the original survey in 1946 onlyto have some of them become active inthe past six months, or at a time whenwe were seriously considering closing

July, 1951The Health Bulletinthem, at least, relative to active followupwork.Following the mass survey, a gradualdecline occurred in the death rate fortuberculosis for the total population,and we noticed that for some resison the"culprit" was not as willing, or even asanxious, to risk a fight in the open ashe had been In the early 1940's. Alongwith this decline for the county, as awhole, we noticed a tendency for therenegade to make forays on certainisolated groups in the county. Was thisa retreat "Into The Hills" and a changeto gorilla warfare. In view of these findings,it was decided to "meet fire withfire" by planning an intensive, epidemiologicaltype x-ray survey in this areafor this particular group.A review of the morbidity and mortalityrates for tuberculosis in the varioustownships in the county over athree-year period revealed a significantnumber of cases and deaths occurringin a selected group of the populationin this particular area of the county.As previously reported,(i) "Althoughthis township represented only fifteenper cent of the total population, durihgthe three years preceding the specialx-ray survey (January, 1950), twentyfiveper cent of aU tuberculosis deathsin Halifax Comity occurred there. Whileonly nineteen 'per cent of the negropopulation lived within this township,thirty-four per cent or approximatelyone-third of all negro deaths from tuberculosisin the coimty during the threeyear study period occurred in this area.Moreover, throughout the county as awhole, where the negro population constitutedfifty-eight per cent of the totalpopulation, sixty-six per cent of thetotal deaths from tuberculosis wereamong negroes; whUe in the Enfieldtownship during the same three-yearperiod, eighty-eight per cent of thedeaths from tuberculosis were negroes.During 1947 and 1948, one hundred percent of the deaths from pulmonary tuberculosisin the Enfield township werenegroes."A spot map, pin pointing the casesand deaths from this disease during1947, 1948 and 1949, was used to localizethe principle tuberculosis problem InHalifax County within this township.Prom the spot map study, the tuberculosisproblem localized itself still fiu--ther within the township aroimd seventeendistinct communities."In order to establish a base line todetermine exactly the number of negroesliving in these seventeen commimities,the negro principals and teachers inthis area were called upon to conducta census."During the organizational and educationalphases of this special epidemiologicalsurvey, all efforts were directedtoward the particular group in question,namely, the negroes in a selected area ofthe Enfield township. We had no streetbanners, brass bands, window placards,posters or parades. Rather the individualapproach was followed as strictly aspossible. This type of approach wasmuch more difficult than the mass approach,and I suppose that pioneerworkers in public health would have referredto It as 'shoe leather' epidemiology."A negro principal in the area, itseems to the writer, hit the nail squarelyon the head when he said, 'Doctor, mypeople are Ignorant and superstitious.Many of them are afraid of this type ofthing. Many of them do not receivenewspapers, and, moreover, many ofthem do not even read. A lot of mypeople do not have radios. You will haveto sit down with them in a personal appealin order to persuade them to comein for these x-rays'. Therefore, everyavailable member of the health departmenttogether with lay workers weredispatched to these various seventeencommunities during the x-ray survey inorder to make personal appeals to thesepeople in an effort to get them in forx-ray. Appeals were also made to allland owners In this area for their cooperationin furnishing transportationfor their tenants. Each of the seventeencommunities was given a specific dateon which to report to the x-ray bus."This special survey resulted in thex-raying of 2,790 citizens, of which 2,107were negroes, representing sixty-fourper cent of all the negroes in the study

6 The Health Bulletin July, 1951area. Forty-two cases of significant tuberculosis,including five hospital cases,were revealed, giving a discovery rateof 1.8 active cases per 1,000 citizensx-rayed, compared to less than 1 per1,000 for the state as a whole and to.8 per 1,000 as discovered in the conventionalmass x-ray s'orvey conducted inthe county in 1946.Including seven additional hospitalcases diagnosed immediately followingthis survey, and from this same group,a discovery rate of 4.3 hospital casesper 1,000 citizens x-rayed during andimmediately following the study resulted.These seven cases did not report tothe x-ray bus during the scheduled survey,in spite of all the intensive effortsof the workers to get them. These findingspoint up some of the difficulties offighting "In The Hills."The staff had hardly recovered fromthis epidemiological survey when thegood news was received from Dr. WilliamA. Smith, Director of the Sectionof Tuberculosis Control, State Board ofHealth, that five mobile x-ray unitswould be coming our way by the followingJanuary, 1951, for a second massx-ray survey of the total populationin the county. This, then, introduced usto the fourth and most recent phase ofcase finding for tuberculosis in HalifaxCounty.As a result of our studies in the specialsurvey, we decided to apply as many ofthese epidemiological principles to thesecond mass x-ray survey as possible.Under the excellent direction of MissLula Belle Highsmith, Public HealthEducator from the Section of TuberculosisControl, State Board of Health,and with the capable assistance of herassociate, Mrs. Mildred Page and, alsoMrs. Velma Joyner from the NorthCarolina Tuberculosis Association, asplendid organizational and educationalprogram was planned and executed,prior to the actual x-ray schedule. Thefollowing factors were emphasizedthroughout these preliminary stages:(1) All contacts of known tuberculosiscases must be x-rayed regardless of age;(2) Importance of x-raying all negroes,particularly those in the lower economicgroups; (3) Since mass x-ray surveysthroughout the county had revealed thereservoir of active tuberculosis to beamong older people, it was emphasizedthat all citizens forty-five years of ageand older, and particularly those sixtyfiveyears of age and older must bex-rayed; (4) Importance of all ruralagricultural workers being x-rayed, sinceit had been noted that this group inthe previous studies in North Carolinahad shown a high incidence of tuberculosis.In order to highlight the importanceof the individual approach in the secondmass x-ray survey, working committeesfor both white and negro groups wereorganized in each major community inthe county rather than having oneoverall committee or group for the entirecounty. The four special factorsmentioned above were stressed in all ofthe meetings; and, also, it was emphasizedthat the several working committeesshould continue their effortsthroughout the entire x-ray schedule inorder to sustain interest in the project.Needless to say, the entu-e staff ofthe health department, particularly thenurses, were briefed again and again onthe special epidemiological factors whichwe felt were of particular importance atthe time of this survey.Inasmuch as the previous mass x-raystudy in this covmty, as well as the resultsof the x-ray surveys throughoutthe coimty, had been largely non productiveof active reinfection tuberculosisamong school children, no special scheduleswere made for the schools in thecounty; however, school children overfifteen years of age were urged to comein to the buses at the regular locations.Even though we did not include theschools in our x-ray schedule, an intensiveeducational program was conductedthroughout the three school systems inthe county during the entire study.In setting up the x-ray schedule forthe county, not only population densities,transportation and availability ofpower were considered, but the mofbidityand mortality rates for the variouscommunities were also used as importantfactors in determining the exact

July, 1951The Health Bulletinx-ray location. All of the tentativesights were visited by representativesfrom the State Board of Health, LocalHealth Department and Power Companiesbefore the final schedule, whichincluded thirty-eight separate x-raysites, was approved as final.At least one Public Health Nurse wasmade responsible for the successfuloperation of each x-ray location, andeach x-ray site was visited periodicallyduring each day to make certain thatthe x-ray take for the day was holdingup to expectations. When it was foundthat the x-ray total was falling considerablybelow the known x-ray populationfor a given area, special conferenceswere held and commando groups weresent into the field to visit the homes,churches and schools to make every effortpossible to start the people movingtoward the x-ray buses.For example, in one location it wasfoimd that the first day's x-ray take hadfallen considerably short of the expectedtotal; where-upon, six nurses were sentinto that area the following day to visitevery home to learn why the people werenot coming in. These nurses, visiting 714homes during the day, heard some veryinteresting excuses as to why peoplehad not responded. Here are a few ofthese reasons given the nurses duringtheir commando operations:"No man is smart enough to makesomething to see my lungs.""Don't want the home broken if T. B.is found in the family.""Anything free is half done.""It is for poor people who can't paytheir nrr.aie doctor."•The last time I took a picture on thex-ray imit, I got sick.""In case the wife or husband is foundto have T. B., he must go to the Sanatorivun.What God put together, let noman put asimder.""I heard that getting near the x-raymachine will make you sterUe.""I am too old to have T. B.""You just want to put me in the Sanatoriumand let me die.""My wife won't let me get an x-ray.""I am afraid the machine would electrocuteme.""I am a retired Veteran, they will giveme a check-up when I want it.""If I have tuberculosis, I don't wantto know it.""God didn't intend for anyone to bex-rayed or to take medicine.""No tuberculosis has ever been in myfamily and I know I don't have it."After learning the above reasons fornot reporting for x-rays, of course, wewere abie to convince many of thesepeople that these beliefs were withoutfoimdation and were able to motivatethem to be x-rayed; however, there werestill others who held steadfast to theirlife long beliefs and refused to be budged.This, I'm sure, highly pleased oiarcunning enemy, "T. B.," for surely theseare the people who constitute his dwindling"happy hunting grounds."Before presenting the provisional resultsof our second mass x-ray survey,perhaps it would be well to establish abase line with the present pertinentdata(2) relating to tuberculosis in thecoiuaty as compared with North Carolina.As present in Table 1, the residenttuberculosis morbidity rate for 1950 inHalifax County was 87.2 per hundredthousand population compared with 90.4for North Carolina as a whole, withthe white rate of Halifax County being59.4 compared with 71.4 for the Stateand with the negro rate being 108.4against 139.3 for North Carolina. Theofficial resident tuberculosis mortalityrates (Table 2) for Halifax County andNorth Carolina in 1949 revealed a rateof 34.3 per hundred thousand for HalifaxCounty with 23.9 for North Carolina,while the white mortality rate in thecounty was 19.8 compared with 13.1 forthe State and with the negro rate inthe county being 45.3 compared with 51.5for the State. The number of cases oftuberculosis reported per death (Table3) in 1950 in Halifax County was 2.7compared with 4.7 for the State. Thecounty rate was exactly double our ratefor the previous year, as a result of theepidemiological survey in Enfield. Perhapsthis small avalanche of new casesreported in 1050, as a result of the specialsurvey, is what took some of the"starch out of the sails" of the second

8 The Health Bulletin July, 1951mass x-ray survey just completed in thecounty.When we finally folded our tents andprepared to leave the battlefield a fewdays ago, approximately 24,500 citizenshad been x-rayed with 70 mm films,representing an increase of seventeenper cent over the mass x-ray survey of1946. (The total increase in populationduring the past decade in Halifax Countywas only 31,2 per cent.) This x-raytotal represents sixty-four per cent ofthe total x-ray population in the countyas compared to the fifty-eight per centtake in the previous survey; however,using the more reasonable goal as followedby the United State Public HealthService of taking eighty per cent ofthe population fifteen years of age andolder as a hundred per cent goal, we arrivedat a more favorable figure ofeighty per cent x-rayed. Russell Pierce(3)at the 46th Armual Meeting of the NationalTuberculosis Association in April,1950, as a result of an analysis ofeleven mass surveys which the UnitedStates Public Health Service had conducted,reported that these x-ray takesranged from sixty-nine per cent to 118.7per cent of the total x-ray population.Our take in Halifax County then for1951 would fall in the neighborhood ofthe median for these eleven mass surveysreported.Since we worked so hard in stressingthe four epidemiological factors duringthe organizational and educationalphases of the mass survey, it will beinteresting, even though disappointingto us, to report our results in this respect.In 1946 (Table 4), the numberx-rayed under forty-five years of agewas seventy-seven per cent and in 1951was seventy-six per cent of the total,while the age group forty-five years andolder represented twenty-three per centof the total in 1946 and only one per centbetter in 1951 with twenty-four per cent.The sixty-five years of age and oldergroup in 1946 constituted three per centof the total while in 1951 was four percent. Although percentage-wise, this oneper cent increase looks very anemic, theactual increase in numbers x-rayed inthis stubborn age group sixty-five yearsof age and older was 365.The racial breakdown (Table 5) ofthe total number x-rayed with 70 mmfilms was fifty-three per cent white in1946 and fifty-five per cent in 1951, comparedwith forty-seven per cent fornegroes in 1946 and forty-five per centfor negroes in 1951. Again, it appears inthis mass x-ray survey that om: extraefforts to get a larger percentage ofnegroes x-rayed was somewhat in vain.The total number of hospital cases(Table 6) discovered in the recent x-raystudy was fifteen, including fourteencolored and one white, compared with atotal of twenty for the mass survey in1946, including fifteen negro and fivewhite. The 1951 survey produced a discoveryrate of .6 per thousand citizensx-rayed compared with .9 per thousandin 1946 and 1.8 per thousand in theepidemiological survey in 1950.Nine of the fifteen hospital cases werecontacts from tuberculous families.Some of these contacts reported to thex-ray buses, after having refused to beexamined in our regular fiuoroscopicclinic for years. It is interesting to note,too, that four of the fifteen cases werefrom Enfield which again gave this areathe highest discovery rate.Only one of the fifteen cases was aschool child discovered through routineexamination of school children overfifteen years of age. One of the caseswas a child, age 12, who came in as acontact of a recently discovered case ofactive tuberculosis, and as a result of awritten notice from the health departmentto report for x-ray.The lone white hospital case discoveredwas a male, textile employee, overforty-five years of age, while thirteenof the fourteen negroes were from rural,agricultural areas. Of the negroes, ninewere imder forty-five, and five were overforty-five years of age.The provisional data (14 x 17 films)(Table 7) of this recent mass x-ray surveyrevealed a decrease in the numberof males found to have definite tuberculosisin the age group imder forty-five,with an appreciable increase fromthirty-five per cent in 1946 to fortysevenper cent in 1951 in the forty-five

Jxdy, 1951The Health Bulletinyears of age and older group. The femalesfound to have definite tuberculosisrevealed no appreciable change inthe group under forty-five years, but adecrease was noted from twenty-six percent of the total in 1946 to 21.5 per centin 1951 in the forty-five years of ageand older group.Regarding the racial breakdown(Table 8), the percentages for negroeswith definite tuberculosis in the threeage groups, under forty-five, forty-fiveand older, and sixty-five and older remainedrather constant in 1951 as comparedto 1946, with only a two per centincrease noted in the forty-five years ofage and older group. The white percentagesrevealed a more definite decreasein the under forty-five years group anda deflnite increase in the forty-five yearsand older group. Those over sixty-fiveyears remained essentially constant in1951 as compared with the 1946 findingsfor both races.The writer again wishes to emphasizethat these data are entirely provisionaland certainly more time is needed for amore accurate analysis and evaluationof the survey just completed.To summarize, in the recent massx-ray sxurvey, although nine times asmany citizens were x-rayed throughoutthe county as in the epidemiologicalsurvey, only three times the numberhospital cases were discovered. Puttingthis in a dollars and cents language, wefind that the cost per case discoveredin the epidemiological survey was$300.00* as compared with over $1,300.00*per case for the 1951 mass survey. Withthe dollar rapidly becoming a mereshadow of his former self, certainlyvery careful consideration needs to begiven to the cost aspect of case findingin tuberculosis control.From our meager experiences in tuberculosiscase finding procedvures inHalifax County, the writer is of thedeflnite opinion that more emphasisneeds to be placed on careful preliminaryepidemiological studies so that thedisease can be more accurately localizedto to age, sex, racial, occupational,socio-economic and all other pertinentfactors in order for the case findingactivities to be properly concentrated inthese "target areas." It appears at thistime that there is a very deflnite needfor a change in the case finding battleagainst tuberculosis, using a new type ofstrategy, designed to follow and destroythe enemy where he has retreated intorestricted groups and areas, or "IntoThe Hills."Resident Tuberculosis Cases By ColorWith Rates Per 100,000 Population:North Carolina and Halifax County,1950 (Official Data)TABLE 1*Does not include salaries and travel orfull time personnel of health department.April, 1951.

10 The Health Bulletin July, 1951Total 70 MM—Survey—^Percentage ByAge Halifax County, 1946 and 1951TABLE 4 (Provisional)

July, 1951 The Health Bulletin 11the Mayo Foundation, and Dukeand Western Reserve University. He receivedhonorary degrees from the MedicalCollege of Vii'ginia and from DavidsonCollege. At various times, he wasspecial lecturer at Columbia University,George Washington University Schoolof Medicine, The Medical College of Virginia,Medical School.Retired Last YearDr. MacNider retired from teaching inJune, 1950, after completing fifty-oneyears of service. A graduate of the UniversityMedical School in 1903, he beganteaching while still an undergraduate,in 1899, as assistant in biology. He wasassistant in anatomy, from 1900 until1902; demonstrator in clinical pathology,from 1902 to 1905, and was Professor ofPharmacology and Bacteriology, from1905 until 1911. In his Alma Mater, Dr.MacNider established the first Departmentof Pharmacology in the South.This was in 1905. He was appointedKenan Professor of Pharmacology in1918. In this field, he ranked as one ofthe greatest research men in this country,and became internationally known.He formerly was head of the Age ResearchSociety of London. As a memberof the Committee on the nutritional aspectsof the National Research Council,this distinguished North Carolina physiciandirected studies in a Chicago Hospital,in an attempt to find the characterand the amount of diet, and the propervitamin supplement for ageing and agedindividuals who are mentally disturbed.Dr. MacNider gained worldwide recognition,as a result of discoveries hemade in diseases of the kidney, particularlyBright's. During the First WorldWar, his studies were used as the basisof treatment for nephritis among thearmed forces. As a result of researchcarried on for thirty-three years, showingthe effect of injury to tissues cells,he was awarded the George M. Kobermedal, which is one of the highestawards in medical science, by the Associationof American Physicians. In morethan a half century, the Association hasawarded this medal only nineteen times.Was Internationally KnownAlthough North Carolina was thehome base of this internationally knownmedical scientist, his experience and influenceextended to all sections. He servedas officer and Committee Chairmanin the leading medical societies ofAmerica. His reports of laboratory investigationshave appeared in medicalperiodicals for many years. In 1931, theNew York Academy of Science awardedhim the Gibbs Prize. A year later, theSouthern Medical Association presentedhim with its achievement medal. TheMedical College of Virginia gave him anhonorary degree of Doctor of Science,in 1933, and during the following year,Davidson College made him a Doctor ofLaws.Dr. MacNider was President of theAmerican Pharmacological Society;member of the Executive Council of theFederation of Societies for ExperimentalBiology; representative of the Nation'sPharmacologists on the InternationalBoard of Twelve Medical Examiners;President of the North Carolma MedicalSociety; Member of the InternationalResearch Council; Member of the NationalAcademy of Sciences, and of theAmerican Philosophical Society.There have been and will continue tobe many verbal and written tributes tothis distinguished medical scientist, butthese wUl be merely the echoes fromthe volume of verbal and written tributespaid him while he still lived andlabored in behalf of humanity. He washonored while he yet served, and not,belatedly, after he had passed into thatland where there is no need for theworking tools of the medical profession.In his fifty-one years of associationwith the University, as physician andteacher, Dr. MacNider grew in favoramong all with whom he was associated,and became affectionately known by hisfriends as 'Dr. Billy." The 1951, Yackety-Yack was dedicated to him and to Dr.William C. Coker, Kenan Research Professorof Botany Emeritus. Concerningboth men, the dedication paragraph hadthis to say: "To these men, who haveso given of their lives, energies, and devotions,we humbly dedicate this book,

12 The Health Bulletin July, 1951that it might serve as a reminder to succeedinggenerations of students herethat, thorugh the efforts of such men,has come the greatness of Carohna."When he retired last year. Time Magazinehonored Dr. MacNider by describinghim as one of the world's top authoritieson diseases of the kidney andthe effects of age and injury on celltissue. At a testimonial dinner, lastJune, in his honor. Dr. Alfred N. Richards,of Philadelphia, said of Dr. Mac-Nider's work that it was known theworld over for the light it has thrownon the action of various therapeutic andtoxic agents, such as uranium, chloroformand mercury. The speaker continued:"No one of his friends thinks ofDr. MacNider simply as an inspired teacherand faithful investigator. Theyadmire him for these reasons; they revereand love him for other qualitiessimplicity, truthfulness, humerous understandingof the foibles, as well as thevirtues, of human beings—his own included.He has a genius for friendship."The facts upon which this article isbuilt were taken from biographies appearingin the State press, followingDr. MacNider's death. The late EdwardKidder Graham, while he was Presidentof the University of North Carolina,once made the statement to membersof the press attending a reception at theExecutive Mansion, in Raleigh, that thebest and most understandable Englishin the world is found in the columns ofour newspapers. It also might be statedthat the newspapers of today, with theircurrent facts and figures, will becomethe history of tomorrow, to which studentswill resort for information concerningthe age in which we are living.His Work WiU LiveDr. MacNider's accomplishments inthe field of medicine will continue to benot only useful, but inspirational. Hisfindings have become a permanent partof the book of medical knowledge. Thediscoveries he made, as a result of long,hard work, constitute a distinct contributionto medical practices. His greatestbeneficiaries, however, are not thosewith whom he worked, but those towhom they minister. It would be well forthe public to study the lives of ourgreat medical scientists, as well as toreap benefits of the discoveries theyhave made and are making. We allknow, for example, that we can be immuizedagainst smallpox, through vaccination.How many know that it wasEdward Jenner who discovered and putinto practice the principle of vaccination?His knowledge came through amilk maid. It would be well for eachperson reading this article to read aboutJenner and others whose discoverieshave prolonged human life.We know that a person who has beenbitten by a rabid dog may escape hydrophobiaby taking the Pasteur treatment.There are many who do not thinkof Pasteur as a personality, but atechnique. Everyone is familiar withpasteurized milk, but how many knowthat it was Louis Pasteur who discoveredthat heat would kill harmful bacteriain milk? This noted scientist mademany other discoveries which not onlyhave prolonged human life, but savedproducers of sUk worms, poultry andanimals millions of dollars. The life ofLouis Pasteur was all the more remarkablebecause of the fact that some ofhis most important discoveries weremade after his recovery from a severestroke of paralysis.Another scientist who made a valuablecontribution to the art of prolonginglife was Joseph Lister, the father ofaseptic surgery. It has been said of himthat he applied principles which werediscovered by Pasteur.Many of our great scientists were,themselves, sufferers from various ailments.Yet, their purposes were notselfish, but dedicated to hximanity. Noworthwile medical discovery is sold formoney, but it is given to the publicthrough physicians in all fields. Dr.MacNider, to whose memory this articleis dedicated, made many important observationsduring his long career inmedical research. He, no doubt, hadhis moments of discouragement, but hismeasure of success made him a valuablecontributor to humanity. We mustnot think of scientific discoveries wholly

July, 1951 The Health Bulletin 13in the past tense. These are being made,day by day. But to be useful, such discoveriesmust be more than theoretical.They must be operative. Moreover, theymust be both provable and proved.Ranked With The GreatEach generation has given to theworld many discoveries to make thepeople happier, but possibly none hasmade more effective contributions thanthe present. This can be said because ofsuch men as Dr. MacNider and others,whose lives have been dedicated to thenoble purpose of releaving pain, mendingcrippled individuals and prolonginghuman life. With the possible exceptionof the religious ministry, there is notand never has been a higher calling onthe face of the earth than that of themedical doctor, no matter in whicla particularfield he has chosen to work.There are two broad fields of medicine—curative and preventive. Each occupiesan extremely important place. The twoare interdependent. Without preventivemedicine, additional thousands woulddie annually. BXit for curative medicine,the same would be true. It is ofen thecase that infection cannot be preventedand that its approach cannot be detected.Curative methods, however, havebeen discovered to combat practicallyall types of infection. On the other hand,methods have been discovered for theprevention of many crippling diseases.And so we see the inseparable twins ofmedicine — curative and preventive —walking arm in arm, and working handto hand to make this a healthier andhappier world to live in.WHAT GENERAL PRACTICE ISThe essence of general practice is tolive amongst your patients as a cog inthe whole machine, knowing them sowell in health and in sickness, and frombirth vmtU death, that although onemay keep—and should keep—a clinicalrecord of their illnesses, and althoughone should examine the patient as aroutine, the patient is so familiar to hisfamily doctor that he, of all people, canbe in the best position to give an accuratediagnosis, prognosis and treatmentmost suitable to the patient's way oflife.So proclaims a member of the RoyalSociety of Medicine,i and he goes on inlike vein.Whereas the patient in hospital islike an animal in the Zoo, living underconditions which are artificially madeas near normal as possible of course,but nevertheless out of his natural environment—thegeneral practitioner Isin the position of the big-game hunterEditorial From Southern Medicine andSurgery.IG. O. Barber, M. D., in Proc. Royal Soc.of Med. (London), Feb.studying the patient in his natural environment,the jungle, his lair, in thewild herd, in his home.There is a great deal more to a casein hospital than you can find out byexamining that case in hospital. Theessential causes and tendencies of healthor disease in an individual are in hisheredity and his environment; his parents,his family, his home, his work,his tastes and recreations. And we shallnot get the picture of these most importantfactors by merely asking thepatient about them; we shall obtain onlyhis very limited impression of them.General practice involves knowing allthese things, and applying them to thecase in point. The individual will reactto stress in an individual way. Generalpractice means such a knowledge ofone's patient that one can assess thetype of stress to which he is likely tobe subjected, and the way in which heis most likely to react or break down.The general practitioner should regardthe specialist departments as helpsto his treatment of the patient, ratherthan as places to which he sends hispatient and then be relieved of all fur-

14 The Health Bulletin July, 1951ther responsibility.A third aspect of general practice isthe responsibility for a patient, evensometimes against his will; a responsibilityboth for him and his family, inhealth and in sickness, from birth untildeath. In general practice a visit to apatient does not involve just that patient'ssymptoms. It involves acuteanxiety on the part of the family; ifyou like, a temporary mental illness,an anxiety state, of all concerned. It ispart of general practice to relieve thisalso in such a way that there may beno lasting effect. One has to handlebirth and death, in which the principalplayer is usually the least concerned.In chronic cases it is often said thatnothing can be done. But general practiceconsists in doing something tomake life as bearable as possible for thepatient, and to make him live as comfortablyas he can with his disability.Many people seem to think that thebulk of general practice consists of trivialities.There is no case, however trivial,which is completely without interest.Careful attention to hundredsof apparently trivial cases is more thanrewarded as one catches the earliestpossible stage of serious illness. Muchbecomes almost a reflex action in time,so that one has a tentative diagnosissometimes, arrived at between the timethat the patient opens the door, andwhen he sits down in the chair.Dr. J. D. Simpson, in the discussion:A young man, aged 22, with an excellentathletic, Service, and scholastic record,reported sick on a Monday saying:"Doctor, I have a strained heart. At theend of the course we rowed on SaturdayI felt awful." He was the only son ofdevoted parents. His heart and lungswere normal, b. p. 120/80; exercise tolerancetest good. Saturday he had beento a 12-1 lecture, had lunch in collegeand the boat was out at 1:45 p. m. Hehad had a long wait at the start of a20-minute row and it was a bitterly coldday.My advice was to go straight down tothe river, have a light outing and thenreturn to the VIII next day. He hasrowed and been fit ever since.A cardiological opinion would havetaken two to three days to arrange, andby the time the boy had been examinedhe would have been well on the way toa cardiac neurosis and would have missedhis place in the VIII—a very importantmatter to him.I hope every general practitioner intowhose hands this journal comes willtake this editorial to the editor of hislocal paper, and request publication inpart and editorial comment. You mightwell, also, call attention to the othereditorial in this issue on the generalpractitioner; and take along to yourpaper your copy of S. M. & S. for December,1950, and call attention to theeditorial on pages 408 and 409.It is wonderful to have a great Britishspecialist who does practically all hiswork in oflEice or hospital say that "thefamily doctor can be, of all people, inbest position to give an accurate diagnosis,prognosis and treatment;" andcompare treatment in hospital withtreatment in the home, much to theadvantage of the latter.FROZEN, CONCENTRATEDORANGE JUICE AS NUTRITIOUSAS FRESH FRUITApproximately 98 per cent of the vitaminC in fresh oranges can be retainedin the frozen, concentrated juiceif proper methods are used, a reportto the Council on Foods and Nutritionof the American Medical Associationrevealed.The report, published in the Journalof the American Medical Association,said "the frozen concentrated productcan be as valuable from a nutritivecontent as is fresh orange juice."It was pointed out that fresh orangesof good quality picked at the propertime were essential to insure a highvitamin C content in the concentratedproduct. The report said:"For example, studies indicate thatthe vitamin C content of fresh orangesmay show considerable variation. Thisis due in part to seasonal influences.In general, fruit picked in midseasontends to be higher in vitamin C than

July, 1951 The Health Bulletin 15does that picked early or late in theseason. Other factors, including varietyof fruit, degree of ripeness and conditionof the soil, also significantly affectthe vitamin C content of the freshfruit.""The danger of vitamin C loss," thereport continued, "is most hkely tooccur as a result of improper handlingor storage in the home. For example,if after reconstituting the juice is allowedto stand in open containers at roomtemperature, appreciable losses will occur.However, if the reconstituted juiceis placed in the refrigerator at 40 degreesF., vitamin C losses will be negligible.Ideally, the juice should be consumedas soon as possible after reconstitutingto obtain maximvun vitaminC value."In the same issue, a Journal editorialsaid in part:"When frozen foods are selected, preparedand stored (whether at home orcommercially) according to the best ofcurrently available scientific knowledge,they can compare favorably in nutrientcontent and flavor with the fresh product."Much of the loss of the water-solublevitamins and other water-solubleconstituents of vegetables preserved byfreezing, canning or dehydration occursas the result of the preliminaryblanching or precooking to which theyare subjected . . . Blanching in waterfrequently reduces the ascorbic acid(vitamin C) content of vegetables asmuch as 16 per cent. Such losses tendto be minimized when the blanchingtime is shortened by the use of boilingwater and the same water is used repeatedly.. . ."Another important factor in the preservationof vitamins and flavor is therate of freezing . . . Observers havefound that eight to 12 hours may beused for freezing without significantimpairment. This means the productsfrozen in home freezing cabinets canbe nutritious as those obtained by quickfreezing. The freezing time should notbe increased beyond 12 hours, however,because of deteriorative changes thatmay occur if the temperature is notdropped rapidly enough throughout theentire package. . . ."Storage at degrees F. seems quitesatisfactory, at least when the storageperiod is a year or less. Losses (innutrient value) become much greaterif the temperature is allowed to rise to10 P. or is allowed to fiuctuate betweenand 20 F. At these temperatures peaslose 50 per cent of their original ascorbicacid in one year and show colordeterioration."ISSUES WARNING ABOUT NEW,POISONOUS INSECTICIDESAnticipating an increase in the useof insecticides this season, the AmericanMedical Association editorially issueda warning about the poisonousnature of these products.The editorial, carried in the Journalof the A.M.A., pointed specifically totwo of the newer substances—aldrinand dieldrin. These, as well as the otherinsecticides, are expected to be usedwidely, especially in the southern andcotton-raising areas, it said.Aldrin and dieldrin are available ineither powdered form or as emulsifiedconcentrates. The powdered productscan be absorbed by inhalation, throughthe skin or by swallowing. The concentratesor emulsions also are readilyabsorbed by the body because of thesolvents used in their preparation."The danger of accidental poisoningby inhalation is unknown," the editorialadded, "but intravenous toxicity, whichis possibly the closest measure of potentialdanger from respiratory exposure,is three to six times that of DDT."Aldrin and dieldrin act primarily onthe central nervous system or the gastrointestinalsystem. Taken by mouthwhether by accidental swallowing oreating produce which has been sprayedrecently—they probably will cause nauseaand vomiting, hjTserirritability andconvulsions. The convulsions may ormay not be separated by periods ofdepression. Death may result.The editorial pointed out that noauthentic cases of chronic intoxicationdue to these two products have been

16 The Health Bulletin July, 1951reported to date, but headache, generaldiscomfort, sudden unexplained loss ofweight and loss of appetite would besignificant symptoms. It further waspointed out that in chronic poisoningthere may be a latent period of severalweeks between the last exposure andthe development of symptoms.It was advised that if the skin hasbeen contaminated with the chemicals,the area should be washed thoroughlywith soap and water. Contaminatedclothing should be removed immediatelyand washed thoroughly.At present there is no universal acceptedmethod of treatment for thistype of poisoning. Treatment dependsto some extent on the symptoms andcould include barbiturate therapy, dextrose,amino acids and oxygen.REPORT SHOWS THOROUGHCOOKING OF PORK CUTSDOWN ON DISEASEThorough cooking of fresh pork canhelp to reduce materially the incidenceof trichinosis, an infection from diseasedpork, it was shown in a reportmade public today by Dr. Rodney R.Beard of San Francisco.Dr. Beard, writing in the Journal ofthe American Medical Association, creditedthat as one of the factors in anapparent two-thirds reduction in theincidence of trichinosis in San Franciscosince 1936.Trichinosis is caused by Trichinellaspiralis worms which sometimes arefound in pork. The worms lay eggs inthe human intestinal tract. The embryoswork their way into muscles,especially the diaphragm, where theydevelop. Diarrhea, navisea, colic andfever are the usual early symptoms ofthe disease, followed later by stiffness,pain, swelling of the muscles, fever,sweating and insomnia. The seriousnessof the infection depends on thedegree to which the pork has beeninfected. Severe infections may causedeath.Dr. Beard cited a 1936 study in SanFrancisco of a random sampling of 200human diaphragms taken at autopsy.Trichinosis worms were found in 24per cent of the organs. A more recentstudy of 161 diaphragms, also a randomsampling, showed only 8 per centwere infected—a decrease of two thirds.Three factors were listed by Dr.Beard as possible agents responsiblefor the decrease.He first pointed out that federal,state and local regulations now assureadequate processing of pork productsintended to be eaten without cooking.In San Francisco, for example, stringentlyenforced rules by the local Departmentof Public Health provide foradequate salting and drying of Italianstyle salami, an uncooked product, orpossible prior killing of trichinae byfreezing.Another factor he mentioned was thereduction in the proportion of porkfrom garbage-fed hogs. Wartime scarcityof labor, difficulties of transportationand other factors, he explained,made feeding garbage to hogs unprofitableand many local establishments ofthis kind went out of business. Hecited a Department of Agriculture reportshowing widespread reduction ofinfections in hogs. From 1934 to 1939the infection rate was 3.32 per centas compared with the 0.81 per cent ina recent study.AM.A. COUNCIL SAYSALUMINUM UTENSILS NOTINJURIOUS TO HEALTHThe use of aluminum cooking utensilsin no way is injurious to health,according to a statement issued by theCouncil on Foods and Nutrition of theAmerican Medical Association.The position of the council was madeknown as a result of periodical rumorsthat foods cooked in such utensils affecthealth because of injurious substancesimparted by the vessel, accordingto Dr. James R. Wilson of Chicago,secretary of the council.The driver who doesn't mind beingpassedWill still be PRESENT when passersare PAST!

i1^MEDICAL LIBRARYU. OF N. CCHAPEL KILL, N. C.1^57I TKisBuUetm will be s

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-President RaleighH. Lee Large, M.D Rocky MountMrs. James B. Hunt Lucama, Rt. 1John R. Bender, M.DWinston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaH. C. LuTz, Ph.G. HickoryGeo. Curtis Crump, M.D.AshevilleEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionC. P. Stevick, M.D., M.P.H., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any inwhich you may be interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitis Infantile Paralysis Typhus FeverCancer Influenza Venereal DiseasesConstipation Malaria Residential SewageDiabetes Measles Disposal PlantsDiphtheria Pellagra Sanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFlies Teeth Whooping CoughTuberculosisEpilepsy, Feeble-mmdedness, Mental Health and Habit TrainingRehabilitation of Psychiatric PatientsThe National Mental Health ActSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CareFirst Four MonthsPrenatal Letters (series of nine Five and Six Monthsmonthly letters)Seven and Eight MonthsThe Expectant MotherNine Months to One YearInfant CareOne to Two YearsThe Prevention of Infantile Two to Six YearsDiarrheaInstructions for North CarolinaBreast FeedingMidwivesTable of Heights and WeightsYour Child From One to SixBabv's Daily ScheduleYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageMilitary Preventive Medicine A Keystone Of Military Strength 3Poliomyelitis^^

jclinical! adequateI%w^mimmPUBLI5AED 5YTAE N'>RTf\ CAROLINA STATE B«»ARD-^ AEALTAVol. 66 AUGUST, 1951 No. 8J. W. R. NORTON, M.D., M.P.H., Sute Health Officer JOHN H. HAMILTON, M.D., EditorMILITARY PREVENTIVE MEDICINEA KEYSTONE OF MILITARY STRENGTH*James Stevens Simmons, S.B., M.D., Ph.D., Dr.P.H. S.D.Brigadier General, U. S. A. (Retired)Dean, Harvard School of Public Health,Boston, Mass.(hon.)If I were starting my military careertoday, I should like someone to give mea clear picture of the objectives of theMedical Service of the Army and to indicatethe main channels through whichthe Medical Service and all its personnelcan work most profitably for theachievement of these objectives. I wouldwant this type of orientation to help meIn shaping my own philosophy and allmy future actions as a military surgeon.The Mission of the Medical DepartmentBriefly stated, the responsibility ofthe Medical Service is to keep thesoldier on his feet and fit to fight. Thisis a big order, and the achievement ofthis mission requires broad leadership,clear vision, careful planning, and aggressiveaction by a great variety ofspecialists. The major approaches to theaccomplishments of this mission areand preventive.The Clinical Approach is to organizepersonnel and facilities withwhich to salvage the sick and woundedand restore them to health. A modernarmy must provide effective first aidand rapid evacuation for the wounded.It must have modern facilities, adaptedto combat conditions, so that the sick, and wounded will receive the best possiblemedical care and hospitalization.This must be followed, when feasible,by modern rehabilitation to restore thesoldier to a state of physical and mentalfitness in the shortest possible time.To accomplish this important portion ofthe Medical Service's mission requiresan enormous organization and largenumbers of specialists in every aspect ofcurative surgery and ciu:ative medicine.The Preventive Approach to the conservationof fighting manpower is theeven greater obligation of the MedicalService to protect as many soldiers aspossible against sickness or injury. Thismore constructive approach is madethrough the numerous activities nowincluded imder the term "military preventivemedicine." From the viewpointof military efficiency, it is more desirableto keep the well soldier well thanto provide the expensive and complexfacilities required to restore the sicksoldier to health. For this reason, diseaseprevention should logically be theprimary objective of the Medical Service.It is therefore important that everymember of the military establishmentnot only the personnel of the MedicalService, but all members of the combat•Reprinted by permission from the UnitedStates Armed Forces Medical Journal

arms—should adopt the preventive attitudetoward disease. Every soldier^ould keep in mind the basic truththat "an ounce of prevention is wortha pound of cure" and he should befamiliar with the basic principles thatcan be applied for his protection againstdisease.According to a newspaper announcementseveral weeks ago, an epidemic oftyphus was raging among the Chinesetroops in Korea. Such a report 10 yearsago would have caused us much concern.Today there is no reason for alarm becausewe are armed with effective preventivemeasures developed in the lastwar with which American troops canbe protected against this ancientscourge. We now have an effectivetyphus vaccine and an even more effectivelouse powder. This incident servesto point up the practical importance ofmilitary preventive medicine today. Italso emphasizes the fact that this youngspecialty is not static but is vigorous,rapidly growing, and has infinite possibilitiesfor further development; thisis important because the nation nowfaces the most serious threat for itsentii'e existence. We must immediatelytake steps to strengthen our total healthdefenses in order to conserve bothfighting and working manpower.Since 25 June 1950, the Armed Forceshave been faced with the problem ofmaintaining the health of our troopsfighting in Korea and at the same timeplanning for the prevention of diseaseamong the large forces now being mobilizedand trained to meet the threat ofa third global war. The civil populationis faced with the equally difficult problemof strengthening its program ofpreventive medicine and public healthto conserve industrial manpower and tooperate the expanding health departmentsrequired for civil defense. It istherefore important to take stock ofthe nation's total health facilities—bothmilitary and civilian—in order to makesound plans for the present emergency.Military Preventive MedicineThe aim of preventive medicine Is toprevent physical and mental disease.The Health Bulletin August, 1951In civilian medical schools the term"preventive medicine" is commonly restrictedto the prevention of disease inthe individual; the term "public health"is applied to the prevention of diseaseand the conservation of health in communitiesor other large aggregations ofpeople, such as States or nations. "Militarypreventive medicine" applies tolarge groups of fighting men and thereforeit is comparable to civilian publichealth. Since the beginning of historyevery intelligent military leader hasbeen aware of the hazards of diseaseand has realized the need for somemethod which would protect his troopsagainst sickness. This was true even ofthe barbarians who reluctantly abandonedtheir sick and wounded fightingmen on the battlefield.An early example of an attempt todo something about the American soldier'shealth is afforded by an order,issued by General Washington at Peekskillin the Revolutionary War, entitled:"Instructions for Soldiers in the Serviceof the United States Concerning Meansof Preserving Health." At that timethere was no knowledge concerning thetransmission of infectious diseases andthese instructions emphasized cleanliness,camp hygiene, and the disposal offeces. These activities are still importantto good health, but we now knowthat they are not enough to preventdisease. Therefore, it is not surprisingthat General Washington's troops weredecimated by numerous epidemics.Conditions were no better in the Warof 1812, the Mexican War, or in theCivil War. The commanders and medicalofficers of those days must have beendeeply frustrated at their inability tocontrol the diseases which have alwaysaccompanied war.Development of basic knowledge.—Inthe period following the Civil War, thefoundation for preventive medicine waslaid. From 1860 to 1900 the medical discoveriesof Pasteur, Koch, and Lister,and their associates and followers produceda great reservoir of specific knowledgeabout many of the micro-organismswhich cause disease. It is fortunatethat during that time a member of the

August, 1951The Health BulletinRegular Army Medical Corps, GeorgeM. Sternberg, became interested in thepotentialities of these new discoveries.Having served in the Civil War, andhaving seen the crippling effect of themilitary diseases of that period, heknew that they could not be controlledby any method available at that time.Excited by the promise of these new discoveries,he imdertook pioneer studiesin the newly emerging sciences of bacteriologyand protozoology, and discoveredthe pneumococcus. He publishedthe first American textbook on bacteriologyin 1884, and he was later referredto by Robert Koch as the "father ofAmerican bacteriology."Sternberg served as Surgeon Generalfrom 1893 to 1902 and during this periodhe initiated an extensive program inmilitary preventive medicine. Followingthe bitter experience of our troops withtyphoid, dysentery, and yellow feverduring the Spanish-American War, heorganized special Army research boardsfor the study of diseases in our newlyacquired tropical possessions. His broadvision made possible the important researchesof Major Walter Reed onyellow fever in Cuba—researches whichinfluenced the later work of GeneralGorgas on sanitation in Panama. It ledto Colonel Ashford's studies which showedthat malignant Puerto Rican anemiawas caused by massive hookworm infestation.This was followed by theworld-wide hookworm control programof the Rockefeller Foundation. It providedfor the investigations of ColonelStrong on dysentery, plague, cholera,and other tropical diseases in Manila,the researches of Colonel Craig onmalaria in the Philippines and elsewhere,and for the work of Colonel Silerand others on dengue. It undoubtedlyinfluenced the later work by GeneralDarnall who gave to the world improvedmethods for the chlorination of citywater supplies, and the researches ofGeneral Russell who developed thetriple typhoid vaccine which has beenused successfully by the Armed Forcesin two world wars. Sternberg's broadconcept of the importance of preventivemedicine influenced all of these contributions.It also stimulated otherArmy, Navy, and civilian workers toconduct researches along similar lineswhich have added much to the developmentof both military and civilian preventivemedicine.As evidence of General Sternberg'sleading role in the country's medicaland health activities of his time, it isnoteworthy that he served as Presidentof the American Medical Associationand as President of the American PublicHealth Association. He was also pioneereducator in the new field of militaryand civilian preventive medicine. Whenhe became Surgeon General in 1893,one of his first acts was to organizethe Army Medical School in Washingtonto provide facilities for researchand for postgraduate education of medicaloflBcers with special emphasis onprevention. It was not until 16 yearslater (1909) that the first formal departmentof preventive medicine wasestablished in any civilian medicalschool (Harvard) in this country.Military Health In TheTwentieth CenturySince 1900 there has been a progressiveimprovement in military healthwhich has paralleled closely the advancesin civilian medicine and publichealth. During World War I both theArmy and Navy had well organizedprograms of preventive medicine andtheir health records were much betterthan in previous wars. Typhoid, whichhad been a serious threat even as lateas the Spanish-American War, was wellcontrolled. The most important causesof sickness and death were pandemicinfluenza and other respiratory diseases.There was little exposure totropical diseases.In the 20 postwar years of peace,public health in this country madestill further advances. Just before WorldWar II the crude death rates for theUnited States had decreased from 17per thousand in 1900 to about 10 perthousand in 1940. The expected lifespan at birth for an American citizenhad increased from about 46 years toabout 65 years. As usual, the peacetime

6 The Health Bulletin August, 1951health of our troops stationed in permanentposts in the United States wasbetter than that of the average nonmilitarycitizen. This is generally truebecause (1) the military forces aremade up largely of vigorous young adultswho have been carefully selected; (2)the American military man's way ofliving, including his personal hygiene,diet, housing, and physical training isregulated; (3) he is immimized againstsmallpox, typhoid, and other infectiousdiseases to which he may be exposed;and (4) he lives in a carefully sanitatedenvironment which is rigidly controlledby a well-organized Medical Service.Preventive Medicine ProgramIn World War IIThe hardships imposed by field serviceand combat make it difl&cult to maintainthis type of peacetime health protectionunder the conditions of war.Therefore when it appeared that theUnited States would be drawn intoWorld War II, the Surgeon General ofthe Army began to plan the expansionof the Medical Service to meet the increasedresponsibility of mobilizationand war. The situation was somewhatlike that faced today, but in 1940 wewere not so well prepared for war aswe are now. Although at that time thetotal Medical Service of the RegularArmy consisted of only a few thousandofficers, by the end of the war it hadexpanded to more than 100,000 officersand several hundred thousand enlistedmen a medical force which was largerthan the entire Regular Army prior tothe war.Convinced of the importance of diseaseprevention, to the accomplishmentof his mission the Surgeon Generalplaced primary emphasis on the developmentof a strong aggressive wartimeprogram of military preventivemedicine. This program was planned bythe preventive medicine service in hisoffice in Washington and the directorsof preventive medicine In the majortheater headquarters. It was put intoaction by Medical Service personnel inall the far-flung places where our troopsserved. Its effectiveness can be attributedto the cooperative action of the10 million military persons who carriedit out.The Preventive Medicine Service.—In1940 the Surgeon General started in hisoffice a formal organization whicheventually became the preventive medicineservice. It began with one officerand expanded rapidly until it became amajor imit of his staff. By 1944 thisservice consisted of the following divisions:(1) medical intelligence, (2) epidemiology,(3) veneral disease control,(4) tropical disease control, (5) laboratories,(6) sanitation and hygiene, (7)sanitary engineering, (8) nutrition, (9)occupational health, and (10) civil publichealth. The chief of the service alsoorganized the Board for the Control ofInfluenza and Other Epidemic Diseasesin the United States Army and theUnited States Army Typhus Commission.This Board, composed of morethan 100 civilian consultants to theSurgeon General, was divided into 10special commissions, each of which wasconcerned with a specific problem ofdisease control. It was later called theArmy Epidemiological Board and hasnow become the Armed Forces EpidemiologicalBoard. The U. S. A. TyphusCommission, which was a joint Army,Navy, and Public Health Service organization,was administered through theSecretary of War.The broad objective which guided thisservice in all its planning was to useevery possible facility in the nationmilitary and civUian— to keep the soldierwell. To attain this objective itwas necessary to apply all of the scientificinformation available to the preventionof disease and the conservationof military health and to promote researchto discover and develop moreeffective control methods. In accomplishingthis, the preventive medicineservice enlisted the help of many highlyqualified experts—at home and abroad—and it arranged for the assistance ofnumerous governmental and civilianagencies.The Army's preventive medicine programincluded (1) general measuresused to safeguard the soldier's health,

August, 1951The Health Bulletin(2) measures employed to protect himagainst specific diseases, and (3) theextensive research activities carried onin looking for better methods to controlthe diseases that might attack him. Althoughsome of these activities wereplanned and supervised by divisions ofthe Surgeon General's ofiBce not formallyincluded in the preventive medicineservice, they were a part of the totalprogram.General health measures included thephysical selection of healthy recruits;the provision of healthful clothing,housing, nutrition, and physical training;intensive training in hygiene; andsanitary control of the soldier's environment.The latter was handled cooperativelyby the division of sanitationand hygiene and the division of sanitaryengineering. It included providingfor safe food and water supplies, forthe sanitary disposal of wastes, and thecontrol of many insect vectors androdent reservoirs of disease. The importanceof sanitation was emphasized inthe training courses of all military personneland special intensive training inthe subject was provided for the MedicalService in the Medical Field ServiceSchool at Carlisle Barracks. The sanitaryprogram was operated efficiently,especially in fixed installations, but itwas difficult to maintain adequate sanitationvmder combat conditions and thefilth-borne diarrheas and dysenteriesand certain insect-borne diseases, especiallymalaria, caused much sickness incertain overseas locations. In the continentalUnited States this program wasrelatively successful. The extensive workdone by the Army in its camps andposts was supplemented in the surroundingcivilian areas by sanitary programsoperated through the U. S. PublicHealth Service by State health departments.This cooperative arrangement,which was initiated by the preventivemedicine service in 1940, was of greatimportance. It produced results whichhave had a profound influence on thepresent status of civilian and militaryhealth in the United States.The Conquest of Malaria in the UnitedStates.—A spectacular example is affordedby the present status of malaria.In 1940 the Army started an intensiveprogram for the elimination of mosquitoesin all military installations inthis country. At our request, the U. S.Public Health Service supplemented thisprogi'am with an extra-military mosquitocontrol campaign. The Army programcost about 17 million and that ofthe U. S. Public Health Service about 19million dollars. Considered as a whole,this was the most extensive mosquitocontrolprogram ever operated in anycountry in the history of the world. Itwas highly effective and although millionsof men were trained in camps locatedin the Deep South, relatively fewsoldiers contracted malaria in thiscountry. An important postwar outgrowthof this joint program was theestabhshment of the CommunicableDisease Center with headquarters inAtlanta, Georgia, which is continuingthe fight against malaria and otherdiseases and is now helping to mobilizeour eJitra-miiltary defenses for the presentemergency. It is reassuring to knowthat malaria, which once was a majoraffliction in the South, is now disappearing.Last year the State of Mississippioffered a bonus of $10.00 to anydoctor who could find a new case ofmalaria, and not one case was reported.This story of the conquest of malariain the United States is only one exampleof how the preventive medicine programof World War II exerted a powerfuleffect on the postwar health of thenation.New Insecticides.—Another outstandingcontribution made by om: departmentof sanitation and hygiene was theinitiation and coordination of an extensiveresearch program aimed at thedevelopment of more effective agentsand methods with which to improvemilitary hygiene and sanitation. One ofthe most helpful results of this workwas the development of new wartimeinsect repellents and insecticides whichhave been used so successfully for thecontrol of typhus, bubonic plague, dengue,malaria, and other important diseases.The story of the development ofthese new agents is a romantic tale of

8 The Health Bulletin August, 1951military achievement. Thousands ofstudies were made in many laboratoriesscattered all over the county, but theInitiation, coordination and generalguidance of the entire program of researchand development was carried onin the division of sanitation of the Armypreventive medicine service in Washington.The wartime development of DDTalone has been worth more than thetotal cost of the Army's entire researchprogram during the war. DDT was thegreatest contribution of the war, notonly to military but to civilian health.It has freed us from the fear of typhusand it is now being used to conquermalaria, even in the tropics.Prevention of Specific Diseases.—Inaddition to these general health measures,the Army's preventive medicineprogram included other activities designedto protect the soldier againstspecific diseases. The following divisionsof the preventive medicine service wereconcerned with this phase of the problem;medical intelligence, epidemiology,laboratories, venereal disease control,and tropical disease control. They wereassisted by the Army EpidemiologicalBoard and by the Typhus Commission.The coordinated work of the membersof these five divisions, the Board andthe Commissions, was concerned with(1) the collection of exact informationabout the diseases that might attackAmerican troops in any part of theworld, (2) the analysis of current diseasestatistics, (3) the maintenance ofadequate diagnostic and health laboratoriesfor the identification of diseaseproducingorganisms, (4) the developmentof policies, (5) recommendationsfor qiiick action to control threatenedoutbreaks of disease, and (6) the initiationof medical research in the laboratoriesand in the field to develop moreeffective control methods. Through theseactivities, the Surgeon General waskept informed at all times of the incidenceof disease in our troops and incivil populations throughout most ofthe world. This enabled him to make intelligentplans for the protection of thetroops.Immunization.—Theoretically, theideal method for the specific control ofinfectious diseases would be throughimmunization. Although only a limitednumber of effective immunizing agentshave been discovered, those that areavailable have contributed much to themaintenance of America's fighting manpower.A conference of representativesof the Army, Navy, and U. S. PublicHealth Service held early in 1940 inWashington recommended active immunizationagainst smallpox, typhoid,the paratyphoid fevers, and tetanus. Italso recommended that immunizationagainst certain diseases, including diphtheria,Rocky Mountain spotted fever,plague, and cholera, be used only whenneeded to meet local conditions. Later,other immunizing procedures wereadopted for use under special conditionsas, for example, the vaccinesagainst epidemic typhus and yellowfever, both of which are consideredeffective. Experimental work also wasdone to develop vaccines against thedysenteries, the various types of encephalitis,influenza, et cetera. We stilldo not have a useful vaccine against thedysenteries; the vaccines against encephalitisand influenza still require improvementto meet the needs of theArmy.Occupational Hazards and Health.The division of occupational healthincluded branches dealing with (1) thehealth of workers in Army—owned industrialplants, (2) industrial hazardsand accidents, (3) toxicology and, (4)the hazards of operating tanks andother mechanized Army transportation.This division initiated and supervisedthe activities of the Army IndustrialResearch Laboratory at Johns HopkinsUniversity and the Armored Forces ResearchLaboratory at Fort Knox.Civilian Health In Occupied Countries.—The civil public health division wasconcerned with plans to protect thehealth of the civil population of conqueredor liberated countries insofar asthis influenced military activities.Throughout World War II this divisionworked closely with the medical intelligencedivision and with the War De-

August, 1951The Health Bulletinpartment. It planned for the developmentof strong postwar civil healthprograms in Germany and Japan andassisted in selecting much of the keyitpersonnel to work in these areas.The Control Of DiseaseIn World War IIThe filth-borne gastrointestinal diseases,which include the typhoid fevers,the dysenteries and diarrheas, andcholera, have long been the scourge ofarmies operating in the field. DuringWorld War II, however, none of thesediseases were important except thediarrheas and dysenteries which didcause much temporary illness in certainlocations overseas.The wartime prevalence ofthe acuterespiratory diseases, including influenzaand pneumonia, was higher than duringthe peacetime years from 1930 to 1940,but lower than the rates for World WarI. The mortality from these diseaseswas greatly reduced, undoubtedly becauseof the widespread use of thesulfonamides and, later, penicillin.jAll our previous wars have been accompaniedby a great increase in venerealdisease among troops and in thecivil population. Venereal diseases haveplagued armies since the beginning oftime and have disabled American troopssince the battle of Bunker Hill. Thewartime program for the control ofvenereal diseases was comparatively effectivein this covmtry and in certainlocations abroad. Compared with previouswars, there was a definite reductionin these diseases, but they are byno means under adequate control andthey will constitute an important, unsolvedproblem for the future.The tropical diseases were another importanthazard because so much of thefighting was done in the Tropics. Thishad been anticipated by the SurgeonGeneral, and for years military medicalofficers had been urging that morestudies be made to discover better agentswith which to protect troops in thefield against tropical diseases. In additionto the insecticides previously mentioned,researches were directed at thediscovery of an effective prophylacticdrug for field use against malaria. Millionsof dollars were spent in the searchfor new compounds which could be givento the soldier in the field to kill malarialsporozoites at the time of their injectionby the bite of the mosquito. Althoughthe ideal prophylactic has notyet been found, this research programproved to us that quinacrine, when properlyused, will prevent falciparum butwill only suppress vivax malaria. Moreimportant, it led to the discovery of anumber of new antimalarial drugs. Someof these are highly effective for treatmentin the clinical case and others, forexample chloroquine, are more usefulthan quinacrine for suppression.Although malaria was well controlledin this covmtry, it was an importantcause of illness in certain overseas locations,especially in the early part of thewar. There were almost 500,000 admissionsto hospitals during the war, andthe rate was 18.9 per thousand perannum. These figures included manyadmissions for relapses. They do notgive a true picture of the number ofmen infected as many cases were suppressedor cured by the routine use ofquinacrine. Over 80 per cent of these*patients with clinical malaria were admittedto hospitals overseas. Thosetreated in this covmtry were largely relapsesfrom infections contracted abroad.In general, the treatment was excellentand the death rate was not significant.There were many other importanttropical disease, including dengue, filariasisand schistosomiasis, but none ofthese was important as malaria. Thetropical skin diseases were a seriousproblem in many places; this problem isstill unsolved. There were various otherdisease problems, some of which stillneed attention, such as infectioushepatitis, the neurotropic virus infections,and trench foot. Considered as awhole, however, the health of the Armyin World War II was much better thanduring any previous war. There were nogreat epidemics and many of the formerplagues of war were completely controlled.In brief, the results .show thatwithin half a century military preventivemedicine had advanced to the point

10 The Health Bulletin August, 1951where it paid rich dividends in the conservationof America's fighting manpower.In the Spanish-American War therate for deaths from disease among ourtroops was about 25 per thousand annum;13 American soldiers died of diseaseto every 1 killed in battle. InWorld War I the rate was reduced toabout 16; the ratio of disease to battledeaths was 1.1. In World War II thedisease death rate for our total Armyof about 10 million men was only 0.6per thousand per annum; in the EuropeanTheater only one soldier died ofdisease for every 85 killed in battle.This experience of the recent past showsthat the field of preventive medicineand public health now has at handmethods which can be used to conserveboth civilian and military manpower.Unsolved Peacetime Health ProblemsAs we face the present national emergency,it is important to realize that inspite of the progress already made,many health problems must be solvedif we are to conserve the nation's manpowerin preparation for the threat ofa long war. Even under the peacetimeconditions of the last few years, toomany civilians have been incapacitatedor killed by preventable disease andaccidents. The death rate for infectiousdiseases has been reduced, but they arenot yet under control. The mental anddegenerative diseases cause an enormousnational loss in money and manpower.Other unsolved problems include occupationaland industrial hazards anddiseases, nutritional deficiencies, poorhousing, atmospheric contamination,pollution of our streams with sewageand industrial wastes, and the need toconserve and protect the national watersupply. There is much room for improvementin the field of maternal andchild health; this was shown by thelarge number of physical and mentaldefects found in young men examinedby the draft boards during the lastwar. Of those examined since June 1950,to bring the Armed Forces up to threeand one-half million, one million havebeen rejected as physically, mentally, ormorally xinfit.New Defense Health ProblemsIn addition to these unsolved peacetimecivilian problems, we must alsoconsider the new disease hazards of amodern war which might easily beginwith an atomic attack on the UnitedStates and reqiiire the use of Americantroops both in this covmtry and abroad.This means that both the civil and themilitary population must be preparedfor the occurrence of unusual diseasewhich might accompany sabotage andbombing, and the disasters producedby atomic, biologic, or physchologic warfare.It also means that the civil healthagencies must be prepared to combat avariety of diseases, many of which arenow considered vmder control. In addition,the Armed Forces must be preparedto meet the wartime diseaseswhich vmdobutedly will be encounteredin military operations. The existence ofso many unsolved health problems atthis late date in our national developmentis disappointing. It shows thatalthough we Americans boast abouthealth, we still do not have adequatehealth protection and that we still arenot using our total resources for theprevention of disease. Therefore, if weas a nation are to provide and maintainthe healthy manpower required in thepresent emergency and for the infinitelygreater demands over an indefinitelylong time in the future, we must organizea stronger defense health program.Importance Of Preventive MedicineIn The Defense ProgramOur defense program must provide forboth curative and preventive medicine.It is logical, however, even in peacetimeto place the greater emphasis onpreventive medicine in order to decreaseexpensive hospitalization and medicalcare. In time of war there is an addedneed to keep well people well becausethe entire population is needed foractive duty either on the home front orin the fighting line. This means the newprogram must be aimed primarily atprevention. If our country is to make

August, 1951 The Health Bulletin 11the most of its latent preventive facilities,the importance of preventive medicinemust be re-emphasized. Every onein the field of medicine and publichealth should make it his business toknow what needs to be done to preventdisease in this country and, regardless ofhis primary specialty, he should workunselfishly for the accomplishment ofthis objective. If all our 200,000 Americanphysicians will apply the principlesof preventive medicine to the familiesof their patients and give enthusiasticsupport to their community health programs;if all of the coimtry's hospitalswill accept the added responsibility ofserving as real health centers for theircommunities with a view to keeping thepeople well; and if sufficient healthagencies manned by adequate numbersof competent specialists are provided forthe entire country, the physical, mentaland moral fiber of the nation can beenormously strengthened.This is not a Utopian dream, but toaccomplish it quickly is a task whichwill require many revolutionary changes.One basic need is for a thorough revampingof the curriculums of the 79medical schools in order to give themedical graduate a better concept ofthe practical importance of preventivemedicine and public health. He shouldbe indoctrinated with the preventiveattitude. This will help to prepare himfor his wartime responsibilities eitherin civil defense or in the Armed Forces,It should also assist in recruiting thehealth specialists now urgently neededto man our oflBcial and nonofficialcivilian health agencies and for thepreventive medicine organizations ofthe Army, Navy, and Air Force. By thesame token, the military physician andsurgeon should recognize his responsibilityfor preventive medicine in theArmed Forces. The strengthening ofthe civilian health program for theemergency will require the provision ofadditional local health units to coverthe entire country and the taking ofaction to correct the present shortagein health specialists needed in the totalcivilian health program.More Health Specialists Required forthe Defense Program.—The developmentof the emergency health program forthe Armed Forces will requu'e carefulplanning geared to meet the peculiarcircumstances of the present threatagainst us. The Army, Navy, and AirForce must develop and implementsound mobilization plans for the rapidexpansion of their programs of preventivemedicine along lines which will enablethem to carry forward all the advancesnow at our disposal. Each of theArmed Forces Medical Services now hasa good peacetime division of preventivemedicine; therefore, they are in astrategic position to prepare for war,but to expand the present programssufficiently to meet the additional requirements(1) of our forces now fightingin Korea, (2) for the nationalmobilization and training activities nowtmder way, and (3) for the still greaterneeds of another possible global warwill call for large numbers of expertstrained in every aspect of public health.Certain parts of this training can beprovided within the respective services;but large numbers of the officers neededfor key positions will require postgraduatetraining of the type now availableonly in the country's 10 accreditedpostgraduate schools of public health. Itrequires time to carry out such training,and therefore each of the servicesshould rapidly develop adequate poolsof specialists to meet their entire needs.During the last war both military andcivil health were handicapped becaviseit was necessary for the Armed Forcesto draw such personnel largely fromthe inadequate group of trained specialistsrequired by the civil population.This weakened to a dangerous degreethe staffs of civilian health agencies andthe faculties of schools of medicine,dentistry, and public health. In the presentemergency, this mistake must notbe repeated, for to do so would be likedestroying the goose that laid thegolden egg. Large numbers of healthspecialists must therefore be recruitedand mobilized; and this supply must bemaintained in order to operate the nation'swartime military and civilianhealth programs. These specialists will

12 The Health Bulletin August, 1951include health administrators, epidemiologists,public health laboratory experts,public health nurses, health educators,biostatisticians, nutritionists, andindustrial and sanitary engineers. Forthe key administrative and professionalpositions, there is urgent need for physicianswho have the additional postgraduatetraining and experience requiredby the recently established AmericanBoard of Preventive Medicine andPublic Health. The training required isnow available only in the 10 accreditedschools of public health.At present these schools are graduatingonly about one-fifth of the specialistsneeded to fill key positions in thepeacetime civilian health program ofthe country. This makes it clear thatthe national emergency will call for therecruitment of many additional healthspecialists and for expansion of the facilitiesfor their postgraduate training.Although my subject has been militarypreventive medicine, I have dealth atsome length with civilian public healthbecause experience in both fields hastaught me that the two are fundamentallysimilar and interrelated. Theydiffer only in certain details of administrationand application. The expertin military preventive medicine andthe civilian public health specialist bothoperate by applying fundamental knowledgefor the prevention of disease intheir respective popi:ilations. They bothneed research aimed at the solution ofunsolved problems. Civilian health hasalways influenced military health, andthe reverse is also true. Today's emergency,which demands the mobilizationof the entire nation, brings the militarypreventive medicine specialist and thecivilian public health specialist moreclosely together than ever before.POLIOMYELITISBy W. Howard Wilson, M.D.Raleigh, N. C.In spite of the fact that it cripplesless than one-fiftieth as many people asrheumatic fever, and in spite of thefact that only one child in a millioncontracts it, poliomyelitis, or infantileparalysis, is one of the most feared ofall diseases. While the medical professionhas much knowledge of the wayin which it is spread, there is still muchmore to be learned. There is no cure inthe strict sense of the word, but thereis much that can be done by propertreatment.Our first line of defense against aninvasion of infantile paralysis is knowledge,from an inmiediate and practicalpoint of view, of what can be done toanticipate and prepare for an epidemicand of the precautions that should betaken at such a time. We also need furtherknowledge of the cause of infantileparalysis, its means of spread, andimproved methods of treatment. Newfacts have been learned and new methodshave been developed, but much stillremains to be done before infantileparalysis can be removed finally andcompletely from the list of great cripplingdiseases.The hot summer months are generallyregarded as the polio season, becausethe disease usually picks up momentumduring that season. Scientists cannotexplain why, but there are theories thatthe virus which causes polio spreadsmore rapidly when the weather is hot.So far there have been very few casesof poliomyelitis in Raleigh and WakeCounty this year.The modern term used by physiciansand other professional people is poliomyelitis,and this is often called poliofor the sake of brevity. PoliomyeUtisis aptly named, for polio means gray,myelos means spinal cord or marrow,and itis means inflammation. Inflammationof the gray matter of the centralnervous system is the characteristicnervous system abnormality of this disease.Infantile paralysis is the term

August, 1951 The Health Bulletin 13most frequently used, which in one wayis unfortunate, as some people jvunp tothe conclusion that only very youngchildren are attacked. This is not so,for individuals of thirty, forty,or oldermay have the disease, although it istrue that the majority of patients arechildren.When polio is prevalent, one shouldkeep away from crowds and places ofpublic attendance, pay strict attentionto personal hygiene, avoid swimmingin waters that might be polluted, keepflies away from food, avoid sudden chillingfrom plunging into very cold wateron an excessively hot day, and avoidovertiring and extreme fatigue.If symptoms of headace, fever, orgastrointestinal disturbances should occur,then a physician should be notified.If possible, one should avoid tonsiland adenoid operations during epidemics.Perfect health is not proof of protectionagainst infantile paralysis, but arested body is good insiu^ance.One should remember that the chanceof contacting the disease in relation tothe total population is small, so peopleshould not become fearful and spreadpanic.Most cases of poliomyelitis are nonparalyzing.There is no specific means of wardingoff poliomyelitis. During an epidemicmany carriers and persons with mild,imdiagnosable forms of poliomyelitis infectionunintentionally and unknowinglyspread the virus. There is no practicalway to detect these carriers. All thatcan be done is to prevent unnecessarycontact with others. It must be rememberedthat even rigid confinement of achild to his home, however, will not alwaysprevent the disease from beingcarried to him.There is no known drug that willactually cure infantile paralysis. Theuse of serums is apparently of no value.There is no magical or secret method oftreatment that has any merit. Every bitof information gained by every reputablephysician is immediately made generallyavailable. Such knowledge is publishednot only in scientific articles, buteven in newspapers and popular magazines,and is broadcast to the peoplethemselves for their use.On the appearance of the very firstsuspicious symptoms of the disease, suchas fever, headache, stiff neck or legpains, a physician should be called, becausehe might be able to help preventserious complications of poliomyelitisand reduce the crippling that is a commonresult.Treatment should be started at once,preferably in the isolation departmentof the hospital, where the necessaryequipment and the specially trainednurses are available.As soon as the muscle soreness andspasm have been relieved, the affectedmuscles must be re-educated. In thehands of the skilled physician andphysiotherapist much can be done toreturn patients to full use of all theirmuscles, so that there will be a minimumof permanent injury.The ultimate success of treatment ofparalysis depends not alone on thephysician, nurse, physical therapist andhospital staff, but also on the patientand the patient's family. Infantileparalysis, even though it may impair themuscles, does not affect the intelligence.The physician and the patient have thetask of improving the physical state andreadjusting the mental state. Weakenedmuscles in an arm or leg need not meandefeat. They need not even offer a serioushandicap. Success and a happy anduseful life are just as possible for theinfantile paralysis victim as for anyoneelse. Improper attitudes on the part ofthe patient or the patient's too solicitousfamily may lead to maladjustments ofpersonality than can be even greaterhandicaps than physical crippling.Cases of headache, fever, arm or legpain, or stiff neck should be seen by aphysician who will decide whether ornot to send the patient to the hospitalwhere isolation can be adequate, wherea spinal punctui'e can be done if necessary,and where respirators are availablewhen needed, and where cooperation betweenphysicians, orthopaedists, physiotherapists,and nurses can best be

14 The Health Bulletin August, 1951utilized for the welfare of the patientwith poliomyelitis.We look forward to more definite progressin the control of this disease atits soirrce so that attacks may be prevented.Much work has been done towarddeveloping a preventive vaccineagainst poliomyelitis, but this has notbecome practical for use in hiunanbeings.The National Foundation for InfantileParalysis which sponsors the "March ofDimes" campaign, stands ready to givegenerous aid and financial assistance toneedy cases.POLIO POINTERS FOR 1951If Polio ComesDO allow children to play with friendsthey have been with right along. Keepthem away from new people, especiallyin the close daily living of a home.DO wash hands carefully before eatingand always after using the toiletespecially important when polio isaround.Also keep food clean and covered.DO watch for signs of sickness, such asheadache, fever, sore throat, upsetstomach, sore muscles, stiff neck orback, extreme tiredness or nervousness,trouble in breathing or swallowing.DO put a sick person to bed at once,away from others, and call the doctor.Quick action may lessen crippling.DO telephone your local chapter of theNational Foundation for InfantileParalysis, if you need help. Locatethrough telephone book or health department.No patient need go withoutcare for lack of money. Your chapterwill pay what you cannot afford.DO remember—at least half of all poliopatients get well without any crippling.DON'T get over-tired by hard play,exercise, work or travel. This meansmen, women or children.DON'T get chilled. Don't bathe or swimlong in cold water, or sit around inwet clothes.DON'T have mouth or throat operationsduring a polio outbreak.DON'T use another person's towels,dishes, tableware or the like.DON'T take children to places wherethere is polio. Ask your health department.DON'T take your child out of camp orplayground, where there is good healthsupervision.For more information about Polio writeThe NATIONAL FOUNDATIONfor INFANTILE PARALYSIS120 Broadway, New York 5, N. Y.Franklin D. Roosevelt, FovmderThis publication made possible by theMarch of Dimes. — Publication No. 31March, 1951AMERICAN HOSPITAL SERVICESETS ALL-TIME HIGHIN 1950American hospital service in 1950reached an all-time high mark, accordingto the 30th annual report of hospitaldata made pubUc by the Coimcil onMedical Education and Hospitals of theAmerican Medical Association.The number of patients admitted lastyear totaled 17,023,513, representing onenew patient every 1.8 seconds. In 1949,the total was 16,659,973, or one every1.9 seconds. Nongovernmental hospitalsaccomited for 304,955 of the increaseand federal, state, county and city institutionsfor 58,585.Hospital births showed a slight drop.2,815,806 in 1950 as against 2,820,791 in1949. Both figures represented one livebaby every 11.2 seconds.The report, prepared by Dr. F. H.Arestad, Chicago, associate secretary ofthe council, and Miss Mary A. Mc-Govern, was published in the current(May 12) Journal of the A.M.A. Itcovered 6,430 registered hospitals in theUnited States. Excluded were 299 hospitalswhich failed to supply data. Thesein 1949 had accounted for about 260,000admissions and 1.5 per cent of the servicesrendered.The 1,456,912 bed capacity of all registeredhospitals (1,439,030 in 1949) wasdivided as foUows: Federal, 186,793;state, 665,019; city and coimty, 185,229;nonprofit chiirch-related, 150,078; nonprofitassociations, 218,788; proprietary,

August, 1951 The Health Bulletin 1551,005; total governmental, 1,037,041;total nongovernmental, 419,871.Although the nongovernmental hospitalshad only 29 per cent of the bedcapacity, they accounted for 12,706,143admissions, or nearly 75 per cent of thetotal. The admissions by groups were asfollows: Federal, 1,127,937; state, 791,863;city and county, 2,397,570; nonprofitchurch-related 4,944,745; nonprofit associations,6,309,157; proprietary, 1,452,241;total governmental 4,317,370; total nongovernmental12,706,143.The general hospitals with a bedcapacity of 587,917, or 40 per cent ofthe total, provided service for the mostpeople—15,830,170, or 93 per cent of allpatients admitted. In addition, they accountedfor 2,739,212 births, or 97 percent of the total. The average dailycensus of these hospitals was 433,364,or nearly 35 per cent of the patient loadin all hospitals.In the psychiatric division, the bedcapacity was 711,921, or 49 per cent ofthe total. Nervous and mental institutionsadmitted 307,165 patients (308,055in 1949, the record) and had an averagedaily census of 687,567, a new high (675,-096 in 1949).The 1.8 per cent of the total admissionsaccounted for by mental hospitalsdoes not give a full indication of theextensive service carried out in this field,the Journal pointed out."It is necessary to take into considerationthat the psychiatric hospitals maintainan average daily census of 687,567,which is greater than the patient loadin all other hospitals combined," it explained."For the most part the hospitalizationof psychiatric patients is apublic responsibility, as evidenced bythe daily census report of 670,578 in thegovernmental hospitals compared with16, 989 in the nongovernmental group."Tuberculosis hospitals had a bed capacityof 85,746, or 5.8 per cent of thetotal. They admitted 113,275 patientsand had an average daily census of 72,-370, both new high marks.The remaining beds were in maternity,industrial, children's and othertypes of hospitals, accounting for 5.2 percent of the total.The council's report also disclosed that7,118,305 patients, or 43.5 per cent ofadmissions, received operative treatmentin 1950. A previoiis report with such information,covering 1942, showed that44.7 per cent had received operativetreatment in that year.In bed occupancy, the average of allhospitals last year was 85.3 per cent,as against 85.1 per cent in 1949. Governmentalinstitutions as a whole showeda rise to 89.8 per cent from 89.3. Thehighest rate, 95.1 per cent (94.2 in 1949),was in state hospitals, which give theirmajor service to psychiatric care. Thenongovernmental group reported a declineto an average of 74.1 per cent in1950 as compared with 74.7 per cent in1949.The average length of stay in federalhospitals last year was 26.5 days, asagainst 25.8 days the year before. Thestay in the government hospitals rangedfrom averages of 11.3 to 15 days (11.8to 15.4 in 1949). In nongovernmentalgeneral hospitals, the average was 7.9days, as against 8 days in 1949."In all activities associated with hospitaland educational services, the individualhospitals are constantly strivingto improve the standards and qualityof patient care," the Journal pointedout editorially."The hospital field has been generousin its support of educational activities,and many institutions are participatingin the training of medical students,interns, resident physicians, studentnurses, technicians and other hospitalpersonnel. At present 824 hospitals areapproved for internships and 1,102 forresidency training."Accredited professional schools ofnursing, now conducted in 1,106 hospitals,have a student enrolment of 102,-611. In addition, there are 318 hospitalschools of practical nursing in which5,971 students are now in training. Thetechnical fields are represented by 467approved schools of medical technology,30 schools of physical therapy, 24 schoolsof occupational therapy, 18 schools formedical record librarians and 283 schoolsfor x-ray technicians."

16 The Health Bulletin August, 1951YOU CAN LIVE WITH YOURULCER, BUT IT'S UP TO YOUYou can live with your ulcer if youcan learn to relax and enjoy life. Thismay involve some changes in diet andthe elimination of such things as smoking,liquor and hot dogs, but these sacrificeswill be worth while."So said Dr. Paul Wermer of Chicagoin an article in Today's Health, publishedby the American Medical Association.Dr. Wermer is secretary of theCommittee on Research of the A.M.A.'sCoimcil on Pharmacy and Chemistry.About 5 per cent of the populationeventually will become victims of pepticulcer, he said. But, for the most part,these sufferers can take a pat on theback, for the disease occurs usually inhard-driving, intelligent and conscientiouspersons when under undue stress.Peptic ulcers are open sores in twoorgans, the stomach and the duodenum,the first part of the intestine. Those ofthe stomach are called gastric ulcers;those of the duodenum, duodenal ulcers.These areas are bathed in the stomachjuices, which contain pepsin. Pepsin ispresident in both types and for that reasonthey are called peptic.Their cause never has been determineddefinitely. One theory is thatsevere emotional and nervous straincauses a disturbance of the nerve supplyingthe stomach. This nerve, knownas the vagus, influences the blood supplyof the stomach lining."In some manner, the blood supply toa small area of the stomach is sharplydiminished, causing damage," Dr. Wermerpointed out. "The stomach juicesand ferments do the rest."All authorities agree that two conditionsmust exist for a peptic ulcer todevelop. First, there must be an injuryor damage to the mucous membrane,or lining of the stomach. Second,there must be ample stomach juices containingacid and a digestive ferment,pepsin."In the presence of these conditions,the stomach juices treat the damagedarea almost as if it were food. They tryto digest it. Furthermore, the action ofthe acid juices on the ulcer stimulatesthe stomach to manufacture more digestivejuice. If nothing is done, the ulcercan actually be digested through thestomach wall and cause a perforation.This occurs more rarely with duodenalulcer. Only emergency measures will doin such a case."Hut, perforation can occur only ifthe patient neglects the rules of medicationand diet that the physician hasprescribed."By modern-day methods, most ulcerscan be controlled adequately throughmedication and without resort to surgery,provided the patient is cooperative,Dr. Wermer said. The doctor will prescribesomething to counteract theacidity of the stomach juices and suggesta diet which will not upset thedelicate chemical balance of the body.He also will advise what must be doneto relieve nervous tension.How soon relief of the ulcer pain maybe expected depends upon the patient'swillingness to obey orders. It may be aweek or 10 days, even earlier in somecases. But, Dr. Wermer stressed, reliefdoes not mean cure. The doctor willhave to watch the ulcer crater withrepeated fluoroscopic and x-ray examinations.As conditions improve, diet andother restrictions will be liberalized."When you think it over, having anulcer is not too bad," he concluded."You just have to adopt a changed outlook.Don't let things get you riled. Relaxand enjoy life."Summer means that children arespending more time out-of-doors, andthe chances of traffic tragedy in thestreets are increased, the NationalSafety Council warns. Motorists shouldremember that more than three-fourthsof all child traffic deaths result fromthe children crossing between intersections,coming from behind parked carsor playing in the roadway.To keep your vacation free of tragedy,the National Safety Council advises youto limit the distance you drive eachday. Trying to cover too many milesleads to speeding, fatigue and mechanicalfailure. And it's no fun anyway!

If^ ).m.MEDICAL LIBRARYU. OF N. C.CHAPZL HILL, N. C.illPuUiixedtu miMrflCflniNA SlMB°flKD^AEflLTAi TKis BuUetin will be seni free to dnij citizen of fKe Skite upon request IPublished monthly »t the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 66 SEPTEMBER, 1951 No. 9mmmi:if.::iimm iiM.»!B:JiS?SiS ;i&5«;^^SS.-4-Ai:>:>;iS«S;iv:s^?*ft''->;^^iJ«^:^^^^^FLOYD JOHNSON, M.D., Columbus County Health Officerfor thirty years—Has examined thousands of school children.

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-President RaleighH. Lee Large, M.D Rocky MountMrs. James B. Hunt Lucama, Rt. 1John R. Bender, M.DWinston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaH. C. LuTz, Ph.G. HickoryGeo. Curtis Crump, M.D.AshevilleEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OfficerJohn H. Hamilton, M.D., Assistant State Health OflBcer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionC. P. Stevick, M.D., M.P.H., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any Inwhich you may be interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitis Infantile Paralysis Typhus FeverCancer Influenza Venereal DiseasesConstipation Malaria Residential SewageDiabetes Measles Disposal PlantsDiphtheria Pellagra Sanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFlies Teeth Whooping CoughTuberculosisFeeble-mindedness, Mental Health and Habit TrainingThe National Mental Health ActSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CareFirst Four MonthsPrenatal Letters (series of nine Five and Six Monthsmonthly letters)Seven and Eight MonthsThe Expectant MotherNine Months to One YearInfant CareOne to Two YearsThe Prevention of Infantile Two to Six YearsDiarrheaInstructions for North CarolinaBreast FeedingMldwlvesTable of Heights and WeightsYour Child From One to SixBaby's Daily ScheduleYour Child From Six to TwelveGuiding the AdolescentCONTENTSThe School And Pre-School Health Program 3The Development Of The North Carolina CooperativeSchool Health Program 5Mental Hygiene In The Schools 7The New Physical Education Bulletin For The North Carolina Schools 9Health Education Workshop 10Report of Medical And Dental ExaminationsIn Beaufort, Iredell And Swain Counties 11Teacher Screening And Observation Of School Children 13Health Aspects Of Athletics 14Page

IPUBLI5MED BYTAE N^'RTA CAROLINA STATE B^AaP^^AEALTAVol. 66 SEPTEMBER, 1951 No. 9J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorTHE SCHOOL AND PRE-SCHOOL HEALTHPROGRAMC. C. Applewhite, M.D.Director, Local Health DivisionState Board of HealthRaleigh, North CarolinaThe school health program in NorthCarolina reached another milestone in1951 when the school year of the JointSchool Health Program was completedwith marked accomplishment. The cooperativeplan designed and agreedupon by the State Department of PublicInstruction and the State Board ofHealth in 1949 has been assured financialsupport for the next two years bythe State Legislature.It was possible to intensify this prot

The Health Bulletin September, 1951and infant death rates of today ascompared with those of twenty-fiveyears ago.Everyone interested in the welfare ofthe growing child appreciates the valueand importance of a constructive schoolhealth program. Such a program shouldbe continued and made more effectivefrom year to year. However, at thistime it is deemed of paramount importanceto call attention to that trite buttrue statement that "as a twig is bent,so is the tree inclined." As previouslystated, public health workers, parentsand physicians have given close attentionto babies during the first year oflife; however, the so-called "toddler"group of children has apparently beenoverlooked. It is felt that special attentionshould be given to this group inthe future. The school health load hasbeen materially increased by failure toexercise closer supervision over the "oneto six" age group. By the time a childreaches the age of six years, the physicaland emotional pattern of that childhas become fairly well established or"inclined." Every local health departmentshould have as its main objectivethe execution of such a constructivepre-school health program that everypre-school child by the time school ageis reached will be free of all correctablephysical and emotional defects and willhave been immunized against all diseasesfor which an immunizing agentis available. The achievement of suchan objective will not be easy. It will requirepersistent and continuous teamworkon the part of parents, physicians,dentists, Parent-Teachers Associations,and the personnel of local health departments.However, such a program, ifproperly executed, can be expected toproduce the following tangible results:1. The provision for optimum physicaland mental well-being for thechild throughout the pre-schoolperiod as well as assuring the childevery opportunity for sound physicaland emotional growth.2. A sizable reduction in the numberof school children requiring attentionfor the correction of physicaldifficulties or emotional healthproblems.3. The establishment of a pattern formedical care that will encouragea child to seek regular medical attentionfrom his private physicianor dentist throughout his life.4. The time and personnel now beingused to secure the correction ofdefects in school children couldwell be utilized in extending otherphases of the public health program.The second statement, as given above,points to the fact that the school- agechild with a physical defect may havehad the misfortune of living with thatdefect several years before it is revealedin a school health examination. No onewould consider waiting for children toget diphtheria before offering a programof immunization, nor should onewait until the child is six years of agebefore taking action on a remediable defect.It is recognized that the school-agechild is in a more or less controlledsituation. The children are alreadyassembled and accounted for when thehealth workers enter the school buildingto execute the school health program.It is essential that a sound health programfor this age group be maintained.In contrast, the pre-school group is ascattered population. In order to developa sound program with this group,it will be necessary to utilize greaterresources and ingenuity.The Parent-Teachers Association hasgiven significant impetus to the schoolhealth program through the able sponsorshipof pre-school clinics for childrenplanning to enter school. This programhas aided materially in the successof the school health program. Thisagency should be able to make an outstandingcontribution to a more comprehensivepre-school program.The expedient way to carry on aschool health service program is towait until the child enters school. Themore profitable way for the child andcommunity is to initiate and executea sound health program for the agegroup of one to six.

September, 1951The Health Bulletin^ It is sincerely hoped that the personnelof the local health departmentand members of the medical professionwill continue to carry on the constructivematernal and child health programswhich have already achievedstartling results; that the local healthdepartments, Parent-Teachers Associations,and parents will re-double theirefforts to promote a sound programdesigned to induce a normal physicaland emotional development of the preschoolchild; and that everyone interestedin child welfare will continue togive enthusiastic support to a constructiveschool health program. In this way,it will be possible to achieve, for allpractical piirposes, the main objectiveof a joint school health program, namely,the development of a future citizenshipwhich is physically, intellectuallyand emotionally mature.THE DEVELOPMENT OF THE NORTH CAROLINACOOPERATIVE SCHOOL HEALTH PROGRAMBy Charles E. Spencer, DirectorSchool Health Coordinating ServiceRaleigh, North CarolinaThe health of the school children ofNorth Carolina is a concern of manyagencies, organizations and individuals.Successful programs of school healthare, to a great degree, dependent uponthe extent to which those interestedcooperate.For thirty or more years the StateDepartment of Public Instruction andthe State Board of Health have workedtogether on school health programs ina limited and unofiBcial way.The first big step in the developmentof a jointly sponsored program beganwith the establishment of the SchoolHealth Coordinating Service as a jointenterprise of the State Board of Healthand the State Department of PublicInstruction. The Rockefeller Foundationand the General Education Board,assisted financially in the project fora period of eight years.Prom 1939 to 1947 the School HealthCoordinating Service operated largelyas a demonstration project in three tofive selected counties each year.During these years of demonstrationwork emphasis was placed on in-serviceeducation programs for local personnelin the areas of health instruction, tea-- cher screening, healthful school living(environmental sanitation) and physicaleducation.During this period of time consultantPservices to schools and health departmentswere offered by several divisionsof the State Board of Health and theState Department of Public Instructioneach one operating more or less independentlyof the other.Another step was taken in 1947 tobring about a more cooperative schoolhealth program. On May 29, 1947, theState Health Officer, Dr. Carl V. Reynolds,and the State Superintendent,Dr. Clyde A. Erwin, upon recommendationof the then Co -Director, Dr. C. P.Stevick and Charles E. Spencer andwith the advise of the Advisory SchoolHealth Committee changed the policiesgoverning the work of the SchoolHealth Coordinating Service. BeginningSeptember 1, 1947 this Division of theState Department of Public Instructionand the State Board of Health began tooffer its services to the State as a wholein the promotion of:1. Health and safety instruction inthe public schools.2. Better health facilities.3. A more extended health serviceprogram.4. Physical education in grades 1-12.The 1949 General Assembly providedthe "where-with-all" to make progressin a cooperative school health programon a state-wide basis on a scale notachieved in any other state in the Na-

6 The Health Bulletin September, 1951tion. Upon request of the State Boardof Education, supported by the StateBoard of Health, the 1949 General Assemblyappropriated for school health$550,000 for each year of the bienniumto the State Board of Education to Deused as grants in aid to city and countyschool administrative units.The 1949 General Assembly also increasedthe appropriation to the StateBoard of Health and thus enabled thisDepartment to earmark an amountequal to 40(J per pupil to be allocated tolocal health departments.These appropriations have made itpossible for the State Department ofPublic Instruction and the State Boardof Health, with the School Health CoordinatingService serving as the administrativeunit for both agencies, tomake still greater progress in developingwhat may truly be called a "JointSchool Health Program" involving theactive cooperation of many agencies,organizations, and individuals.In order to develop a sound schoolhealth program utilizing all of the resourcesavailable the two state agenciesagreed to require joint planning andbudgeting on the part of school superintendentsand health officers beforeapproval of budgets. This has resultednot only in planning the expenditureof school health funds but has resultedin cooperation in the wise use of thetime of health department personnelmost of whom spend some time workingin schools or with school personnel.The extent to which the local superintendentand health officer havebrought others in on the planning hasvaried considerably and the exact mannerin which the several agencies andorganizations helped in the planningand carrying out the school programshave also varied to meet the needs ofthe groups concerned.Ten Regional School Health Conferenceswere held in September last yearthe chief purposes of which were:1. To promote joint planning.2. To interpret the school healthprograms to those invited to attend.3. To stimulate more cooperation andteam work by the various groupsconcerned with school health.These Regional Health Conferenceswere sponsored by the State AdvisorySchool Health Committee composed ofrepresentatives of the several divisionsof the State Board of Health and theState Department of Public Instructionhaving some part in the total healthprogram and a representative of themedical and dental societies, the WelfareDepartment and the North CarolinaCongress of Parents and Teachers.Incidentally, it should be pointed outthat the organization of this committeewas a forward step in developing bettercooperation and understanding on thepart of those working in State agenciesand organizations.No attempt will be made to reportthe discussions and all the conclusionsreached at the above mentioned RegionalSchool Health Conferences buta few conclusions pertinent to the subjectof this article are:1. That joint planning is conduciveto better understanding.2. That there is better cooperation onthe part of those who help carryon the various phases of the schoolhealth program when they, in oneway or another, participate in theplanning.3. That better programs can beachieved when there is real understandingand cooperation.The progress made in the schoolhealth program during the past twoyears is in itself a demonstration ofwhat can be achieved through cooperation.In some phases of the health programprogress can be observed but cannotbe stated in measurable terms. Forexample, improvement in the healthinstruction program cannot be measuredover a short period of time instatistical terms.However, in the matter of finding andcorrecting defects of childen much canbe noted. Reports sent in to the SchoolHealth Coordinating Service indicatethat thousands of chronic remediabledefects of children have been foundand corrected. For children of parentsunable to pay for such services schoolhealth funds have been used. Voluntary

ISeptember, 1951 The Health Bulletin 7agencies and other organizations have of operation of the "Joint School Healthassisted in these programs. Moreover, Program" made possible by the approthefollow-up program by school and priation of the 1949 General Assembly,health department personnel have re- The 1951 General Assembly approprisultedin getting parents, who could ated the same amount for school healthpay, to seek and pay for medical serv- as the 1949 General Assembly,ices for their children. With two years of experience inThe achievements in improving the planning the expenditure of schoolhealth of school children in North Caro- health funds and of cooperatively carrylinaduring the past two years can bej^g out of those phases of the programattributed to the cooperation of: school^^^^ related to these funds as well aspersonnel including teachers, principals,^.j^^gg related to it, the parents cansupervisors, health educators, andj-jg^tfuily expect a high level of healthsuperintendents; health departmentf^j. their children in the future,personnel including nurses, health edu- ^ . , ^ v. ^.v,cators, sanitarians and health officers:The unofficial figures showmg theitems of expenditure of State Board ofprivate physicians and dentists; welfareofficers; volunteer agencies and other Education school health funds for thecommunity organizations. period July 1, 1950 to June 30, 1951 isJune 30, 1951 ended the second year as follows:Salaries: Health Educators $ 30,632.97Nurses 88,043.12Physicians 5,973,25Audiometer Technicians and Dentists 9,274.12Travel: Health Educators 4,312.87Nurses 14,348.00Physicians 185.11Audiometer Technicians and Dentists 1.875.39Clinic Fees for Medical Examinations 28,592.43Correction of Defects 304,563.17SuppUes 22,201.43Equipment 16,339.41In-Service Training 2,316.00$528,657.27IMENTAL HYGIENE IN THE SCHOOLSBy R. M. Fink, Ph.D.Consultant in Mental HygieneNorth Carolina School Health Coordinating ServiceRaleigh, North CarolinaEach year in North Carolina about25,000 teachers influence the lives ofabout 900,000 children. If the future islike the past about 36,000 of these childrenwill eventually enter a mental hospital,and about 81,000 more will havetheir lives seriously upset by personalitydisorders.Four years ago the North CarolinaSchool Health Coordinating Service initiateda small program aimed at theimprovement of the mental health ofschool chfldren, with the hope that thisprogram would also contribute to theprevention of mental illness. The 25,000teachers and school administrators of

8 The Health Bulletin September, 1951the State were recognized as a forcewhich, over a period of years, couldexercise a strong influence for the mentalhealth of the citizens of the State.During these four years a variety ofmethods have been used to educateschool people in the principles of mentalhygiene as they may be applied inschool administration and instruction.We have used films, lectures, discussions,case studies, socio-drama, publications,radio programs, personalitytests, parent education and the like.Teachers have studied individualchildren; they have examined their ownmental health; administrators haveworked with teachers to eliminate unnecessaryanxieties aroused by schoolpractices; some courses of study havebeen examined from the viewpoint oftheir influences on mental health:classes have been organized with thedeliberate intent of aiding children tounderstand their emotions; instructionin sex education has been initiated bysome school systems, etc.In the school year 1950-51 thirtyschool administrative units receivedhelp from the Coordinating Service inplanning and executing in-service educationin mental hygiene for teachers.In seven units extensive programs werecarried on during the major portionof the school year. Nine otherunits developed programs in which theactual meeting time amounted to foiu"to eight hours. Thirty-six one day programswere held. In addition, one programwas held for nurses from twelvecounties.During the summer months the CoordinatingService cooperated in theeducation of groups of teachers at theUniversity of North Carolina, NorthCarolina College, Western CarolinaTeachers College, and Catawba College.During this same year every schoolsupervisor in the State was suppliedwith a looseleaf handbook containingpractical suggestions for working withteachers. This is a continuous serviceto supervisors. Two of the recent bulletinswere "Mental Health and Fear ofAuthority" and "Adjustment to thePirst Year of School."Approximately 5000 pamphlets dealingwith emotional readiness for beginningschool were supplied to schooldistricts at cost for free distribution toparents. Two hundred schools purchased,at cost, a collection of pamphletsconcerning mental health in theschools. Four hundred of these "kits"were used by schools in the previoustwo years.During this year one major projectwas initiated in the primary grades ofone county. This is a three year studywith the purpose of trying to learnwhether primary teachers can be taughtimderstandings and practices which willincrease the emotional stability of thesechildren during the first three years ofschool.The most important question that canbe asked concerning this program is."Does it work?" We do not know. Webelieve that it does, but the evidenceis difficult to collect. Indeed, the resultsthat we hope to see may not appearuntil these children are well into adulthood.Yet there are many indicationsthat the program is worthwhile.Each year there is an increasing demandfor help by the schools of theState. For the past two years it hasbeen impossible to meet many requests.School people think that the service isvaluable. One supervisor, perhaps withexcessive enthusiasm, remarked, "Thisis the most important in-service trainingprogram we have ever had."Many teachers feel that they havepersonally benefitted from their study.For example, one stated, "I have alwaysworried too much over little, unimportantthings. As a result of the workshop,I think I understand why I let myselfbecome like that, and I believe that Ihave become more cheerful and aneasier person to work with. I teach withless tension, too."Many teachers have given examplesof pupils whom they think they havebeen able to help as a result of increasedunderstandings of mental hygiene.A girl who was the most unpopularin my room last year was voted themost popular this year as a result, I

September, 1951The Health Bulletinfeel sure, of the ideas I got fromlectures and films.There has been a freer teacherpupilrelationship in my room sinceI have realized the need for outletsfor pent-up emotions—frank discussions,too.We suggested to the parents thatthey have a garden, raise chickensand hogs and can fruit. By so doingthe mother would be able to spendmore time with the children and savemore than she makes working for sixor seven dollars a week.As a result, I believe, of the thingsI learned and did Ronald is no longeras nervous as he used to be. He hasalmost stopped telling those highlyexaggerated stories about his divorcedfather. His school work has improved,too.During the past four years we havedeliberately scattered our efforts intoevery aspect of school life which hasseemed of interest to teachers. To someextent this experimentation will becontinued, but it seems wise now toconcentrate our efforts in four areas:1. Emotional adjustment during theprimary grades with emphasis onthe first grade.2. Hiiman Relations Classes for theearly adolescent.3. A study of the worries and fearsof high school students with attentionto the implications for highschool teachers.4. The mental health of the teacherand administrator.It would be ridiculous to believe thatthe pubUc schools can eliminate mentalillness. It would be equally ridiculousto ignore the fact that 25,000 teacherswith knowledge of the principles andpractice of mental hygiene can make amajor contribution to the mental healthof North Carolina's children.ITHE NEW PHYSICAL EDUCATION BULLETINFOR THE NORTH CAROLINA SCHOOLSBy Helen StuaetAdvisor in Physical EducationSchool Health Coordinating ServiceRaleigh, North CarolinaThe State bulletin of Physical andHealth Education for Elementary andSecondary Schools has served as aneffective guide to teachers and supervisorsin conducting health and physicaleducation programs throughout thestate of North Carolina.This publication has been in continuoususe since 1940, and it was thoughtadvisable to select and compile materialfor a teacher's guide in line with thechanged practices and policies in generaleducation, particularly in the fieldof physical education.The task of preparing a new bulletinwas under the direction of Mr. CharlesE. Spencer, Director of the SchoolHealth Coordinating Service and Mrs.Ruth Moore Davis,(i) State Adviser inINow employed by Charlotte City SchoolsPhysical Education. They were ably assistedby many professional leaders inthe field. Work on the guide requiredendless planning and study by thegroups in order that the new manualwould include a curriculum that wouldmeet the needs and interests of childrenin each school unit.As a result of the valuable contributionmade by these persons in the stateall material for the new bulletin wascompleted and sent in early this year.This publication is now being printedand will be ready for distribution inJanuary, 1952.The revised guide contains the followingareas of study:The first area on the organization andadministration of physical education iswritten to help teachers, supervisors,and administrators to plan and organize

10 The Health Bulletin September, 1951a good program for their own particularschool or administrative unit. The basicphilosophy of physical education isclearly stated through the discussion ofthe child, his needs, and his ways ofacquiring motor skills. Schedules andprocedures for setting up a program areoutlined. Standards for facilities andequipment are suggested.The game area describes suitable activitiesfor physical education in grade1-8. All analysis of skills developedthrough lead up games is given. Thissection also contains relays with thegeneral teaching suggestions, rhythms,individual and dual sports, stunts andtvunbling and many other activities thatchallenge the interests of our boys andgirls because they parallel with thenormal growth and development of each.Desirable types of physical activityon body mechanics, self testing activities,recreation, camping, intramurals,aquatics and special day programs arealso presented because these activitieshave become an important phase ofphysical education programs.The general purpose of this newcourse of study in physical educationis to provide an abundance of practicalmaterials that can be used by classroomteachers in rural and city schools sothat their teaching will be more effectiveand it is a hope that each one willrealize a feeling of satisfaction from theuse of the new bulletin as a guide.HEALTH EDUCATION WORKSHOPCHAPEL HILL, N. C—JUNE 11-JULY 19, 1951By Annie Ray Moore, Health EducatorSchool Health Coordinating ServiceRaleigh, North CarolinaNot all the way from Manteo toMurphy but from Hatteras to Rutherfordtoncame the 30 teachers, principals,and supervisors to attend the HealthEducation Workshop. These participantsrepresented all grades from 1 thorugh12 and principals and supervisors too.They came from the following coimties:Catawba, Chatham, Cumberland, Dare,Durham, Gaston, Forsyth, Harnett,Mecklenburg, Onslow, Randolph, Rowan,Rutherford and Wake.Again this summer the workshop wasjointly sponsored and carried on for sixweeks by the University of North Carolinaand the School Health CoordinatingService of the State Department ofPublic Instruction and the State Boardof Health. Charles E. Spencer, Directorof the School Health Coordinating Service,directed the workshop. The N. C.Division of the American Cancer Societyand the North Carolina TuberculosisAssociation provided financial assistance.Many participants receivedscholarships from their own county orcity Tuberculosis Association, CancerSociety, or School Health Fund.These school people came to the workshopto get help in solving health problemsand to improve their own schooland commimlty health programs.The first several days were spent ingetting acquainted with resources andin identifying and defining health problems.Then by planning together the participantsand staff were able to providemany experiences through which theparticipants were able to acquire scientificinformation and practical techniquesfor solving these problems.Each participant had a variety ofexperiences. These activities includedworking in large and small groups, committeework, field trips, film showings,panel discussion, demonstrations, lecture-discussions,interviews, physicaleducation and recreation.Visiting consultants to the workshopprovided scientific information and aknowledge of resources. These consultantscame from the University staff andcommunity, from the official and volun-

September, 1951 The Health Bulletin 11tary state agencies, and from the U. S.Office of Education.In addition to the activities listedabove health services provided valuableeducational experiences. Each participanthad a medical examination, achest x-ray, a Snellen eye test, anaudiometer test, and went through thecancer detection center in Durham.Continuous evaluation by staff andparticipants was another valuable experience.This helped to keep the plans"up-to-date" to meet the needs of theparticipants.Near the end of the session a periodwas spent in discussing the ways ofworking "back home." This discussionrevealed that each participant had concreteplans for improving the healthprogram in his school and community.With the interest and enthusiasm exhibitedby these participants at theend of six weeks and with their competenciesin recognizing and solvinghealth problems, the hope for betterhealth will no doubt be realized formore children in North Carolina.REPORT OF MEDICAL AND DENTAL EXAMINATIONSIN BEAUFORT, IREDELL AND SWAIN COUNTIESBy Charles E. Spencer, DirectorMrs. Annie Ray Moore, Health EducatorSchool Health Coordinating ServiceRaleigh, North CarolinaMedical and dental examinations weregiven in Beaufort, Iredell and Swaincounties as a part of a "Survey of PublicEducation" made by the Departmentof Public Instruction vmder the directionof Dr. Allen S. Hurlburt. TheSchool Health Coordinating Service participatedin the study in those phasesof the school program relating to thehealth of children. The survey on thehealth phase of the school program inBeaufort County, Washington City, IredellCovmty, Mooresville, Statesville andSwam County was made on 9th gradestudents, one-quarter of the students ingrades 10, 11 and 12 and in the 8thgrade in some schools. In addition tomedical and dental examinations thesame groups were given a health knowledgetest and questionnaire of healthhabits.The medical and dental examinationswere carried out by state and local personnelas follows:1. Medical examinations were made byprivate physicians and health officers.2. Dental examinations were made bydentists of the Division of the StateBoard of Health.3. Audiometer tests were made bylocal audiometer technicians.4. Stool examinations and urinalysiswere made by public health nurses,technicians and the State Laboratoryof Hygiene.5. Snellen eye testing, measuring ofheight and weight were done byteachers.The final report of the "Survey onPublic Education," which will be published,will give the number and percentageof children found to have thefollowing defects— skin, scalp, vision,hearing, nose, mouth, teeth, glands,chest and lungs, heart, hernia, genitalia,orthopedic neurological, hookworm, otherintestinal parasites, urinalysis, hemoglobinand throat (tonsils).

12 The Health Bulletin September, 1951Summary of Findings of Medical and Dental Examinationsd)CountyWhite NegroNumber children examined 943 213Number children with no defect 151 42Number with defects 792 171Percent of children with defects 84 81Number with one defect 397 103Percent with one defect 42 49Number with 2-3 defects 352 61Percent with 2-3 defects 37 29Number with 4 or more defects 43 7Percent with 4 or more defects 5 3Average number of defects per child 1.7 1.6Dental Inspections Only (In addition to those includedNumber examined 562 142Number with no defects 104 24Number with defects 458 118Percent with defects 82 84CityWhiteTotal

September, 1951 The Health Bulletin 13be true of at least some of the defectsfound in this survey. This beingthe case effort should be increasedin both elementary schoolsand secondary schools to carry outthe above four recommendations.6. There should be a good medicalexamination for all 9th grade studentsfor the educational opportunitiesas well as to discover defects.As was foimd in this studyas soon as 9th grade pupils in onecounty were found to need defectscorrected, pupils and parents followedthrough to get the correctionsdone by the family physiciansor some specialists referred to bythe family physicians. It is recommendedthat the examinations bein the 9th grade in high school becausethat is the last grade inschool where a health course is requiredand it leaves time duringthe high school life to followthrough to get corrections done.TEACHER SCREENING AND OBSERVATIONOF SCHOOL CHILDRENBy Annie Ray Moore, Health EducatorSchool Health Coordinating ServiceRaleigh, North Carolinafirst screening in the fallTo know the children better and tofind their special health needs are verygood reasons why teachers screen andobserve their children."Screening means picking out thosechildren who need special teaching ormedical care." By taking a good look atall the children to find out which onesdo need help, the teacher learns manythings about those who do not appearto have any special problems.One of the most valuable resourcepersons to the teacher in this programis the public health niurse. The teacherand nurse make a team to work togetherto find those children with specialhealth problems. After these defectsand problems have been found, the.teacher and nurse work together to getsomething done about it.When the teacher has completed her(usually duringthe first month or six weeks ofschool), she arranges a conference withthe nurse if possible. Together they goover problems of the children together.Teacher and nurse decide which childrenshould be referred for medical examinationseither to their family physicianor to the Health Department.After the medical examination hasbeen held, the teacher and nurse worktogether to follow up on recommendationsby the physician. The teacher isin a key position to influence childrento get corrections done. The nurse doesan invaluable service through her homevisits to interpret needs to the parents.The Screening Record. In order to dothe best job of teaching and guiding achild in health activities, it is importantto know what has gone before. Thereforeit is essential to have some kindof record.The "North Carolina Teacher Screeningand Observation Record" has beendeveloped to help the teacher find thosechildren who need help and to keep arecord of what is done about it. Forseveral years most of the counties haveused the "Health Appraisal Form"—one-year type teacher screening record.During the past year "the North CarolinaTeacher Screening and ObservationRecord" has been developed to take theplace of the one-year type. These arer»w being printed and will be ready foruse this school year. A bulletin containingsuggestions for use of the record hasbeen prepared.County and city school superintendentsmay order these records fromMr. L. H. Jobe, Director of Publications,State Department of Public Instruction,Raleigh. These forms may be purchasedat cost out of school health funds.

14 The Health Bulletin September', 1951The teachers and nurses in NorthCarolina deserve a great real of creditfor the tremendous progress that hasbeen made In the screening program inNorth Carolina in recent years. And byprogress we mean the large number ofchildren who are receiving individualattention in finding their health needs.With school health fimds available tohelp with some of the follow up andwith the increased interest and efforton the part of teachers and nurses,many more children will have opportimitiesto improve their health and toget corrections made early.HEALTH ASPECTS OF ATHLETICSBy Taylor DodsonAdvisor in Physical EducationState Department of Public InstructionRaleigh, North CarolinaThe last fifty years has been a periodof phenomenal growth in athletics inthe United States. This athletic competitionin our North Carolina highschools is part of the American traditionand is no doubt the natural endresult in a country which has built itsgreatness upon a competitive system ofcapitalistic philosophy.Educators and laymen alike agreethat athletics have an important andvital part in the program of educationfor children and youth, if athletics areused to develop and promote worthwhileeducational goals. If this function isserved the misuse of athletics for theglorification of a coach, school or facultywill not be as prevalent as it toooften is at present.The student is the most importantconsideration in the athletic program.His welfare is of paramount importanceand the operation of the athletic programmust be planned with this inmind. Activities must be selected andconducted on the basis of their contributionto the purposes of education.Mere participation in an interschoolsports program will not necessarily resultin the desired outcomes. If theseoutcomes are to accrue the programmust be administered by high qualityleadership according to nationally recognizedstandards of desirable competition.Education must seek to meet the needof individuals. This means that theneeds of the physically handicappedstudent must be met as well as those ofthe highly skilled individual who wantscompetition with others of superiorability. This competition is, or shouldbe, an integral part of the total programof health and physical education.The competitive interschool programmust be the outgrowth of a broad programof instruction for all studentswhich is supplemented by a varied intramuraland recreational program forthose who desire and need additionalactivity. The interschool program participantsrepresent the upper ten percent in athletic ability, and they shouldnot receive an undue proportion of themstructional time, facilities and equipment.Interschool leagues and highly competitiveathletics should be confined tohigh schools. They are inappropriate forchildren of elementary school age. Itis important to remember that childrenof this age are going through a periodof rapid growth with consequent bodilyreadjustments, emotional stress, mentaland social readjustments. It is felt thatduring this period when there is onlypartial ossification of bones, there isparticular vulnerability to joint injurieswith a healing hazard after injury tothe growth areas of these bones whichcannot be disregarded.All parents like to see their childrenstrong, healthy and physically skilled.Most adults enjoy seeing youth inaction. Efficiency in athletics, precisionin executing intricate plays, and win-

September, 1951 The Health Bulletin 15ning interschool contests which cateronly to the strong and skillful are notenough. Basic, fundamental skills shouldbe taught to all students. Unless thetotal welfare of every student is consideredand there is cooperation on thepart of all school personnel, many studentswill be neglected.Physical activities, properly conducted,may contribute to pupil health and developmentalneeds, lead to more wholesomerecreation, serve as a motivatingforce for student participation in otheractivities and foster school-communityspirit. Improperly conducted, they willsurely lead to over emphasis on winningteams, long schedules, many tournaments,loss of school time on long trips,grudge games, vuisportsmanlike conduct,riots or near riots, and exploitation ofboys and girls.In order to protect the health andinsure the safety of participants andat the same time promote an educationallysoimd athletic program, thefollowing standards of athletic competitionhave been proposed by a committeeof school administrators.1. All schools must, if they participatein any interscholastic sports program,conform to the following eligibility requirements:a. A player must be a regularly enrolledmember of the school and hisparents or guardian must reside inthe same school district.b. A player must have been in attendancefor at least 60 per cent ofthe previous term at an approvedhigh school.c. A player must secure passinggrades on at least three courses eachterm. At least one of these coursesmust be one that is required forgraduation from high school.d. A student, upon entering grade9, is eligible for competition on highschool athletic teams only during thesucceeding eight consecutive semestersor terms of 90 days each.e. No student may participate inhigh school athletic contests who is19 years of age before July 1 of thefiscal school year.f. No student may participate inschool contests after graduation orafter being eligible for graduationfrom high school.g. No students who have enrolledin a college, or who have signed acontract for professional play will beeligible for high school competition.h. Students who have participatedin all star games are ineligible forfurther participation in that particularsport.2. State school laws require that allgate receipts from athletic contests behandled by a bonded school treasurer.3. No more than one football, twobaseball, two basketball games, twotennis and two golf matches per weekmay be played. It is strongly recommendedthat girls' basketball games belimited to one a week.4. Limit the season's games to tenfootball, 20 basketball and 20 baseball.It is recommended that girls' basketballbe limited to 14 games per season.5. Soccer, track, wrestling, swimmingand other interscholastic sports shouldbe limited to one meet, game or matchper week. No boxing.6. No spring football.7. No practice games except intersquad games prior to the regular scheduleof games.8. No games played before schoolopens or after school closes.9. No post season games except countyor state play offs. No regional orstate championship games for girls.10. No players to be approved for postseasonor bowl games.11. Trips that involve overnight traveland out of state games are stronglydiscouraged.12. No tournaments or games sponsoredby organizations or individualsother than bona fide public schools maybe entered.13. No more than two tournaments aany one sport.year may be entered inGitls are limited to participation in onetournament.14. Coaches must be certificated teacherswho are bona fide members of theschool faculty.15. It is recommended that girls teamsbe coached by women teachers and re-

16 The Health Bulletin September, 19.jTquired that a woman teacher accompanythe team on all trips and be presentwhen games are played.16. All players must receive a medicalexamination prior to the beginning ofpractice in any sport.17. Players must receive a medicalexamination prior to his or her returnto play or practice following a seriousinjury or illness.18. It is recommended that players becovered by adequate medical and accidentinsm-ance and that medical aidbe immediately available at all gamesinvolving body contact.19. Practice in any sport may notstart before August 15 and at leastthree weeks practice must precede thefirst game or contest in any sport.20. Tournament play should be limitedto three days in any week and thereshould be at least 24 hours between successivecontests played by a team. Underno conditions should there be morethan one track meet or football gamein one week.21. Interschool competition for boysand girls in grades one through eight isstrongly opposed and it is recommendedthat this practice be discontinued. It isalso recommended that intercity, intercommunityand interschool games betweenteams composed of elementaryschool age children sponsored by communityorganizations be discouraged inevery way possible.22. It is recommended that violationof any of the above regulations wouldforfeit the school's right to participatein interschool athletics for a specifiedperiod of time.All of the above regulations are aimedat safeguarding the health and welfareof the individual player. Numbers 16-20are more directly related to the healthof the students. Other considerationswhich are of vital importance to thehealth of team members include suchthings as clean imiforms for practiceand play, adequate dressing and showerfacilities which are kept in a sanitarycondition, provision of clean towels, individualpaper cups for water duringgames, adequate sleep and rest, lengthof practice periods, amount of dust anddirt on gymnasium floors, protectiveequipment for hazardous games, andchecking to see that students who areactually HI do not participate. Such arethe duties of teachers and principals.There is more involved in safeguardingthe health of school children thanmeets the eye of the casual observeras can readily be seen from considerationof the above paragraph. It is theresponsibility of all the people in thecommunity to demand that athletics beconducted according to safe and saneprinciples. It is also our responsibility torefuse to condone anything that failsto measure up to the best in terms ofsafeguarding the welfare of boys andgirls.SEPARATE BABIES FROM TBMOTHERS AS PRECAUTIONAGAINST DISEASEBabies born of tuberculous motherswho are removed from contact with themother immediately after birth do notcontact the disease, according to threepediatricians.Drs. B"red Ratner of New York, AlexanderE. Rostler of Fall River, Mass.,and Pierre S. Salgado of Port-Au-Prince,Haiti, writing in the American Journalof Diseases of Children, added that withproper diet these infants will grow anddevelop the same as infants born ofhealthy mothers.According to the article, the incidenceof prematurity in offspring oftuberculous mothers is exceedingly high,ranging from 23 to 64 per cent, dependingon the severity of the disease in themother.The American Journal of Diseases ofChildren is a publication of the AmericanMedical Association.Don't let your children play with fii-eworkson the Fourth of July, the NationalSafety Council suggests. Theyoungsters—and you, too—wUl get abigger thrill from a public display. Andit's a lot safer.

MEDICAL LIBRARYU. OF N. C.CHAPEL HILL, N. C.I TKis Bulletm -will be sent free fo dnij citizen of ri\e Skt^e upon request IPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 66 OCTOBER, 1951 No. 10^4N«(HALIFAX COUNTY HEALTH CENTER

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. DrxoN, M.D., President AydenHubert B. Haywood, M.D., Vice-President RaleighH. Lee Lahge, M.D Rocky MoiintMrs. James B. Hunt Lucama, Rt. 1John R. Bender, M.DWinston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G. HickoryGeo. Curtis Crump, M.D.AshevilleEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionC. P. Stevick, M.D., M.P.H., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any inwhich you may be interested.Adenoids andAppendicitisHookwormInfantileDiseaseParalysisTonsils Typhoid FeverTyphus FeverCancer InfluenzaConstipation MalariaVenereal DiseasesResidential SewageDiabetes Measles Disposal PlaintsSanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFlies Teeth Whoophig CoughDiphtheria PellagraTuberculosisFeeble-mindedness, Mental Health and Habit TrainingThe National Mental Health ActSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CareFirst Four MonthsPrenatal Letters (series of nine Five and Six Monthsmonthly letters)Seven and Eight MonthsThe Expectant MotherNine Months to One YearInfant CareOne to Two YearsThe Prevention of Infantile Two to Six YearsDiarrheaInstructions for North CarolinaBreast FeedingMldwivesTable of Heights and WeightsYour Child From One to SixBaby's Daily ScheduleYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageSummary Of Highlights Of Meeting Of The North CarolinaPublic Health Association 3Veterinary Public Health 6In-Service Education For Public Health Nurses 9Major Phases Of The Public Health Program In Halifax County 12

Vol. 66 OCTOBER, 1951 No. 10J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorSUMMARY OF HIGHLIGHTS OF MEETING OF THENORTH CAROLINA PUBLIC HEALTH ASSOCIATIONWinst-on-Salem, September 13-14-15By M. B. Bethel, M.D.City Health Officer, Charlotte, N. C.Having come again to Winston-Salemfor our annual meeting, having experienceda most delightful and profitablesession and having been immeasureablyenriched thereby we must first of allcommend our governing board for theirwise decision to meet here on thisoccasion.President Parker has done a magnificentjob. It is obvious that the Association'sguiding board, and the committees,and those responsible for thisprogram have supported him well. Occasionssuch as this do not just happen.They are slowly and painstakingly,and even painfully put together.Called upon to sum up the highlightsof this meeting, I approached the jobwith a certain integrity. I paid attentionwhat was said, made notes andafter each session wrote copiously, recordingmy impressions with fidelity.There were scouts who brought newsof the several section meetings.It boils down to this. There was nosingle thing said that should have beenleft unsaid. Some speakers were moreeloquent, to be sure, but all had worthwhilepoints to make. We are all aboutalike.Erudition is no indicator of sinceritynor is accomplishment an accurategauge of effort. If I select, therefore,certain things or people for commentplease do not take it to indicate thatunmentioned effort went unappreciated.Rather construe it to mean that anycontribution you may personally havemade was above reproach, and cannotbe improved or elucidated by criticismor comparison.When the first Session was called toorder and the conclave was formallyunder way, there was a fitting levity togrease the initial creaking of the wheelsHis Honor the Mayor didn't show up toaward the key to the City nor did theState's Health Officer arrive in time toreceive it—but no matter. I doubt ifMayor Kurfees could have spoken halfso well as his emissary and certainlynone in our midst can match the Mc-Pheeters for a gracious reply.Dr. Mordecai on behalf of our hostcity issued a further welcome that wasthe epitome of something or other. Amixture of sagacity and wit and witheringscorn it should be duly chronicledand preserved through the ages.Prior to his presidential address Mr.Parker deprecated such effort on thepart of our chiefs and suggested thatthis annual custom be abandoned. Hethen proceeded to give able testimony torefute the cause he had espoused, andmade us a speech which was the essenceof discernment and practicality.Weighted, quite understandably, with

The Health Bulletin October, 1951sanitation's viewpoint his central themewas delivery of public health programsthat hit their marks; for the good ofthe people and not for enlargement ofthe budget nor for personal aggrandizement.And indeed this was, in substance,the gist of the Second general session'sprogram on civil defense—Public Healthwell done is directly in line with civildefense, except that something elsemust be added and an extra measureof service must be delivered. PublicHealth workers generally share a peculiardedication. Most could do half asmuch work and still hold their jobs.Half again as much will be requiredin civil defense preparation, and unlimitedeffort will be our lot in theevent of military disaster. The participants,representative of each of theseveral activities in organized publichealth (except for the laboratory whichwas not accounted for) told of plansthat have been made locally or statewide,and offered suggestions for thebenefit of their respective colleagues.Dr. Bosley, whom I delight to call ourprettiest doctor, left us in wonder atthe prospect of serving a meal, in themidst of carnage and disorder, withoutheat or water to prepare it.The Third general session, on Thursdayevening, as the second had been,was under John Wrights gracious andpurposeful presiding. With neither dillyingor dallying, the program beganonly a few minutes late and ended exactlyon time.Though there had been changes inthe lineup prior to the game we hadthe first team in that night and theprogram was excellent, but quite beyondrecalling in any detail.Last year I was filled with antagonismas several fairly literate but uncomprehendingnewspaper editors toldus how to run our business. This yearI was swept along in the tide of understandingand helpfulness manifested bythe panel members. Dr. Robert moderateda not immoderate group, withsparkle and zest. Dr. Beamer, asidefrom anything he said, even his jokes,exhibits medical attitudes and publichealth appreciation far superior to thatwhich we are accustomed to encounter.Mr. Gibson, the school superintendentmember of the panel, was completelywholesome and refreshing in repeatedlyaffirming his faith in the rising generation.President Messick, manifesting theprofundity expected of a college president,outlined teacher training in mattersof health that should prove simultaneouslythe goal and the despair ofother educators to achieve. I have purposelysaved till last the delightfulDean Elizabeth Kemble from the schoolof nursing at Chapel Hill. Charming inappearance, in personality sublime, andwith a deep throaty voice that causeslisteners to hang onto her every word,it is obvious that God put brains in herhead instead of wheels.What did all this illustrious panelhave to say? Why—simply that theyunderstood, in general terms, the breadthand scope of our problems and that,insofar as they were able in their respectivefields, they would help us solvethem.Came Friday morning and the Sectionmeetings. The sanitarians led offwith J. M. Jarrett, and up on the roofthe big guns boomed all day long. Dr.Clyde Erwin, the Honorable BrandonHodges, Mr. James King down fromAnn Arbor, and Emil Chanlett fromtheChapel Hill painted the picture ofsanitarian and what he ought to be.The health officers, filling their roomto overflowing, divided their time betweenvenereal disease, mental hospitalsand alcoholic rehabilitation, and flouridationof water supplies. Heartening itis to note that all venereal diseases areon the way down, though distant is theday when they can be counted out. Dr.David Young had a less rosy picture topaint about his mental institutions andabout reclaiming alcoholics, but even sowe seem in North Carolina to be ableto maintain a tag end position in theorder of the States without great dangerof dropping clear out of the race.We cannot, however, even thank Godfor South Carolina. Whether Mississippihas forged ahead he did not disclose.Fluoridation of communal water sup-

.largeThere isno longer any question.The nurses spent their morning reviewingthe mid-century White Houseconference on children and youth, andin considering its aftermath in NorthCarolina. It is perhaps enough that soa group was engaged in this pur-but unfortunate that more of uscould not have a fuller comprehension.Dedicated to this proposition, "for;every child a fair chance for a healthypersonality" it is devoutly to be hopedisuitiIOctober, 1951The Health Bulletinplies was listed as an ever more promisingmeasure of caries prevention-—a potent weapon likely to come intowide acceptance in North Carolina as itis doing elsewhere.The Secretaries were up and aboutquite early Friday morning, to breakfasttogether. Thus fortified, and erethe tedium of the day benumbed them,they plunged heroically into the monumentaltask of "Records and ReportsRequirements of the Federal Agencies."That, I submit, is the most ambitiousundertaking of any of the Sections.The Laboratory Section pursued twotopics—Public Health Aspects of FrozenFoods, and The Fluoridation of Water.In the eyes of their speakers the typicalfrozen food and the usual lockerplant presented no problem that couldnot be handled through application ofexisting Food and Drug laws and ofcurrent sanitation procedures. Theywere somewhat more at sea aboutperishable manufactured products suchas salads, spreads, and the like and hadto face up to a certain inability to copewith the problem, in the absence ofstandards and without adequate priorexperience.Water fluoridation, in these learnedprecincts long since accepted, wasstudied from the point of technical applicationrather than from the standpointof "to be or not to be."that such success will obtain in thewake of the 1950 conference as has occurredfollowing its several predecessors.With all sections now accounted forexcept the Health Educators I fearthere is no accounting for them. Withcharacteristic enterprise they havetackled civil defense. They have lived It,practiced it and preached it; before,now, and undoubtedly hereafter; sothat at this convention they are in farmore formidable array than Stalin andhis legions. Since we shall vmdoubtedlyhear more from them when we get backhome and since they have not concludedtheir deliberations I do not feelderelict in ray duty by not informingyou more fully concerning their activity.and tri-Last night combined triviaumph, frivolity and the fruitful. Thedistinguished were accorded their duerecognition, and festivity all but replacedsolemnity. Dr. Hubbard, disclosedan unusually accurate appraisal ofpublic health in that he said it growsby evolution rather than by revolution;that it is now, and will ever increasinglybecome, a mainstay of civilization.The discourse of this morning youhave heard and it needs no summary.Coming from a Tarheel so illustrious itdeserves top billing and would be ahighlight on any program.There remain a few items of businessbefore us. At this juncture a year agothere were undercurrents of dissention,strident voices raised in discord andtempers poorly bridled. May I presiune,as eider statesman by virtue of previousservice, to counsel an end to thesethings. Honest differences of opinionthere must surely be, but unity we musthave rather than division.Freedom to speak implies also theright to keep quiet. Follow your inclinationsto either course, but if tothe former, do it with moderation.

The Health Bulletin October, 1951VETERINARY PUBLIC HEALTHBy Maktin p. Hines, D.V.M., M.P.H.North Carolina State Board of HealthThere are today over 80 diseases ofanimals that are transmissible to humans,either directly or indirectly.Many of these animal diseases arefound only in remote, backward areasof the world, where peculiar habits andcustoms, together with a low standardof living, make control and eradicationalmost an impossibility.The field of veterinary public healthis not new, by any means. The closerelationship between animal and humandiseases has been recognized for a longtime. Slowly we have come to realizethat a sound, healthy animal industryis essential to a sound economy and ahealthy population. The control of suchdiseases as cattle tuberculosis, anthrax,glandus and encephalomyelitis are examplesof the accomplishments of veterinariansin public health, not to mentionthe important programs in the fieldof milk and meat sanitation. Yet,withthis great progress in the past, therestill remains a long way to go in protectingthe human population againstdiseases of animal origin.Veterinary Must Set UpRecently, the North Carolina StateBoard of Health established, for thefirst time, a Veterinary Public HealthSection which will operate under theDivision of Epidemiology. It will be thepolicy of the Veterinary Public HealthSection of the State Board of Health toaid the local county and city health departmentsi n establishing adequaterabies control programs, and to beavailable for consultation in regard toany animal diseases transmissible tohuman beings. The duties and responsibilitiesof the State Public HealthVeterinarian will also include coordinatingthe efforts toward local control ofthe various animal diseases that aretransmissible to man, by encouragingaccurate reporting, and by preparingand distributing educational materialthroughout the state.The initial project of the VeterinaryPublic Health Section will be to establisha state-wide rabies control program,with operational phases carriedout through the local health departments.The great number of rabid animalsthat are reported annually is adisgrace, especially when we have theadequate tools at hand to control oreradicate this dreadful disease. Todayonly 12 of the 48 states are free ofrabies and only 12 of the 36 states, withrabies, have adequate programs. Eachyear over 30,000 people in the UnitedStates take the series of vaccine inoculations,as a result of being exposed torabid, or suspected rabid, animals. Thisseries of inoculations is long and oftenpainful, and could be entirely eliminatedby adequate rabies control programs.The most alarming fact at thepresent time concerning rabies is that,during the past 15 years, the number ofrabies cases in anmials has increased.Local rabies control programs are bestcarried out on a county-wide basis.Since the rabid dog does not respectboundaries and often can run thelength and breadth of the averagecounty, successful results cannot be expectedif a program is limited to a cityor town, without including the rural orsuburban areas of that county.Local Progravi EncouragedThere are 100 counties in the stateof North Carolina, and the local publichealth services are provided for all ofthese counties, through 67 local healthdepartments. On April 1 of each year,many of these health departments organizeand promote programs to controlrabies. In past years there has been atendency for the public to "brush aside"these programs in many counties mwhich rabies in animals has not beenprevalent. It is not uncommon to hearone say. "Why bother with the vaccinationof my dog when there has not beena rabid dog in the county for years?"

October, 1951The Health BulletinThis attitude makes a community "ripe"for a rabies epidemic. We know, fromexperience with the various epidemicdiseases of both men and animals, that,in order to be successful in preventinga disease, by vaccination, from assumingepidemic proportions, there mustbe at least 80 per cent of the susceptibledogs vaccinated against the disease. Itis rather difficult for the local healthdepartments to accomplish this highpercentage of vaccinations of dogs,especially since the vaccination mustbe repeated each year. Unfortunately, atthe present time, we do not have arabies vaccine for dogs that will giveprotection against the disease for longerthan one year, but research is beingconducted in this field.It should be emphasized that whenthe public develops a lack of interest Inrabies programs because the danger isnot immediate, there can be only oneresult: the dog population in that areabecomes highly susceptible to rabies, becauseof its lack of immunity, throughannual vaccination. In such instances,the infection only needs to be introducedby one or two rabid animals fromother areas to start a vicious epidemic.Because the public has not alwaysbeen properly informed regarding rabies,there is a great need for accurateinformation as to the procediure tofollow in disposing of dogs that havebitten humans. This is paramount, ifthey are to avoid a lot of needlessantirabic treatment. A dog that hasbitten a person should never be killed,but should be placed in a secure penwith plenty of food and water. If possible,it should be placed in the handsof a veterinarian for observation. Itshould be observed for 21 days and, ifalive at the end of 14 days, the animalmay be considered as being not infectedwith rabies. Most animals that bite aperson while showing symptoms of rabieswill die within 4 to 6 days afterbiting. In case it is impossible to capturea dog alive, it should never be shotthrough the head, because this maymake examination of the brain forrabies impossible at the State Laboratoryof Hygiene. If a person has themisfortune to be bitten by a dog orother animal suspected of having rabies,he should first wash bite woimd withsoap and warm, running water andthen consult his physician or healthdepartment immediately for advice regardingcare of the wound and obtainingantirabic vaccine treatment. Whena dog that has bitten a person getsaway, it is usually necessary to assvimethat the dog was rabid and to have theanti - rabies treatment administered.The decision must be made by the attendingphysician as to whether or notthe treatment is given in such cases.Rabies Control MeasuresTheie are three simple measureswhich, If properly carried out, willadequately control rabies. The first isthat of annual anti-rabies vaccinationof all dogs. The importance andvalue of this measure has been provedbeyond all doubt. This measure is a"must" In a rabies control program.The second measure is the impoundmentof all ownerless and stray dogs.It is these dogs that will not be vaccinated,and very often it is the straydog that is responsible for the spreadof rabies. This measure requires theoperation of a hiunane shelter wherethe stray dogs are kept for a specifiedperiod of time and where, if they areunclaimed at the end of that period,they are humanely destroyed.The third measure is registration ofall dogs. This measure has its importance,in that is establishes responsibilityfor dog ownership, assures anaccurate dog census, and identifies unwantedstrays.Although the dog is the most importantanimal to consider in any rabiescontrol program, there are several otheranimals, including wild animals, thatare important in the spread of rabies.Rabies in foxes has become very importantin some of the southeasternstates where regions have become overpopulatedwith foxes. Foxes transmitrabies by biting cattle in these areas,resulting in a great economic loss to thefarmer. Rabies in foxes also presents aproblem in the control of the diseasein dogs, since infection in the wild life

8 The Health Bulletin October, 1951means a constant threat to the dogpopulation, by the introduction of thedisease through susceptible hosts. Thisis the reason why control of stray dogsthat have not been vaccinated is soimportant in any control program. Inthe midwestern states skunks play animportant part in the control of rabies,by transmitting the disease to domesticanimals. Rabies control programs inthe midwest often must take measuresto reduce or eliminate the skunk populationfor effective control of the diseasein dogs and cattle. Rabies can becontrolled and eventually eradicated ifeveryone gives his complete support tothe local programs organized to defeatthis menace.Brucellosis A Problem,Another pressing problem in the fieldof animal diseases that are transmissibleto man is brucellosis, or undulantfever, as it is known to most people.Brucellosis is a specific infectious diseaseof animals and man, which iscaused by micro-organisms, or bacteria.In cattle, the disease is known as Bang'sDisease, or contagious abortion; inswine, it is known as contagious abortion;in man, brucellosis is known asundulant fever. The report cases of humanbrucellosis in the United Stateshave increased from 100 cases in 1929to more than 7,000 annually in recentyears. There were 21 cases reported inNorth Carolina in 1950. This is a lowfigure, compared to other states, andcan be attributed largely to the low incidenceof infection in North Carolinacattle, which is a result of the excellenteradication program that is being carriedon by the Veterinary Division ofthe Department of Agriculture. Becauseof the difficulty of diagnosing brucellosisin human beings, public health officialsrealize that the present numberof cases that are reported representonly a small fraction of the actual incidence.Brucellosis is not transmissablefrom human to human, so we realizetoday that the control of this diseasein humans is dependent on the eradicationof the disease in animals, togetherwith the sanitary handling andprocessing of foods of animal origin.A Public Health ProblemBrucellosis also affects the publichealth, indirectly, by the loss of foodproducts from infected herds; for example,in some herds, the milk productionis reduced by about 22 per centand the calf crop by 40 per cent, whenthere is infection with brucellosis. Noone will deny that a reduction of foodproduction seriously affects the publichealth. It costs the farmers of theUnited States over $1,000,000,000 eachyear to live with this insidious disease.There are generally two ways in whichhuman beings may become infected.These are: First, the consumption ofmilk or of other dairy products notproperly pasteurized from infectedcows; and, second, from contact withinfected animals and their infective discharges.To control brucellosis, we must firsteradicate the disease from our domesticanimals and thus eliminate this reservoirof infection. Until this is accomplished,we can prevent the diseasein humans only by using daii-y productsthat have been properly pasteurized;by eating meat products that have beenprocessed under sanitary conditions andwhich have received proper inspection,and by avoiding contact with infectedanimals and their discharges. Brucellosisin human beings frequently results ina serious, debilitating, incapacitatingillness of long duration. It can be preventedin human beings and eradicatedin animals.

October, 1951The Health BulletinIN-SERVICE EDUCATION FOR PUBLIC HEALTHNURSESBy Maetha Rebecca Swindell, Supervising NurseDistrict Health DepartmentElizabeth City, N. C.IThere has long been a recognition ofthe need to give Public Health Nursesmore security in their role of assistancein clinics. The first step in the developmentof such a program would be theselection of an area where such servicecould be concentrated. With this inmind, the Nursing Consultant fromChildrens Bureau was asked to come toNorth Carolina to help develop theseplans and the clinic selected for demonstrationwas the Orthopedic Clinic heldeach month in Elizabeth City, N. C.This clinic which serves the northeasternsection of the state comprisingthe following counties: Dare, Currituck,Camden, Pasquotank, Perquimans,Chowan, Gates, Washington and Tyrrell,has been in operation for manyyears under the sponsorship of theAmerican Legion and American LegionAtixillary, the Crippled Children's Divisionof the State Rehabilitation Service,and the local Health Department. Dr. R.B. Raney, (Chief) of Orthopedic Service,Duke Hospital, Durham, N. C, is theMedical Director, and the nursing staffof the District Health Departmentrender the clinic nursing service. Recentaddition of physical therapy personnelfrom the State Board of Health hasbeen included in the service.In the fall of 1949 the first nursingconference was held to formulate plansfor in-service institutes and in May1950 Miss Coggans from the Childrens'Bureau, Miss Ruth Council and MissLilly Fentress from the Crippled Children'sDivision, State Board of Health,met with the nursing staff that coversthis clinic. This fore-runner conferencebrought out the following points: (1)The Public Health Nurse is not securein this clinic due to lack of knowledgeof orthopedic terms; (2) teaching methodsand content; (3) clinic operationsand the specific place of the nurse inthe clinic. These basic needs we wouldrecognize as applicable to all clinics,and the principles as applying to allservices the same.It was brought out in group discussionthat the over-all emphasis of reviewshould be on the total growth anddevelopment of the child. To developthis program the following points wouldbe kept in mind:1. Selection of an area where servicecould be concentrated.2. Determine with nurses how needsmay be met.3. Plan for staff education that willmeet the need.4. Outline of staff education program.5. Evaluation to see if this may beused or is applicable to other clinics.Since the selection of area had alreadybeen made, the next step was todetermine from the nurses themselveswhat their needs were, for only withthis information could ways and meansbe devised to meet those needs. I wouldlike to discuss the general feelings expressedby the nurses.Better methods of case finding werefelt to be of great importance. If thenurse is to recognize the deviation fromthe normal, she must be entirelyconfidentin recognition of the normal. Thepreventive aspects of orthopedic nursingwould certainly require betterknowledge of the Evaluation of theNewborn, for which no better sourcecan be used than Dr. Ethel Dunham'ssplendid book with which every nurseshould be completely familiar. Not onlyin the orthopedic clinic itself but infield and other clinic services the importanceof good history taking, withspecial emphasis on birth history(length of labor, presentation, size,forceps, bleeding, etc.) needs to be

10 The Health Bulletin October, 1951stressed, and would very likely prove tobe of great importance in case finding.Recognition of the import of the historywould enter into the nurse's interpretationto the family and the patient, andthe preparation of the child for theclinic experience. It is essential that wedo not lose sight of the fact that thisexperience to the child is of greatsignificance since it carmot remain anisolated instance but enters into thetotal needs of the child. The emotionaland social needs of the patient are thesame as those for the nurse, and withthis transferral of understanding thenurse can better recognize the patient'sand family's degree of acceptance ofthe handicap. We must recognize fearsand anxieties in their proper relationto the total needs of the patient, andthe significant warning signs such asbelligerence, day-dreaming, reversion toinfantile habits, etc., as basic expressionsof fears that we can help to overcomeor prevent by a better understandingof the child himself. It is essentialthat we be able to give the mothersand the patients a comprehensive andunderstandable interpretation of thetreatment that has been recommendedand be sure that it is understood. Thenurse, of course, would be expected tofollow the child in home visiting as theneed indicated, but the original interviewin the clinic has a different impactupon the patient and family than isexpected in subsequent visits. Full interpretationwould also mean that thenurses have complete and up-to dateinformation of all resources availablefor the complete recovery of the patient.When we fully understand thatany patient is a person with a specialneed and that our professional duty isto be able to help that individual tofind all methods of meeting that need,then our report will more closely approachthe optimum level that will affectnot only the growth of the patient,but contribute immeasurably to thegrowth of the nurse herself. In ourknowledge of resources we must alsotake into account the community attitudeswhich will affect the rehabilitationof the patient or his developmentas a self-supporting individual. We mayoften find that our commimities aregreatly in need of education along theselines.To emphasize the point that nursesare aware of their own needs in increasingtheir professional abilities, the followingquestions were brought out inregard to orthopedic nursing servicespecifically:1. What is being done in other statesand advised by progressive educatorsabout the child who is too slow to keepup with normal children, but has noneed to be separated from his family bybeing placed in a special institution?2. How can the Public Health Nursehelp the school child or family withsuch a situation where special classesare not available?3. How can the Public Health Nursehelp in situations involving delayed ordefective speech when special classesare not available?4. What are some practical thingsthat can be done about pigeon toes?5. How can we prevent or help earlycurvature of the spine?6. What is the corrective exercise forflat feet; clinical significance and treatment?7. What age is the best for correctionof club-foot?8. Can cleft-palate and hair-lip becorrected at the same time?9. Should pes planus 3rd degree oecorrected?10. What nursing care would be givento the rheumatoid arthritic patient?11. Are braces advisable for faultyposture in children?12. Is it possible to correct clawfootwithout surgery?13. What instruction should be givena mother taking her child home afterreduction of congenital dislocation orhip?14. What is the most effective procedureto apply a wet hot pack to aninfiamed joint?15. How is an elderly patient, recentlyhaving had a hip cast removed, preparedto begin getting up and usingcrutches?16. The need for discussion of the

October, 1931 The Health Bulletin 11normal growth and development of tbschild.17. Which is the authoratative thinking,the discipline of non-discipline ofthe child?18. Discussion of congenital dislocationof the hip joint and treatment.19. Discussion of osteomyelitis andtreatment.One point brought^ out very clearlyby the nurses was their feeling thatpediatric service should be a part of theorthopedic service, or vice versa, but ofcourse the planning of such would bedepartmental with the Health Officer,attending Orthopedist and Pediatritianin cooperation with the Crippled ChildrensSection of the State Board ofHealth. Another main point was theneed for post-clinic conferences withthe attending orthopedist in review ofoutstanding cases.Since the original objective was toimprove the orthopedic clinic serviceroutine we felt there were four mainobjectives to plan for. There were (1)Increased knowledge of the nursingpersonnel in the clinic service; (2)Home service; (3) Follow-up; (4) Correlationof orthopedics into all services.It would naturally follow that thenext step would be to determine howthese objectives might be reached in agiven period of time. We hoped thatwe would be able to plan ten all-dayconferences beginning in November 1950and ending in the summer of 1951, andas a starting point w-e had to examinethe resources available and arrange appointmenttimes. Specialist serviceavailable from the state level would bePediatritian, Medical Social Worker,Nutritionist, Psychiatrist, Clinical PediatricNurse, Psychologist and specialistin the teaching field from East CarolinaTeachers College, Greenville.Correspondence was begun with variouspeople and although some of thepoints could not be included in thisfirst program the following conferenceswere planned and held:Nor7nal Body Mechanics and StructuralFunctions—November 10, 1950Miss Jessie Stevenson, VanderbiltUniversity, Nashville, Tenn.Post - Orthopedic Clinic Conference —November 29, 1950Miss Ruth CouncilMiss Lillie Fentress, State Board ofHealth, Raleigh, N. C.Aspects of the Medical Social Worker—January 31, 1951Miss Virginia Elliott, State Departmentof Welfare, Raleigh, N. C.Miss Katherine Barrier, State Departmentof Health, Raleigh, N. C.Maternal and Child Health—March 13,1951Dr. Sidney Chipman, School of PublicHealth, Chapel Hill, N. C.Miss Jean Ribentisch, School of PublicHealth, Chapel Hill, N. C.Mental Health—April 23, 1951Dr. R. M. Fink, State Board ofHealth, Raleigh, N. C.Rehabilitation—May 31, 1951Miss Evelyn JohnsonMiss Lillie FentressMiss Ruth Council, State Board ofHealth, Raleigh, N. C.The nurses from the counties servedby this orthopedic clinic were invitedto attend each of these institutes andthe attendance was most gratifying.However, regular schedules in their departmentsmade this impossible in somecases, but it was vividly brought out inthe evaluation of the program that allof the nurses felt that they had profiteda great deal by this review andhoped that some of the remaining problemscould be included in a program ofstudy in the coming year. Each nursewas asked to submit a brief resume ofthe program and how it had helped herin her own services. Some of the reviewswere brief, others in detail, andsome of the nurses did not respond, butthe consensus of expression was thatthey felt much more secm'e in patientnurserelationship. It is sometimes hardto bring out specific points and tie themup with discussion points in previousgroup work, but it has been noticeableboth in clinic and field work that thesenurses have shown a more poised, professionalattitude in their work. Theirincreased confidence in themselves hasbeen noted especially in the clinic service.I would like to quote from some

12 The Health Bulletin October, 1951of the reports as I feel they ratherclearly summarize the reports receivedfrom the other nurses.* * * »"It is my opinion that in these seriesof meetings the instructors have triedto accentuate the normal and to reviewthe normal and preventive aspects oforthopedic nursing and allied healthfunctions."* * * *"I have given the medical socialworker some very unjust and destructivecriticism because I did not knowtheir duties and limitations and lawsunder which they had to work . ..""before this discussion (Miss Stevenson)I have never been able to recognize amild club foot; before this explanationall infants had deformed feet .". ."Dr. Chipman's and Miss Rebentisch'sdiscussions were directed toward thegrowth and development of the normalchild from infancy. This meeting meantmore to me than any I have attendedas I have used part of the informationgained in several talks I've had to makesince then . . ."* * * •"The psychological aspect of the entireseries was one of the most strikingpoints to me, and I feel impressed memost because this is one of the phasesof the program that is neglected by somany Public Health Nurses .". ."The institutes I have attended in thein-service educational program havebeen very valuable to me. I believe itis the only way to keep Public HealthNurses informed and alert on a varietyof subjects. The information obtainedI have been able to use in interviewingin the clinics, well-baby, prenatal, orthopedicand home visiting. I believethe time spent in these institutes hasbeen well worth while."* * • *"I belive that the Public Health Nursein the field who is chiefly concernedwith getting a job done, and often byantiquated methods, is especially inneed of in-service training to keep herabreast, to a degree, with the rapidchanges in all fields, and, of course, toreview the basic things that are lostby non-use."* * * *It has been especially gratifying tofeel that the group of nurses in thisarea of the state have responded sowell to a program of in-service education,and plans are being made to carryon this type of work. We all feel thereis much yet to be reviewed, but recognizethat limitations over which wehave no control may delay part of theprogram. We are especially grateful tothose people who gave so freely of theirtime and effort to make this programsuccessful.MAJOR PHASES OF THE PUBLIC HEALTHPROGRAM IN HALIFAX COUNTYBy Robert F. Young, M.D., M.P.H.County Health OfficerThe present staff of the HalifaxCounty Health Department consists ofthe following positions: Health Officer,Supervisor of Nurses, Senior PublicHealth Nurse, three Junior PublicHealth Nurses, four Registered Nursesin Public Health, Senior Sanitarian,Junior Sanitarian, Assistant Sanitarian,Junior Public Health Investigator, JuniorBacteriologist, Senior General Clerk,Junior General Clerk, and two Typistclerks. In addition to the regular personnel,various technical consultantsare assigned to the local health departmentfrom time to time by the StateBoard of Health and by other agencies.The new Health Center located inHalifax consists of eighteen rooms, exclusiveof six restrooms, with a total of5,500 square feet of floor space. In the

October, 1951 The Health Bulletin 13tclinic area there are four examinationrooms equipped with the most modernfacilities; x-ray room and dark roomwith new equipment; laboratory completelyequipped for public health labooratoryservice; library and conferenceroom with facilities recessed in the floorfor installation of dental equipment,should a full time dentist become available;two storage rooms; large assemblyand reception room; information center;and in the administration sectionof the building are located the ofiBcesfor the personnel. This Health Centerwas constructed under the Federal HospitalSurvey and Construction Act asadministered in North Carolina throughthe North Carolina Medical Care Commission.The costs of the building andequipment were prorated as follows:Federal $29,348.00State 18,208.10Local 31,442.90Total $79,000.00Public Health is usually defined todayas "The art and science of preventingdisease, prolonging life, and promotingphysical, mental and social weUbeingthrough organized comxnunity effort.Public Health embraces the total population,not any particular economicclass, race or creed. No chain is strongerthan its weakest link. Dr. M. J. Rosenau,in speaking of each person havinghis share of health said, "These thingshe shall have as a matter of justice andnot of charity."The Public Health Program of theHalifax County Health Departmentconsists of the following principalgroups of services:/. VITAL STATISTICS1. Registration of Birth Certificates2. Registration of Death and StillbirthCertificates3. Tabulation, interpretation and publicationof the essential facts of VitalStatisticsAt the present time all births anddeaths in Halifax County, with the exceptionof those occurring in RoanokeRapids and Roanoke Rapids Township,are registered in the Halifax CountyHealth Department. Moreover, a specialreport is received from the RoanokeRapids Township of the births anddeaths occurring there. Copies of thesebirth and death certificates are filed inthe Health Department, with a secondset being filed with the local Register ofDeeds, and with the original certificatesbeing mailed to the State Board ofHealth each month. Certified copies ofbirth and death certificates occurringafter 1913 can be obtained from eitherthe Register of Deeds or from the StateBoard of Health.II.CONTROL OF COMMUNICABLEDISEASES1. Tuberculosis(1) The Control Program for Tuberculosisincludes the early diagnosis ofthe disease, prompt hospitalization ofactive cases of tuberculosis, x-ray studiesof all contacts, and an intensiveeducational program, as well as specialstudies to locate the disease and a rehabilitationprogram. An x-ray clinic isheld in the Health Center every Fridayafternoon at one o'clock. Every citizenin Halifax County is entitled to a freex-ray examination in this clinic byappointment.(2) Special X-Ray Surveys—A MassX-Ray Survey was held in HalifaxCounty in 1946-47, during which timeapproximately 22,000 citizens were x-rayed; a special survey in Enfield, Januaryand February 1950, with 3,000 x-rayed; and a second Mass X-Ray Surveyin 1951, with approximately 25,000x-rayed.cases, and all(3) Tuberculosis Register—This registercontains the names of every knowncase of tuberculosis in Halifax County,together with all the contacts of theseother essential data pertainingto the status and progress ofthese cases of tuberculosis.(4) Home Visiting — Our PublicHealth Nurses visit all suspected casesof tuberculosis regularly, so long asthey remain at home, and also visitcontacts of tuberculosis cases in an effortto get them in to the x-ray clinicregularly for periodic checks-ups.(5) Laboratory Diagnosis—The HalifaxCounty Health Department Labora-

14 The Health Bulletin October, 19.51tory is used to assist in the TuberculosisControl Program in the regular examinationsof sputum of patients and. contacts.(6) Halifax County Sanatorium—TheHalifax County Sanatorium with twenty-eightbeds plays an important partIn the Tuberculosis Control Program inthis county. Patients are not admittedto this institution until a definite diagnosisof active tuberculosis is made.After these patients are admitted here,they are given the best attention thata county sanatorium can provide. Patientsreceive essentially the same treatmentin the Halifax County Sanatoriumas is given in the State Sanatoria,with the exception of major surgery. Dr.Herman Easom of the Eastern NorthCarolina Sanatorium has commendedthe officials in Halifax County for thesplendid work being done in our sanatorium.2. Venereal Disease—Venereal DiseaseClinics are held regularly at thefollowing points in the county:Scotland Neck, Halifax County Clinic,Monday at 1:00 P. M.Enfleld, Municipal Building, Tuesdayat 1:00 P. M.Littleton, Municipal Building, Tuesdayat 1:00 P. M.Weldon, Bank Building, Friday at9:30 A. M.Roanoke Rapids, Rosemary Clinic,Friday at 1:00 P. M.All new cases of syphilis discoveredat the present time are referred to theEastern Medical Center at Durham fortreatment. Here a complete course oftreatment isgiven over a period of tendays, whereas, in the past, an eighteenmonths course was required for theadequate treatment of syphilis in localclinics. A trained investigator interviewseach new case of a venereal diseaseto learn, if possible, the contactsand source of infection in an effort toprevent the spread and to eventuallycontrol these diseases.3. Special control measures are carriedout by the Health Department incooperation with the private physiciansin other communicable diseases, suchas, diphtheria, scarlet fever, poliomyelitis,meningitis, typhoid fever andothers. As mentioned above, the HalifaxCounty Health Department Laboratoryplays an important role in thecontrol of communicable diseases.III.ENVIRONMENTAL SANITATION"Sanitation is the quality of livingthat is expressed in the clean home,the clean farm, the clean business andindustry, the clean neighborhood, theclean community."1. The Halifax County Health Department,in cooperation with the StateBoard of Health, has an importantfunction in the supervision and controlof good handling places, such as, cafes,restaurants, meat markets, hotels, andothers. Regular inspections of thesefood handling establishments are madeby our food sanitarian, and a GradePosted in a Prominent Place in each ofthese establishments. EVERY CITIZENSHOULD TAKE CAREFUL NOTICEOF THE GRADE OF THESE FOODHANDLING ESTABLISHMENTSWHEN FIRST ENTERING THEM.Food handler's schools are conductedperiodically.2. Milk Sanitation—Our food sanitarianalso makes regular inspectionsof all milk producers and milk plantswithin Halifax County and also withinthe area from which milk is receivedinto Halifax County. Milk is one of thebest foods known to man, but it isalso one of the best culture media forbacteria known and, therefore, has tobe very closely supervised in order toprevent serious milk-borne epidemics.3. Rural Sanitation — Consultationservice is available to all citizens in thecounty on Safe Water Supplies and onAdequate Sewage Disposal Facilities.4. Insect and Rodent Control—Importantprograms are conducted by theHealth Department in the control ofrats and also in the control of mosquitoesand flies. For instance, a MalariaControl Program is conducted eachspring and summer for about fivemonths, during which time all homesin which there have been cases ofmalaria diagnosed by physicians are

October, 1951 The Health Bulletin 15Isprayed with DDT. This DDT sprayingProgram is conducted in cooperationwith the Malaria Control Division ofthe State Board of Health which furnishesa truck and the materials forthis work.IV. PUBLIC HEALTH LABORATORYSERVICESReference has already been made tothe importance of the laboratory in thePublic Health Program. The laboratoryin the Halifax County Health Departmenthas recently been added and isone of the best equipped laboratories ina local health department in the State.Public Health is a science that requiresexacting procedures in order to procurereliable results. All the laboratory proceduresare conducted free of chargeexcept for pre-marital blood tests forwhich a nominal fee is charged. Thepre-marital blood tests are required byNorth Carolina law, together withphysical examinations, before licensescan be issued.V. HYGIENE OF MATERNITY. IN-FANCY, AND CHILDHOOD, IN-CLUDING SUPERVISION OF THEHEALTH SCHOOL CHILD.I 1. Maternity and Infancy Clinics areconducted at the following points inthe county each month:tHalifax County Health Center, FirstWednesday, at 1:00 P. M.Hobgood Colored School, SecondWednesday, at 1:00 P. M.Enfield City Hall, Second Thursday,at 1:00 P. M.Scotland Neck, Halifax County ClinicThird Wednesday, at 1:00 P. M.Littleton City Hall, Fourth Tuesday,at 1:00 P. M.HoUister Colored School, FourthWednesday, at 1:00 P. M.At these Maternity and Infancy Clinicscomplete examinations are given thepatients attending these clinics.2. Immunizations—Immunizations fordiphtheria, whooping cough and smallpoxare offered free of charge to theinfants in the Maternity and InfancyClinics. The ideal time to begin immunizationfor diphtheria and whoopingcough is during infancy, at aboutthree months of age. Ideally, infantsshould be immunized for tetanus at thissame time. The child should be givena booster immunization for these threechildhood diseases and vaccinated forsmallpox at one year of age and againat six years. Approximately eighty oreighty-five per cent of the deaths fromdiphtheria and whooping cough occurduring the first three years of life;therefore, this is the period of lifewhen the protection is needed mostagainst these diseases.3. Preschool clinics are held eachyear throughout the county, at whichtime preschool children are given physicalexaminations and are given boosterdoses of diphtheria and whooping coughvaccine and vaccinated again for smallpox.North Carolina law requires allchildren to present certificates certifyingthat they have been adequately immunizedfor diphtheria and whoopingcough and adequately vaccinated forsmallpox before they can be admittedto school.4. Considerable work is done in theschools for the children, with the teachers,public health nurses, health officerand family physicians cooperatingin the program. Hundreds of physicaldefects are discovered and corrected annuallyin this School Health Program.Special programs are also conducted inthe schools from time to time, such asthe vision clinics which are held incooperation with the State Commissionfor the Blind and the Lions Clubs. AHearing Conservation Program initiatedby the Roanoke Rapids Exchange Clubis administered in the schools in cooperationwith the Division of OralHygiene of the State Board of Healthand the local dentists. The KiwanisClub and Woman's Club in RoanokeRapids sponsor a special oral hygieneprogram for Roanoke Rapids.5. Orthopedic Clinic—This clinic initiatedand sponsored by the RoanokeRapids Rotary Club meets monthly, thefirst Thursday, at the Rosemary BaptistChurch, Roanoke Rapids, at one o'clockin the afternoon. This is primarily aclinic for crippled children, but persons

16 The Health Bulletin October, 1951of all ages from this section of thestate are admitted to the clinic forfree examination and advice. The StateBoard of Health, the State Vocationaland Rehabilitation Department, theHalifax County Health Department,Halifax County Welfare Departmentand the Northampton County HealthDepartment cooperate in the operationof this clinic.HEALTH EDUCATIONVI.Health Education of the General Publicconstitutes one of the biggest problemsin Public Health, in that advancesin Medical Science and Public Healthremain far ahead of the attitudes ofthe general public. For example, it iswell known today that diphtheria couldbe controlled among children of preschoolage, provided over fifty per centof this group could be adequately immunized;however, a large percentageof parents still neglect to have theirchildren immunized at the proper age,or even at all, for this dread disease.We know, too, that most of the deathsfrom cancer could be prevented if onlycitizens in the cancer age would submitthemselves to their physicians or to aCancer Detection Clinic for thoroughphysical examinations at least onceeach year. The same thing can be saidof tuberculosis and many other conditions.Therefore, public-health departmentstoday have a big responsibilityin educating the public to theadvantages offered by present day publichealth programs. The Health Departmenthas a speakers bureau, twomotion picture projectors, a slide projector,a record player and film stripprojector with loud speaker attachment,exhibits, demonstrations andliterature on all phases of Public Healthand related subjects, all of which areused for promoting public health education.VII.MENTAL HYGIENE ANDCHRONIC DISEASES1. Principal service in this field at thepresent time is a Cancer DetectionClinic which meets the first and thirdTuesdays of each month at 8:30 A. M.,Health Center, Halifax. This clinic issponsored by the Halifax County MedicalSociety in cooperation with theHalifax County Health Department,Halifax County Cancer Unit, and theState Board of Health. In this clinic,free examinations are offered to allcitizens forty years of age and older,and this service is available not onlyto the citizens of Halifax County butalso to citizens of adjoining countiesand Southside Virginia. In addition tothis detection clinic, a special project isnow being conducted in RoanokeRapids by the Cancer Mobile Unit,furnished by the State Board of Health,whereby free x-rays of the stomachare offered to all citizens thirty-fiveyears of age and older.VIII. ACCIDENT CONTROLPlans are now underway to set up aPilot Automobile Accident Control Programin Halifax County. This programwill be extended to home, school andindustrial accidents in the near future.September 25, 1951

Buy Christmas Seals*l\>MEDICAL LIBRARY^r^y^s^ ^' OT U, C.\liyi CHAPILL HILL, N. C.wI TKis Bulletin will fee sent free to dnij ciiizen of iKe Skii-e upon request jPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 66 NOVEMBER, 1951 No. 11HelpFIGHT TB

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-President RaleighH. Ln Large, M.D Rocky MountMrs. James B. Hunt Lucama, Rt. 1John R. BENDsai, M.D Winston-SalemBin J. Lawrence, M.D RaleighA. C. Current, DJ).S GastonlaH. C. Lutz, Ph.G. Hickory6«o. Curtis Crump, M.D.AshevilleEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Appucwhitk, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionC. P. Stkvick, M.D., M.P.H., Director Epidemiology DivisionFREE HEALTH UTERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting It. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any inwhich you may be Interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitis InfantUe Paralysis Typhxis FeverCancer Influenza Venereal DiseasesConstipation Malaria Residential SewageDiabetes Measles Disposal PlantsDiphtheria Pellagra Sanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFlies Teeth Whooping CoughTuberculosisFeeble-mindedness, Mental Health and Habit TrainingThe National Mental Health ActSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal Care First Four MonthsPrenatal Letters (series of nine Five and Six Monthsmonthly letters)Seven and Eight MonthsThe Expecunt MotherNine Months to One YearInfant Care One to Two YearsThe Prevention of Infantile Two to Six YearsDiarrhea Instructions for North CarolinaBreast FeedingMid wivesTable of Heights and WeightsYour ChUd From One to SixBaby's Daily ScheduleYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageActivities of the Tuberculosis Control Section, Division of Epidemiology. _ 3Christmas Seals At Work In North Carolina 8Tuberculosis In The United States Yesterday—Today—And Tomorrow.. 10Keeping Faith 13

PU6LI5AAEDBYTAE NORTA CAROLINAA STATE B^ARD^^ B^ARD'^AEALTAIBAEALTAVol. 66 NOVEMBER, 1951 No. 11J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorACTIVITIES OF THE TUBERCULOSIS CONTROLSECTION, DIVISION OF EPIDEMIOLOGYBy William A. Smith, M.D.State Board of Health, Raleigh, N. C.1. GENERALa. The Tuberculosis Section, Divisionof Epidemiology, has been in operationsince January, 1945. During 1945, thisSection X-rayed only 18,242 persons dueto a shortage of personnel and equipment.Begirming January 1, 1946, operationsbecame more active and duringthat year over 200,000 persons wereexamined.Prior to 1947, the Section was assistedby the U. S. Public Health Service whichfurnished both equipment and personnel.In February, 1947 this assistancewas withdrawn; and since then, theState Board of Health has used its ownpersonnel and equipment in carryingout surveys. To date, over 1,400,000 personshave been X-rayed by our units;and of these it is estimated that over42,000 have been re-examined on accountof definite or suspected chest disease.Hence, over one-half the X-rayablepopulation of North Carolina has beenexamined by the State Board of Health.There are thirteen counties whichperform their own X-ray surveys and alarge niomber of counties and cities, 84in number which maintain active tuberculosisclinics. The people of NorthCarolina, therefore, are well served withX-ray diagnostic facilities.The mission of the Tuberculosis Sectionis to:(1) Conduct community-wide X-raysurveys of the general population andspecial groups. Tliis is done throughcounty or city health oflBcers.(2) Maintain a consultant nursingservice.(3) Carry out health education incormection with publicity prior to andduring community-wide surveys.(4) Maintain liaison with:1. State Institutions for better casefinding2. Director of the State Sanatoria3. State and local tuberculosis associations4. Local Health Departments forplanning tuberculosis surveys andother matters relating to tuberculosiscontrol5. The N. C. Division of VocationalRehabilitation6. The State Board of Pubhc WelfareCommunity-wide chest X-ray surveysof the general population are considered"the spearhead of the attack on tuberculosis."Such surveys have been supportedby the U. S. Public Health Servicefor several years and have beenconducted by practically aU states andterritories. It is recognized that theX-ray is the most reliable method ofdiagnosis of chest disease and offers thebest opportunities in case supervision.A tuberculosis control program is incompletewithout facilities for X-ray

examination of the general population,and such examinations are considered abasic part of any progressive tuberculosisprogram. However, the survey oflarge groups of people is of no valueunless there are facilities to re-examinethose persons who show evidence ofChest disease which are detected throughmeans of the X-ray made on the mobileunit. This Section emphasizes the reexaminationof all such persons, and in1950 our follow-up technicians were ableto re-examine, during and immediatelyafter commimity-wide siirveys, an averageof 92% of persons who requiredX-ray examination in order to establisha definite diagnosis. The re-examinationof persons with definite or suspecteddisease found during special surveys wasnot as successful as the re-examinationof those person detected with diseasein community- wide or mass surveys.This was due in a large measure to thefact that it was not practicable for usto assign a follow-up technician to thesespecial siurveys.It is our policy, in the case of community-wideor mass sui'veys, to conductthe so-called 14 x 17 X-ray clinicsfor a reasonable length of time afterthe survey has been completed. In somecases our personnel has remained in thearea for this purpose as long as twomonths after the completion of thesurvey. Generally, it is necessary for thetechnician or technicians to remain inthe area about one month. However,this is dependent on the wishes of thelocal health officer.b. EquipmentThe Tuberculosis Control Sectionowns 10 X-ray units. One of these is aportable 60 M. A. Westinghouse Machinewhich is used in the follow-up diagnosticclinics. One 70 mm. photoroentgenmachine is on loan at theDuke University Medical School Hospital,Durham and one of the sametype units is on loan at the BaptistHospital, Winston-Salem. Five 70 mm.photo-roentgen units are used for community-widesurveys and two of thesame type are used for special surveys.One of the units assigned for specialsurveys has been in use by the U. S.The Health Bulletin November, 1951Army Recruiting Service in Raleighsince September, 1950 for the examinationof Army Inductees. Other equipmentconsists of eight tractor trucks,one Chevrolet carry-all, one generator,and spare X-ray pai-ts. The Section hason loan X-ray equipment at the Wake,Mecklenburg, and Forsyth CountyHealth Departments.c. Method of AdministrationIn a community-wide survey four mobileX-ray units operate simultaneously,and a fifth unit is held in reserve to beused in case of break down. The centraloffice in Raleigh furnishes the localhealth officer a report of those personswho should be re-examined on accovmtof definite or suspected chest disease, aswell as a report of those who havenormal findings. X-ray pictures takenby the mobile imits are developed andinterpreted at the central office inRaleigh. The large picture, which isnecessary to confirm the diagnosis, isdeveloped at the site of the survey andforwarded to the Central Sanatorium,McCain, for interpretation.d. Community-wide (Mass) & SpecialSurveysCommunity-wide surveys have beenconducted in 75 counties. In one countya special survey was conducted in whichthe results were equivalent to a commimity-widesurvey and might properlybe considered a mass siu-vey. However,publicity and other measures incidentto a community-wide survey were notconducted in the county.One hundred twenty-six special surveyshave been carried out, and thenmnber of X-rays made ranged as highas 8,000. In these surveys one to twounits were used.It is our policy to schedule specialsurveys six months in advance. Community-widesurveys have been scheduledfor 1952 and 1953; and by thattime, providing there are no cancellations,one hundred counties will havebeen surveyed, eight of which will bere-surveys.e. PersonnelPersonnel totals twenty-three personswhich includes:(1) Two doctors

November, 1951The Health Bulletin(2) Eleven X-ray technicians(3) One part-time consultant nxirse(4) Seven clerks(5) Two health educators (one white,one negro).Personnel has been reduced by threetechnicians during the current year onaccount of a reduction in the budget.2. SURVEYS ACTIVITIESa. Planning activities prior to carryingout community-wide surveys consistof two pre-planning conferences. Theseare held at the local health departmentor a place designated by the local healthoflBcer. The first conference is held sixmonths prior to the survey, and thesecond conference two months prior tothe survey. Persons who are invited toattend these pre-planning conferencesare listed below:(1) The Health Officer and his staff(2) Representatives from:a. The local Medical Societyb. County Commissionersc. Board of Healthd. School Boarde. Local Tubercvilosis Associationf. Local Power Companyg. Coimty Demonstration Agentsh. County Welfare Representativesi. Ministers of the Gospelj. Members of Civic Organizationsk. Negro organizations and schools1. Any other persons interested inPublic HealthCases of tuberculosis found per 10,000persons x-rayed in Eastern and Westernareas of North Carolina by race.Area Total White Non-WhiteEastern N. O. 148.7 171.9 114.8Western N. C. 52.4 55.3 38.3b. White and Non-White Rates (practicallyall non-white limited to theNeg^o Race)It is of interest to note that of thetotal population examined by our mobileX-ray vmits there are more white personswho have tuberculosis than nonwhite.The non- white death rate is fourtimes the white death rate, and theexplanation for the low non- white morbidityis probably due to the fact thatthe non-white individuals x-rayed didnot ccmstitute a representative sampleof the population.Comparison of White and Non -WhiteTuberculosis'^ Mortality and MorbidityRates North Carolina, 1947-1949.MORBIDITY RATESWhite Rate Negro Rate Percent NecroYear Per 100,000 Per 100,000 Exceeds White1947 80.4 137.4 70.9%1948 71.0 124.4 75.2%1949 75.0 120.7 60.9%3. FIE

6 The Health Bulletin November, 1951Cases of tuberculosis found per 10,000X-rayed by occupation and race.Occupation Total White Non-WhiteIndustrialOccupations 62.3 65.0 36.9AgriculturalOccupations 168.1 204.6 121.4d. Incidence of probably active andquestionably active cases of tuberculosis.Mass surveys conducted in 1949 inwhich over 170,000 persons were examinedin Eastern and Western counties(89,836 East, 84,035 West) shows the following:Probably or Questionably Active Casesof Tuberculosis Estimated Per 10,000Persons Examined in Selected Easternand Western Counties in 1949.Total 25.6Eastern Counties 29.0Western Counties 22.0e. Hospital Cases(1) In 1949, in eight counties representingWestern, Piedmont, and Easterncounties, the rate of hospital casesfound per 10,000 examined on mass surveyswas 10.2; and the incidence of"new" hospital cases was 9.7 per 10,000.(2) In 1950, in fifteen Eastern countiesthe rate of hospital cases was 7.4 per10,000 persons examined. These figuresindicate that the tuberculosis hospitalrate is declining.f. The incidence of tuberculosis detectedby the X-ray unit on loan toDuke Hospital.These examinations included hospitaladmission, clinic cases, hospital personneland certain other selected cases.The results of the Duke Hospital Programare as follows. The rate shown includesminimal, moderate, and far advancedcases;Year

November, 1951The Health BulletinMID WEST AND WESTERN STATESWyoming 3.8Utah 6.8Iowa 8.0Nebraska 8.2Idaho 9.4SOUTHERN STATES, HAWAII ANDPUERTO RICOFlorida 18.1North Carolina 18.4South Carolina 19.8West Virginia 20.5Oklahoma 22.2Delaware 22.3Hawaii 22.8Georgia 23.8Mississippi 25.6Texas 26.0Virginia 27.5Arkansas 31.3Tennessee 33.3Maryland 33.8Kentucky 34.1District of Columbia 49.1Puerto Rico 128.1EASTERN STATESConnecticut 15.9Maine 16.2Pennsylvania 22,7New Jersey 24.3New York 25.5Death rates in cities outside theUnited States are of considerable interest.The death rates per 100,000 population01 certain large cities are tabulatedbelowCITIES OUTSIDE THEUNITED STATESLondon (1945) 87Berlin (1946) 260Vienna (1945) 257Rio de Janeiro (1942) 312Rome (1945) 176Copenhagen (1945) 49Stockholm (1945) 60Oslo (1945) 61b. Morbidity or Case RateAlthough the death rate from tuberculosishas fallen steadily for Tnanyyears, the morbidity has been consistentlyhigh. Community-wide chest surveysbegan in 1945, and these surveysmay have stimulated more accurate reporting.The number of cases reportedin 1950 was 3,653, which is the largestnumber reported in the history of theState. However, a smaller number ofcases has been reported for the first sixmonths of 1951 than was reported inthe first six months of 1950. This declinein the number of cases may be dueto variations in the reporting of casesof borderline significance. Again, it maymean that a peak has been reached fornew cases; and that from now on, therewill not be such a wide difference betweenthe number of cases found andthe niunber of deaths.c. Mortality and Morbidity by Race.The 1950 population of North Carolinawas 4,061,929. The white populationwas 2,983,110 and non-white (mostlynegroes) 1,078,819. The death rate forwhites in 1950 was 10.0 per 100,000 population,and the death rate of non-whitewas 41.8.The white morbidity rate was 69.5 per100,000 population, and the non-whitemorbidity 146.5.Both the death and morbidity ratesamong non-white is much higher thanamong the white population; but, asbefore stated, it has been found thatthe white population shows a higherdisease incidence in cormnunity-wideX-ray surveys than does the non-whitepopulation. In all probability, a selectivenon-white group comes to the mobiletmits for X-ray. The Negro Health Educatorresigned in June of this year, andanother Negro Educator has recentlybeen employed. It is hoped that moreinterest can be stimulated among theNegro Race in having X-ray examinations.5. BUDGETAppropriations both Federal and Stateare tabulated below:1950-1951Federal $234,731.00State 27,965.00Total $262,696.001951-1952Federal $176,700.00State 27,965.00Total $204,665.00

8 The Health Bulletin November, 1951The current appropriation representsa reduction of $58,031.00. Of the totalamount, $93,615 has been allotted toother units of the State Board of Healthand to local Health Departments concernedwith tuberculosis control.6. SUMMARYCommunity-wide surveys have beenscheduled for 1952 and 1953. Specialsurveys which include mental institutions,special groups such as teachersand those persons who require a healthcard; also schools, colleges and othergroups selected by local health ofBcershave been scheduled to May, 1952.The general planning, in so far ascommunity-wide surveys is concerned,is to complete the survey of those countieswho have requested surveys and aresurvey of those counties who mayapply. To date, two counties have hadcommunity-wide surveys for the secondtime. By the end of the present schedule,100 counties will have been surveyedprovided there are no cancellations,and eight of these will have hadsurveys for the second time.We expect to emphasize the survey ofmental and other State institutions, andto conduct special surveys from anepidemiological stand point. The HalifaxCounty special survey conducted in 1950is an example of successful X-ray examinationof known areas of infection.Tuberculosis is not the health problemit was 25 years ago. The majorityof cases now occur among older persons,although among young adultsit is still a leading cause of death dueto a more rapid reduction of certainother causes.Control of the disease involves casefinding, clinic, nursing, hospital, andlaboratory services, health education, rehabilitationas well as welfare servicesand vital statistics. Control will not befound, as expressed by Dr's. Audersonand Blomquist of the U.S.P.H. "in thesum of case finding, medical care andsocial assistance—it will be fovmd in thecoordination of these activities, and inthe manner in which they are knit together."CHRISTMAS SEALS AT WORK INCAROLINABy Frank W. Webster, Executive SecretaryNorth Carolina Tuberculosis AssociationRaleigh, N. C.NORTHOne of the flasher exhibits quite oftendisplayed by tuberculosis associationscarry this message, "Christmas SealsWork for You Year Round." And oncein a while associations sum up for theirreaders how the seals do this. That isthe purpose of this article.Effective tuberculosis control includesamong other things the following activities:case-finding, case supervision,treatment, rehabilitation, education andresearch. Christmas Seals are engagedin all the major tuberculosis controlactivities with the exception of treatment,which if participated in at all isdone only in an emergency, for treatmentis far too expensive to be takencare of with voluntary funds which arespent with the idea of the greatest goodfor the greatest number. Because healtheducation is the major function thatthe seals perform a look at the yearroundactivities in this phase of theprogram may suEBce, as health educationis the foundation upon which allof the other functions rest.An appropriate beginning might wellbe with the association's staff. Eachstaff member is given an opportunity tolearn the latest information in his fieldand he in turn participates in trainingprograms for other workers. Special emphasisis given to the training of workersin local associations, both through plannedprograms and in field service.Ever since seals have been employed

November, 1951The Health Bulletinas a medium for fighting tubercvilosistheir importance in working with schoolshas been recognized. Today as in thepast they are accepting challengingopportiinities to make significant contributionsto school health, using allof the schools—professional, medical,schools of nursing, colleges, high schoolsand even the elementary schools.Professional schools are being aidedin the organization and financing ofstudy programs, by providing scholarshipsor fellowships and by assistingwith special institutes, conferences andworkshops. We are particularly proud ofthe special training courses that we havesupported at the University of NorthCarolina and the North Carolina Collegeat Durham. These courses include healtheducation workshops, nurse trainingcourses and for the past two years acourse at Chapel Hill dealing with thesocial services of the tuberculous and hisfamily. Students in the medical schoolsare supplied with special literature ontuberculosis. The tuberculosis problemin the state and the program for controlare being interpreted to the students inmany of the state's colleges. Pact-findingcommittees of high school studentsare promoted to create an Interest onthe part of the students and developan appreciation for the efforts put forthin TB control. Case-finding is also promotedin high schools. In the elementaryschools the policy has been to promotegood general health practices. Thishas been attempted through in-servicetraining for teachers. Recently the materialsin the state adopted healthtextbooks have been supplemented. Theefforts in the school are cooperative,and cooperatively we are seeking togreatly expand the school health program.Mass media are employed also. Formletters go out to local associations overthe state which treat a variety of subjects.The New Letter carries a columnon "What's New" which describes neweducational materials. Abstracts andbulletins are sent to local doctors andarticles are prepared for newspapersand radio. Talks, consultation, movies,filmstrips, etc. are offered to PTA's,Civic organizations and other specialgroups throughout the state. An informationalservice is maintained andfulfills imlimited requests for advice andrecommendations on educational materials.It was stated in the outset that educationwas the keynote in every phaseof the program. In case-finding educationhas been almost the sole weaponemployed by the seals on the state level.Seals in local communities supply inmany instances the personnel, facilitiesand education for participation.In terms of cost for hospitalization ofa relapsed tuberculosis case, it is notedthat the monetary involvement is usuallydoubled or tripled; making rehabilitationa must in meeting the needs of thetuberculous. Seals supplied grants forthe initial program in one of the statesanatoriums. The Rehabilitation Committeeof the North Carolina TuberculosisAssociation holds periodic meetingsto discuss and formulate plans for improvingthe state program.Another phase of the program whichthe seals helps to make possible is thatof research. There is no phase of tuberculosiswhich is not affected by research.It was research which was responsiblefor the discovery of the specific organismwhich causes tuberculosis—the tuberclebacillus; it was research which led tothe discovery aid in the detection oftuberculosis — the X-ray; it was research,coupled with experience, whichrevealed the value of rest in tuberculosistreatment; it was through research thatstreptomycin and PAS were discoveredthat undoubtedly better drugs for tuberculosistreatment will be found. Sealssend research fimds outside of the statebut they return not only to enable researchactivities to be carried on withinour own institutions but to bring resultsfrom the thirty-five medical researchprojects in 14 states and the Districtof Columbia.The Seal Sale Campaign is the initialstep that the seals take on their complicatedjourney of relieving humansufferings. We should not think of it interms of dollars and cents alone. TheSale itself is an educational mediimi and

10 The Health Bulletin November, 1951education is the foundation upon whichthe program rests.The 1950 Seal Sale in North Carolinawas $422,204.46. Six per cent of thisamount was sent to the National Association.The other 94 per cent was keptfor work in North Carolina. Sixty-fivethousand, three hundred fifty dollarsand eighty one cents was budgeted tothe North Carolina Tuberculosis Associationfor its program and the largerportion or $331,522.17 is being spent onlocal programs in the counties where themoney was raised. Listed below are theexpenditures of the NCTA for the lastfiscal year:Health Education andInformation $30,925Rehabilitation 2,392Administration 8,296Seal Sale 8,036Research 4,222Field and Organization 16,126TUBERCULOSIS IN THE UNITED STATESYESTERDAY—TODAY—AND TOMORROWBy David T. SmithProfessor of Bacteriology, Duke Medical SchoolPast President of the National Tuberculosis AssociationDurham, N. C.(Condensed from a tallc given at the Annual Meeting of NTA,Cincinnati, Ohio, May, 1951)It is appropriate at the mid-centuryto look back at the accomplishments ofthe past 50 years, to evaluate the problemsof today and to make plans for thenext 50 years.Progress made in the control of tuberculosisis truly phenomenal whenmeasured by the decrease in the deathrate. The rate has fallen from approximately200 per 100,000 in 1900 to a provisional22.2 in 1950. At least four majorfactors have contributed to this decline:(1) constitutional resistance with geneticselection and propagation of the moreresistant individuals (2) a marked improvementin the general economiclevel of the population, (3) education ofthe public about the importance of anearly diagnosis, and (4) the detection,isolation and treatment of the opepcarriers of tubercle bacilli. It is difficult,if not impossible, to evaluate therelative importance of these four factors.Although the genetic factor is beyondour control there is evidence that it hasbeen in operation a long time in WestemEurope. The decline in death ratefrom tuberculosis as revealed by Englishstatistics began many years before Kochdiscovered the tubercle bacillus and beforemodern methods of isolation andtreatment were introduced.The importance of the economic factorcan hardly be over-emphasized and yetwe must confess our ignorance of therelative significance of environmentalsituations such as excessive labor, restrictedrecreation, inadequate housingand a poorly balanced diet. Some observationsby Robinson during World WarI and World War II suggest that a properlybalanced diet is the most importantsingle factor in increasing the resistanceto tuberculosis. A study of occupationalmortahty groups by Whitneyshowed that the tuberculosis death ratein the poorest paid day laborers wasseven times as high as among the professionalgroups. The minimal deathrate from tuberculosis was not amongphysicians, as might have been expected,but among bankers, brokers andmoney lenders.The educational campaign carried onby the National Tuberculosis Associationand its affiliates has been very effectivein removing the stigma from the diagnosisof tuberculosis and stimulating an

November, 1951 The Health Bulletin 11early investigation of suspicious symptoms;but its statistical effect in reducingthe death rate cannot be calculated.There is no doubt that the programof control stimulated by the foundersof the National Tuberculosis Associationhas played a very large part inaccelerating the decline in the deathrate which had already been initiatedby the genetic factor and reinforced byimprovement in economic conditions.However, we cannot assign a numericalor percentage value to this program. Inonly a few isolated instances is it possibleto study population groups wherethe genetic, racial and economic factorsare really comparable. In such a situationhere in North Carolina there wasa lower death rate and a progressivedecline in counties where all cases couldbe treated adequately.Tuberculosis TodayPAfter congratulating ourselves andadvertising to the public our phenomenalsuccess in lowering the deathrate of tuberculosis from 200 per 100,000to 22.2 per 100,000, we must admit thatF the death rate is not and never was anf accurate measure of the importance ofthe tuberculosis problem. This statementis true even though tuberculosis remainsthe chief cause of death from disease inindividuals between the ages of 15 and34 and kills more people than all theother infectious and parasitic diseasescombined. The deaths in 1950 of 33,557individuals from a disease which Isknown to be preventable is indeed anappalling loss of himian resources.Our chief problem today is the living,not the dead. It is the living victims oftuberculosis who suffer physical painand mental anguish, whose homes arebroken, whose families are impoverished,and finally it is the living who spreadthe disease to healthy individuals. Wedo not know the actual number of casesof tuberculosis among the citizens of theUnited States. The studies by Edwardsand Drolet in 1950 and the data compiledby Dempsey, indicate that themorbidity rate does not parellel that ofthe death rate.The value of mass radiographic surveyshas been questioned on the groundsthat the cost is excessive when dividedby the number of active cases of tuberculosisdiscovered by this method. If weare thinking only of the individual patient,the cost might be considered excessive,but the primary object of thetuberculosis control program is the detectionand isolation of the spreaders ofthe disease. One such apparently healthyspreader may easHy infect a sufficientnumber of healthy individuals to costthe public eventually himdreds of thousandsof dollars. There is also the educationalvalue of a mass survey to beconsidered. Another defect pointed outis the possibility suggested by Dr. J.Arthur Myers and supported by Dr.Robert F. Young that those who respondto an invitation to have freeX-rays are not truly representativesamples and suggests that there mightbe even more tuberculosis of a moredangerous type in those who were notreached as in those who were studied.The routine X-raying of all admissionsto hospitals and clinics is giving arate of 10-18 per 1,000 and shows manymore moderately advanced and far advancedcases than does mass surveys ofapparently healthy individuals. Calculationsbased on the most conservativefigure of 0.6 per cent indicate that morethan 40,000 unrecognized cases of tuberculosisare admitted to the generalhospitals of the United States each year.As of today, not one state or one countyin the United States has an entirelyadequate case-finding program and thisstatement includes those states andcounties where the death rate is below20 or below 10 per 100,000 as well asthose with higher rates. In all of theseareas there are unknown, imdetected,open cases which are spreading the infection.It is axiomatic that a case-findingprogram cannot fimction eflScientlywithout an adequate number of sanatoriimibeds for the hospitalization ofthe active cases discovered by the survey.One survey published in 1950 showsthat only six states had 2.5 beds perdeath and seven had less than 1. Presentcalculations indicate that the ratio

12 The Health Bulletin November, 1951should cartainly be at least 3 beds foreach annual death. The number of newbeds needed in the United States calculatedon this ratio is 39,291 or approximatelyone-third more than we have atthe present time. Even this number isa conservative figure and definitelylower than the 58,815 estimated as neededby the U. S. Public Health Servicewhich made its calculations from theaverage number of deaths in the 1940-44period.Tuberculosis TomorrowOur plans for tomorrow must be subdividedinto (1) the near future and(2) the distant futvure.It is imperative that more comprehensivecase-finding programs be formulated,adequate nimibers of sanatoriimibeds be built, and effective follow-upand rehabilitation be provided. Whenthis goal has been reached we can planthen the more distant future in whichthe tubercle bacillus will be eliminated.In the past we have used the deathrate as our guide to progress, althoughit was never an accurate measure ofthe magnitude of the problem. For thepresent we use the case incidence, ormore precisely the case report rate, althoughwe realize that many cases remainundetected and unreported. In thefuture we must focus on the amountof tuberculous infection in the populationin contrast to tuberculous disease.Tuberculous Infection is measured withthe tuberculin test. Healthy individualsharboring virulent tubercle bacilli intheir bodies have no symptoms andusually pass successfully all examinationsincluding X-rays of the chest andyet they may become in a few monthsor years new active cases capable ofspreading the disease to others. Theability to harbor living virulent tuberclebacilli in the body tissues without developingclinical tuberculosis is controlledpartly by the genetic factor andpartly by economic conditions. Of thetwo the latter is definitely more important.This was shown during WorldWar I and World War II in the populationof Western Europe where the geneticfactor has been in operation for severalthousand years and yet during thesewar years, with their accompanyingeconomic disruption, the death ratedoubled and quadrupled. Our own populationis not safe from a similar reversalof the case rate and death rateas long as Uving vinUent tubercle bacilliare being harbored in the tissues of aconsiderable proportion of the population.In 1900 in urban areas nearly 100per cent of individuals over 15 years ofage gave positive tuberculin tests andeven in rural areas 50 to 75 per cent ofadults were positive. Large scale tuberculintesting 25 years ago, as a part ofthe then current case-finding programs,showed a decline to about 75 per centin urban populations and 25 to 50 percent in rural areas. Tuberculin testingas a case-finding method was abandonedin favor of mass radiography and so welack current information regarding thetuberculinization of our people as measviredby the tuberculin test.On the basis of studies made showingtuberculin reactors in the different agegroups, from 4.2 per cent to 20.2 percent, if the extremely conservative figureof 10 per cent tuberculin reactors ismultiplied by the total popvUation of150 millions, we find that at least 15,-000,000 citizens may have virulent tuberclebacilli in their body tissues. Asmall, but unkown, percentage will developclinical symptoms and an evensmaller fraction will become disseminatorsof tubercle bacilli; but these15,000,000 remain a potential danger tothemselves and to their fellow citizens.Hence, our goal for the future must bethe reduction of the tuberculin reactorsfrom 15,000,000 to 0.Universal B. C. G. vaccination is notthe answer to the problem. The degreeof immunity induced by B. C. G. vaccinationis slight and transient. Furthermore,the artificial induction of a positivetuberculin destroys the value oftuberculin testing as a guide to our successin eliminating tuberculous infectionfrom the population. The tuberclebacillus can be completely eliminatedby our standard methods of detection,isolation and treatment provided thesemeasures are applied with sufficient

November, 1951 The Health Bulletin 13vigor. Leprosy was eliminated fromWestern Europe during the latter halfof the Middle Ages by the simple procedureof detection and isolation.Contrary to popular opinion the eradicationof tuberculosis is not "just aroundthe corner." We are scarcely half-waythrough the job and its completion willrequire as much efifort, enthusiasm, anddevotion as that expended by our predecessorsin reducing the death ratefrom 200 per 100,000 to 23 per 100,000.KEEPING FAITHBy Roland L. Garrett, PresidentNorth Carolina Tuberculosis AssociationElizabeth City, N. C.A few years ago, tliree years to beexact, an article appeared in this Bulletinbearing the same title as the oneyou are now reading— "Keeping Faith."That article, among other things, referredto the faith of an American boyawaiting a visit from Santa Claus ascompared to that of tuberculosis associationsand committees in North Carolinaawaiting the results of the ChristmasSeal Sale. In each case there wasan awarding of the faith.Looking back to 1906 the year inwhich the North Carolina TuberculosisAssociation was organized we can pointwith a degree of pride and humility toa program of tuberculosis control participatedin, promoted and in some instancesspearheaded by the North CarolinaTxiberculosis Association. That programin which the association workedin cooperation with ofQcial and othervoluntary agencies has wrought improvementin the tuberculosis situationin the state of which each of its citizenshas a right to be justly proud. I refer tothe constantly decreasing death rate;the discovery rate of 4.5 cases per deathin North Carolina as compared with 3.6for the nation, which is indicative of amuch improved case-finding program;the earlier stages in which the diseaseis detected, signifying a more intensiveeducation program; and the niunerousattempts at rehabilitation necessary tohelp a patient readjust a community living.Tuberculosis associations do not workin competition with official agenciescharged with the responsibility of controllingtuberculosis in a given area. Insteadthey are the lengthening shadowsof a group of far-seeing men determinedto organize their efforts towardsstrengthening the official agencies intheir control of this dread disease. Unhamperedby political ties and withfunds donated specifically for the purposethey have pioneered in new fieldsand opened up new avenues necessaryfor the official agency's progress. As ateam these agencies have "marshalledthe power of science, shaped the knowledgeand understanding of men in thefight against tuberculosis," and are attemptingto design a pattern for futureprograms not of control but of eventualeradication.Dr. Wade Hampton Frost expressedthe possibility of eradication in 1935when he stated, "Eradication of tuberculosisis now an expectation sufficientlywell grounded to justify shaping ourtuberculosis control program toward thisdefinite end. We have reached the stageat which the biological balance isagainst the survival of the tuberclebacillus. If this balance can be maintainedand the source of infection furtherreduced, the control of tuberculosisis within our grasp."The tuberculosis associations, local,state and national, are dedicated tohelping "maintain this balance" and atthe same time to demonstrating neweractivities in the field of tuberculosis control.These associations look forward tothe day when tuberculosis is relegatedto such an unimportant position thatefforts to control it are no longer neces-

14 The Health Bulletin November, 1951sary. It is this state of affairs and onlythis that shoiild put limitation on theirwork. In view of concerted attempts todraw all voluntary agencies into oneunited fund drive for the support oftheir program, regardless of the natureof that program, those persons (andthey are many) who want to see tuberculosiscontrol continue on its forwardmarch should "look before they leap."Look at the purpose for which the SealSale is conducted, not alone to raisefunds but to help educate the masses.Look at the need—3,368 new cases inNorth Carolina in 1950 with all thatdiscovery of cases entails education,case-finding, treatment and rehabilitation.Look at the associations' recordof progress, education, demonstration,research. See how the funds are spentaccording to the needs in the local communities—andstrengthen their faith inthe agencies that are attempting to holdthe gains that have been made in TBcontrol and carry forward to completionthe unfinished task. In the face ofdiminishing returns, which the late Dr.Milton Roseneau warned against as weapproach effective tuberculosis control,we must speed up and increase oiir efforts.The severity of tuberculosis as acontagious, crippling social destructiveagent does not warrant our turningaside to accept the fads or satisfy thewhims of those who see a little lessinterference from those who promotethe cause as a justification for settingthe controls on who should give, when,who should receiveand how and alsowhat quota.The very nature of tuberculosis demandsthat the people know. To fightthe disease with knowledge is just asimportant now as it was when thedecision to do so was made back in1904 and in 1906 when the National andState Associations were organzied respectively.The Christmas Seal Sale isan additional means of giving widespreadinformation. Can we afford tomiss any opportunity to reach the peoplewith information about tuberculosisand the part that they must play asindividuals and as commimities in itseradication?Keeping faith goes beyond the purchasingof Christmas Seals. It meansacquainting oneself with the tuberculosisproblem as it exists today. It meansknowing the facilities that are neededfor control, the use that's made of themand also the unmet needs. It meansfinding the place in which you canmake your greatest contribution—it maybe in case-finding, education, treatment,research, or rehabilitation. It may bein helping to keep your association free.Whatever the task, if we break faith,we lose "balance" and we, the people,suffer.

November, 1951 The Health Bulletin 15Deaths from Tuberculosis by County and Race: 1 950

16 The Health Bulletin November, 1951Deaths from Tuberculosis by County and Race: 1 950

C H A REiL /H I L L ,ir*»rv C .3^WMEDICAL LIBRARYU . OF N . C .I TKis Bulletin will be sent free fo anij citizen of iKe 5kite upon request IPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Ralieigh, N. C. under Act of August 24, 1912Vol. 66 DECEMBER, 1951 No. 12Uv-^'Si^^jasfc^BEAUFORT COUNTY HEALTH CENTER, WASHINGTON, N. C.

MEMBERS OF THE NORTH CAROUNA STATE BOARD OF HEALTHG. G. Dkon, MD., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighH. Lee Large, M.D Rocky MountMrs. James B. Hunt Lucama, Rt. 1John R. Bender, M.DWlnston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaH. C. LuTZ, Ph.G. HickoryGeo. Curtis Crump, M.D.AshevilleEXECUTIVE STAFFJ. W. R. Norton, M.D., Secretary and State Health OflacerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Dfrector Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionC. P. Stevick, M.D., M.PJH., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which wUlbe sent free to any citizen requesting it. The Board also has available for distributionwithout charge special literature on the following subjects. Ask for any inwhich you may be interested.Adenoids and Tonsils Hookworm Disease Typhoid FeverAppendicitis Infantile Paralysis Typhus FeverCancer Iniiuenza Venereal DiseasesConstipation Malaria Residential SewageDiabetes Measles Disposal PlantsDiphtheria PeUagra Sanitary PriviesDon't Spit Placards Scarlet Fever Water SuppliesFiles Teeth Whooping CoughTuberculosisFeeble-mindedness, Mental Health and Habit TrainingThe National Mental Health ActSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CareFirst Four MonthsPrenatal Letters (series of nine Five and Six Monthsmonthly letters)Seven and Eight MonthsThe Expectant MotherNine Months to One YearInfant CareOne to Two YearsThe Prevention of Infantile Two to Six YearsDiarrheaInstructions for North CarolinaBreast FeedingMidwivesTable of Heights and WeightsYour Child From One to SixBaby's Daily SchedvdeYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageConununicable Disease Control In Civil Defense 3Sanitarian In Civil Defense 6North Carolina Nurses In Civil Defense 11Nutrition And Food In The Civil Defense Program 13The Role Of The Health Educator In Civil Defense 14

PUBLI5AED BYTAE NRTA CAROLINA STATE 5*>ARD»/AEALTA|Vol. 66 DECEMBER, 1951 No. 12J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorCOMMUNICABLE DISEASE CONTROL INCIVIL DEFENSEC. p. Stevick, M.D., M.P.H.Director, Division of EpidemiologyNorth Carolina State Board of HealthThere seems to be considerable diflacultyin arousing interest in civil defenseon the part of most governmentalagencies and individual citizens.We in the field of public health areprobably much less affected by thislack of enthusiasm than is any othergroup because we have always had astrong feeling of urgency aboutstrengthening and improving the healthand well-being of the population, and,basically, a civil defense public healthprogram is merely a sound and efficientpeace-time program with certainchanges in emphasis and a few additionalresponsibilities. This principleapplies in particular to communicabledisease control.Commimicable disease control forcivil defense purposes requires considerationof the following pertinentfactors:Factor No. 1. Problems created bymovements of the population duringmobilization as well as following a disasterin a distant part of the country.I feel that both of these types of populationdisturbance should be consideredas part of civil defense and that theeffects of mobilization particularly requireaction now. Certain sections inthe eastern part of North Carolina arealready facing serious housing and sanitationproblems. The local ratios ofpublic health personnel to populationare becoming increasingly inadequatein those areas. The entire state is involvedat this time in the movement ofindividuals and families in connectionwith military service and industrial employment.Such conditions as these setthe stage for various communicabledisease problems. Where housing andsanitation become extremely bad wemight expect an increase in dysenteryand other enteric diseases. Venerealdiseases may increase. Meningococcusmeningitis may become a greater problem.For the state as a whole, influenza,diphtheria, and pertussis are almostcertain to increase.Factor 2. Importation of diseasesfrom foreign countries due to increasedtravel of civilian and military personnel,and the difficulty of maintainingadequate national quarantine proceduresunder emergency conditions.This is another problem we face rightnow. Up to September 1 we have hadtwelve Korean War veterans reportedas having malaria relapses after returningto this state. Smallpox is nowprevalent in many countries from whichpeople are entering the United States.Several county health officers in thisstate have been notified in recentmonths of exposed persons visiting theirareas who were subject to observationfor the duration of their incubationperiods. Yellow fever has recently ap-

peared in Central America. Encephalitisis another Korean problem which mayaffect us at any time, and many otherdiseases could be added to this list.During demobilization in 1945 NorthCarolina experienced a 123% increasein diphtheria over the previous year.Presumably, this was due to the returnfrom Germany of service men who hadbecome carriers as a result of the increaseddiphtheria incidence in Europe.Factor 3. The increase in incidenceof communicable diseases as a resultof a local disaster. In such a case, theproblems would be the same as thoseresulting from mass movement of thepopulation, but on a more extensivescale and with fewer resoxxrces to combatthem. In addition, lowered housingconditions and inadequate nutritionover a period of time are certain to befollowed by rising tuberculosis rates.Flea-borne typhus fever and plaguecould become epidemic under extremeconditions.Factor 4.The possible use of infectiousdisease agents by the enemy. ThisIs still an unknown problem. Thepractical possibilities of this type ofwarfare are limited to airborne infection,certain diseases spread by insectsand animals, and contamination ofcommon vehicles such as food andwater. There is little likelihood that anunlimited, self - propagating epidemicmight be initiated by these or othermeans except as a terminal phase ofmassive disaster.Accidental laboratory infections havedemonstrated the possibility of airtransmission of brucellosis, tularemia,Q fever, typhus fever, Rocky Mountainspotted fever, psittacosis, yellow fever,certain of the encephaUtides, coccidioidomycosis,and many others. Certainof these diseases, once introduced bymeans of air transmission, could bespread further by animal and insectvectors. Our meat, milk, and poultrysupply could be abolished in a comparativelyshort time by the introductionof rinderpest and foot-and-mouth diseaseof cattle, and Asiatic Newcastledisease of poultry. Water or food-borneThe Health Bulletin December, 1951contamination of practical importanceincludes the well known intestinal infections,and possibly chemicals or biologicaltoxins.Communicable disease control measm*esof major importance in civil defense,in addition to sanitation, are:(1) Immunization of appropriate segmentsof the population with selectedantigens; (2) Reduction of existing reservoirsof infection to as low a levelas possible; (3) Observation for andprompt reporting of any unusual changein the pattern of communicable diseaseincidence so that appropriate controlmeasures could be instituted.It wovild be impractical to administerto every adult and child all of the variovLScommunicable disease antigens thatare now available with the purpose ofproviding protection against all possibleexposures in the future. Not only wouldthis be xmsound technically and administrativelybut also the public wouldprobably offer very little cooperation atthis time to such a plan, which couldbe properly designated "Operation Pincushion"!Present recommendations are that wecontinue the current immunizationpolicy with the development of a planto immvuiize the entire populationrapidly against actual disease hazardsas they arise.Late in January 1951 a strain of influenzavirus was flown to this countryfrom England. One thousand doses ofa vaccine were prepared by one pharmaceuticalcompany in 22 days and byanother in 23 days. Previously, sixmonths to a year would have beenneeded for such preparation. It hasbeen estimated that as many as onemillion doses of this vaccine could havebeen prepared in five weeks. Thisevent, together with the fact that NewYork City immimized 5,000,000 personsagainst smallpox in approximatelytwenty-five days, probably representsthe pattern for emergency immunizationof the future against certain diseases.There is a definite nation-wide trendtoward the administration of childhoodimmunizations at an earlier age than

December, 1951The Health Bulletinformerly, and to the use of the triplecombined antigen containing diphtheriaand tetanus toxoids and pertussis vaccine.The Immunization policy publishedin the May 1951 issue of the HealthBulletin is based on this trend.A recently observed and unexpected,practical advantage of an immunizationschedule early in the first year oflife is that it probably minimizes therisk of local paralysis from concurrentpoliomyelitis. The incidence of this diseasein the age group under six monthsis extremely low.Adult immunization should be limitedto revaccination against smallpox atintervals of five to ten years, the typhoidfever only in endemic areas andamong persons exposed to known carriers,and to Rocky Mountain spottedfever for individuals working in thewoods or hunting frequently.For the present time, it is much betterpublic health practice to decreasethe time spent on ts^ihoid immunizationand increase the time spent ondiphtheria, pertussis, and tetanus immunizationsof children, and smallpoxvaccination of children and adults. Ifand when conditions deteriorate to acritical level, tsTJhoid immunization canbe begun on a mass scale and continuedas long as necessary.Renewed emphasis at this time ondiphtheria immunization would be a"mvist" in this state imder normal conditionsand is even more urgent as partof civil defense preparation. The suddenincrease of 123 per cent that wehad in 1945 as compared to 1944 wasaccompanied by only a 21 per cent increasefor the nation. The North Carolinadiphtheria rate in 1949 was 13.7cases per 100,000 population as comparedto the national rate of 5.4, orabout 2^/^ cases for us to 1 for theUnited States as a whole. In 1950 theNorth Carolina rate dropped onlyslightly to 12.3 while the national ratedropped to 3.9, or slightly over 3 casesfor us to 1 for the coiuitry. This stateranked tenth in size in the nation in1950, but our total of 503 diphtheriacases was exceeded only by Texas with900 cases. Alabama was third with 319cases. If we do nothing else in thepublic health civil defense program, wemust get busy on this diphtheria problem!Tuberculosis and the venereal diseasesare two of the most important reservoirsof infection in the populationwhich must be reduced as rapidly aspossible during the remaining period ofgrace before a possible disaster opensthe gates for a return of these diseasesto their former levels.The most important possibility remainingfor strengthening our venerealdisease control program is the developmentof cooperation with private practitionersso as to make possible contactinterviews of their patients. A NorthCarolina physician reported last yearthan an interview of one of his privates3T)hilis patients led to a series of infectedcontacts who, in turn, were interviewedwith the result that therewere located the following previouslyuntreated infections: 2 primary sj^Dhilis,5 secondary s3T)hilis, 4 chancroid, 4lymphogranuloma venereum, and 3gonorrhea. Every health departmentshould also continue to give high priorityto contact interviews of all clinicpatients. Every person infected with avenereal disease is a source of valuableepidemiological information. We shouldact upon this information with thesame urgency as we woiild evidence regardinga saboteur in our midst.As one additional method of takingevery advantage of all sources of informationregarding infected persons,it is recommended that all health departmentsreview all their existingvenereal disease clinic records as soonas possible and recall all persons needingfurther follow-up before final discharge.The tuberculosis control program canbe greatly improved in efficiency by ourtaking advantage of the informationobtained in Halifax County by Dr.Yoimg relative to the pin-pointing ofpopulation groups for x-ray surveys andthrough the experience gained from theDuke Hospital mass x-ray survey.By careful use of epidemiologicaldata, Dr. Young increased the discovery

6 The Health Bulletin December, 1951rate of active cases for a selected areaof Halifax County surveyed in January1950 to 1.8 per 1000, or exactly doublethe rate for that county in a routinemass survey in 1946. For details of Dr.Young's procedures, I refer you to hisexcellent article in the July 1951 HealthBulletin.A photofluorograph unit assigned toDuke Hospital was used in x-raying15,338 persons in 1950. These individualswere patients, visitors, and hospitalpersonnel. There were discovered 9.9cases of moderately and far advancedtuberculosis per 1000 persons. This isalmost five times as high as the rateof 2.1 moderately and far advancedcases per 1000 persons found in the160,133 non-hospital survey films takenin 1950. Every health department shouldstudy the possibility of cooperative continuoussurveys in local hospitals. Thesmall size of the hospital is not adeterring factor. Various types of arrangementscan be made to providethis service at a reasonable cost.Observation for unusual patterns ofcormnunicable disease incidence is abasic essential in preventing widespreadoutbreaks of naturally occurringdiseases and for the early detection ofpossible attempts at biological warfare.In order to make reporting somewhateasier, the Division of Epidemiology hasprepared for consideration by the StateBoard of Health a new type of reportcard to be put into use on January 1,1952, This card in intended to replacethe present three cards used to reportcommunicable diseases. At the time ofintroducing this card to local physiciansan ideal opportunity will exist forhealth departments to re-emphasizethe need for careful reporting of alldiseases presently required to be reportedand any unusual appearance ofany other disease.Observation of school and industrialabsenteeism, as well as hospital admissionsby local health officers, industrialphysicians, and private practitionerswill be of help in the early detection ofwidespread illness. This probably canbe done best by delegating a certainamount of responsibility to school, industrialand hospital personnel whohave been properly instructed as towhat information is needed.All of the states of this country arenow participating in an epidemic reportingsystem. North Carolina healthofficers were notified of this programon January 4, 1951, together with therequest that reports be submittedpromptly regarding the unusual incidenceof any disease, whether on thereportable list or not. This reportingprogram, if properly emphasized byeach state, will be of great mutualbenefit to all. For this reason everyprivate physician and public healthworker as a member of the epidemiologicalintelligence corps has a responsibilityin the reporting of diseases notonly to his own community but also tothe state and nation.SANITARIAN IN CIVIL DEFENSEBy J. M. Jarrett, DirectorSanitary Engineering DivisionNorth Carolina State Board of HealthIn considering the role of the sanitarianin Civil Defense activities, weare immediately reminded of the sanitationproblems which may be createdby any type of major disaster, such asfloods, tornadoes, fires and earthquakes,as well as destruction wrought by war.Therefore, before we get into a detaileddiscussion of the many items involvedand the suggestions which havebeen made as to emergency or remedialmeasures which would need to be takenfollowing a bombing or other destructionbrought about by an attack by theenemy, we might list the major headingsor topics which will be discussed

December, 1951The Health Bulletinlater on in this paper. Items which thesanitarian and sanitary engineer wouldbe primarily concerned would be thoserelating to (1) water supply sanitation,(2) waste disposal, both domestic sewageand industrial waste, (3) the disposalof garbage and refuse, (4) milksanitation, (5) food sanitation, (6)vector control, and (7) but not least ofthe group, the training of lay personnelto assist the sanitarians in connectionwith Civil Defense activities.The training, not only of our ownpersonnel, but of lay groups assvunesmajor importance in the considerationof this problem. When we consider, forexample, that work that was necessaryin connection with the flood of a fewyears back on the Cape Fear River, atwhich time it was necessary to requestthe assistance of sanitarians from agroup of counties throughout the Statefor work on this program, as I rememberat that time, we recruited 19 or 20men and they devoted a week or tendays to emergency work in connectionwith rural water supplies and ruralexcreta disposal. The district engineersand sanitarians from the State Boardof Health spent more time in the area,and they were of course, involved withpublic water supplies, although themajor time was devoted to those homesin the outlying areas and in the ruralsections which depended on privatewater supplies and private methods ofsewage disposal. Remember that herewere 18 or 20 men devoting a week orten days to primarily a rural problemin lowlands affected by the flooding ofthe Cape Fear River and we can visualizethe number of men who would beneeded and the enormity of the problemshould a bombing attack occur onany of our major cities or towns. Otherdisasters in the State have called forthe transfer and recruiting of thosetrained personnel available to assistwith problems that had developed. Wethought at the time that we were confrontedwith real problems. Dr. YoungI am siure, when wrestling with theflood on the Roanoke River in HalifaxCounty, was satisfied that he had quitea problem, but we have not yet had abombing.Realizing that the first thing whichwe should do was to outline and brieflydiscuss the various items mentionedabove with Civil Defense authorities inthe State, we prepared for submissionby Dr. Norton to the State Civil DefenseDirector an outline of the thingswhich, in our opinion, should be covered.I shovUd like to read this materialto you because I feel that it does, tosome extent, describe the size of theproblems with which we would be faced.Water SupplyDuring times of disaster broughtabout by war or otherwise, the healthof an entire commimity may be seriouslyaffected by an unsafe or inadequatewater supply. It is paramount, therefore,that every measure be taken toassure the safety and adequacy of suchsupplies, since water must be furnishedfor domestic and industrial purposes Inaddition to the enormously increasedquantities that may be required forfighting fires. Damage to water systemsor interruptions of power will confrontwaterworks engineers with many criticalproblems. Preparations to meetthese contingencies are essential stepsin any plan for protection of the commimityin time of war. Proceduresshould be developed for emergencyoperation and control of waterworksand adequate facilities should be providedfor making repairs, disinfectingmains, and restoring interrupted services.The State Board of Health is particularlyconcerned with the technicalmatter of emergency operation andmaintenance of plants and distributionsystems; the establishment of emergencywater service in the event of interruptionof supply; the repair anddisinfection of water mains and appurtancies;and, the augmentation ofwater supplies for fire protection. Otherinformation which is of importance inplanning to meet disaster conditionsconcerns the revision and improvementof distribution system maps and re-

8 The Health Bulletin December, 1951cords; the location of pipes and detectionof leaks; possible causes of contaminationof water mains; emergencylaboratory control, including treatmentof water contaminated by atomic, bacteriological,or chemical warfare agents;and, the physical protection of plantsand equipment from sabotage. The importanceof restoring and maintainingwater supplies following a disaster cannotbe over-emphasized. In case of abombing, it is quite possible that thepublic water supply would be madealmost totally inoperable. In such case,not only would the distribution systembe unable to deliver the quantity ofwater needed for fire fighting and otherpurposes, but it wovild also be subjectedto gross pollution from sewage andother contaminating materials.The basic considerations involved inthe supplying of water to a community,whether in normal times or in times ofdisaster, are quantity and safety. Inthis State, the State Health Departmenthas the responsibility of specifyingthe health standards of public watersupply systems and in supervising theoperation and maintenance of suchsystems. However, the waterworksoperator and local water works officialsare charged with the legal responsibilityof serving only safe water. Itwould, therefore, be logical to expectthe chief executives of local waterutilities to assume civil defense responsibilitiesfor maintaining the publicwater supply in times of disaster.It is, therefore, important that suchofficials should be given a permanentposition in the local organization establishedfor the protection of utilities.Although the Civil Defense HealthServices would not be primarily responsiblefor the quantity of wateravailable following a disaster, the pressingneed for large volumes of waterfor fire protection, regardless of source,must be recognized in developing aplan for civil defense protection.The above describes in a generalmanner the activities relating to civildefense in connection with the watersupply problem; however, such a programshould include activities in thefollowing areas:A. Coordination of the organizationand training programs with other ci/ildefense officials to insure adequatetraining in emergency and de-contaminationmeasures.B. Review modifications planned forexisting water works to insure the inclusionof de-contamination measures,specifically, the installation of emergencydisinfection equipment.C. Review modifications in waterworks operation practice to insuremaintenance of adequate free chlorineresiduals throughout the system.D. Develop improved measures againstbiological, chemical, and radio-activecontamination.E. Request the civil defense transportationservice to survey mobile equipmentthat could be used to transportany de-cantamination devices, equipment,and personnel.F. Survey all extra disinfecting equipmentavailable in the area and makeplans for maintaining it in good repair.Inventory other equipment when necessary.G. Takes steps to insure maintenanceof a safe public water supply involvingincreased use of disinfectants at regulardisinfecting stations, activation ofemergency stations, use of portable disinfectingequipment, etc.H. Insure the bacteriological safetyof water hauled to hospitals, emergencyfeeding centers, first aid stations, andother sites where such emergency waterwould be required.I. De-contamination measures shouldbe conducted by Water DepartmentStaffs. These should include testing todetect contamination of all types, followedby the proper treatment methods.J. Developing security measures forplant protection.K. Coordination of water works activitiesthroughout the State by the StateBoard of Health.Waste Disposal— Sewage and IndustrialThe proper disposal of sewage andindustrial waste is necessary for theprotection of the public health at all

December, 1951The Health Bulletintimes. During times of an emergencythis problem becomes increasingly importantsince the interruption of waterservices will render flush toilets nonoperativeand require the use of primitivemethods of excreta disposal. Also,the disruption of treatment facilitiesfor domestic sewage and industrialwastes may seriously impair the qualityof the raw water available to municipalitiesat points downstream from thedisaster. The health hazards associatedwith such problems are so importantthat supervision and sanitary inspectionby the health department personnelwill be absolutely necessary.The health department program inconnection with the above would consistof activities in the following areas:A. Cooperate in providing emergencysewage disposal facilities including pitprivies on vacant properties, can privies,excrement bags for large apartmenthouses and hotels, privies over manholes,pumping units furnishing waterto the plumbing system of apartmenthouses and hotels to remove sewagedeposits in flush toilets.B. Assistance in locating emergencyequipment for use at municipal sewagetreatment works.Garbage And Rubbish DisposalGarbage and rubbish disposal servicewill, undoubtedly, be one of the firstmunicipal services to be affected in anemergency. The urgency for resumptionof such service immediately will not begreat except at evacuation centers, hospitals,and mass feeding stations. Itwould appear that surveillance of thisservice would be the legitimate concernof health departments during an emergency.In this connection, there shouldbe investigated the establishment ofsanitary landfills for use during anemergency period. The State HealthDepartment through the Sanitary EngineeringDivision will assume the responsibilityfor instructing local healthdepartment personnel in methods ofemergency garbage storage and disposalin order that they may cooperatemore closely with the local service unitsconcerned.Insect And Rodent ControlThe health department should takethe lead in seeing that strict controlmeasures are applied in areas wherethe public health is endangered byconditions promoting the increase ofinsect and rodent vectors of disease.The areas in which control will be appliedare:1. Warehouses and stores where foodis stored and distributed.2. Areas in which bodies might beplaced for a period of time beforeburial.3. Areas designated as dumping orincineration areas for garbage or rubbish.4. Areas in which large numbers ofpit privies might be set up.5. Any area where rodent populationpresents a problem.6. Emergency hospitals, evacuationcenters, and rest areas.In the event of an open physical attack,insect and rodent control wouldnot constitute an immediate emergencyproblem, but extensive measure wouldbe necessary following the attack. Thedemolition of storage warehouses andother buildings would provide food andharborages for rodents. Disruption ofnormal garbage storage, collection, anddisposal facilities would cause increasedbreeding of both rodents and insects.Craters created by falling bombs would,in many instances, hold water and becomemosquito-breeding places. Allavailable resources, such as local healthdepartment personnel and pest controloperators and lay volunteer workersshould be organized, trained, and madeavailable to assist in the control of theinsects and rodents following attacksof this kind.An immediate emergency would b

10 The Health Bulletin December, 1951ing of lay personnel or others detailedto assist with this work.MilkIt is recognized that there is a definiteneed for the preparation of aplan of action that can be followed byState and Local Civil Defense Organizationsin developing a program ofwar-time civil defense as it relates tomilk supplies. This plan should embracethe following areas of action:1. Diversion of raw milk supply fromwar-time disaster areas to previovLslydesignated processing plants outsidethe target area and the distribution ofthe processed milk or milk productwhere needed.2. Resumption of operations by undamagedplants in target areas and therehabilitation of practically undamagedplants.3. Training of auxilary milk sanitationpersonnel and key milk processingplant personnel in methods of emergencyoperation.4. Alternate methods for the treatmentof raw milk in the event thatpasteurization of the majority of thepublic supply is not possible.5. Development of emergency standardscovering the production and theprocessing of milk.6. Education of the general public inthe dangers of consuming raw milk andin the methods for the home treatmentof such milk.7. Substitution in disaster areas andin likely target areas of powdered, condensedand evaporated milk would improvemilk supply.8. Research on emergency methodsfor the treatment and preservation ofmilk, methods for the de-contaminationof milk and milk products, includingcanned and packed products,and on the de-contamination of milkequipment.FoodThe importance of food sanitation toCivil Defense Health Services must notbe overlooked. The public health responsibilityshould be limited to thesanitation aspect of the problem. Areasin which action is needed to meet theproblem are outlined below:1. Compilation of pertinent informationand statistical data and the analysisand evaluation of such data inorder to arrive at a sound basis for adevelopment of a plan of action anda determination of requirements forpersonnel, equipment, supplies, etc.2. Preparation of a plan for each likelytarget area for the establishment ofmass feeding centers.3. Determination of requirements ofequipment and supplies needed to implementthe plan.4. Selection and training of personnelfrom the restaurant industry and of laypersonnel.5. The maintenance of adequate foodsanitation staffs in likely target areacities and near-by communities.6. Development of emergency standardscovering the preparation, handling,and serving of food and drink in disasterareas.7. Education of the general public inemergency methods to be followed inthe home for the preparation, preservation,storage, and use of foods underemergency conditions.HousingIn the establishment of emergencyhousing facilities by other units of theCivil Defense Organization, the healthdepartment would certainly be expectedto establish the standards of sanitationto be applied to such housing orshelter areas. The enforcement or applicationof any such standards establishedwould, no doubt, fall upon thelocal health authorities as one of theirlocal responsibilities. The coordinationof this activity through the SanitaryEngineering Division would be includedin our program of assistance or aid.Referring again to training, the needfor the provision of special trainingfor Civil Defense workers in allbranches of activity relating to healthand sanitation should by now be recognized.In connection with the trainingof sanitarians and lay personneland in connection with Civil Defense

December, 1951 The Health Bulletin 11measures, we have certain facilities alreadyavailable through the school ofPublic Health, Field Training Center, atthe University of North Carolina, andwe also have as a nuclear a staff oftrained people in this Division who couldassist in the training of other fieldpersonnel. Also, because of our relationshipwith the Public Health Service, weare in a position to secure and disseminatethe latest information with particularreference to special problemswhich may arise. Through our officialconnection and close relationship withother organizations, such as the NorthCarolina Section of the AmericanWater Works Association, the NorthCarolina Waterworks Operators Association,and the North Carolina Sewageand Industrial Waste Association,we are in a position to work throughthese organizations with training andas a clearing house of information forthose employed or engaged in municipalwater supply protection and sewagetreatment practices. We feel, also,that we could secure assistance fromour State Restaurant Association andother organizations of that type whowould be vitally affected and who certainlyshould be concerned with sanitationin Civil Defense.In closing, I should like to also pointout that the above brief outline coversthe items on which we feel that somedefinite decision could be reached andin which a program might be developed.We also recognize that additional problemsother than those mentioned abovemay be present in cormection withatomic warfare, biological warfare orchemical warfare. At the present time,because of the fact that informationin connection with these subjects hasbeen restricted, we are not in a positionto outline in a definite way othermeasures which should be consideredin the manner in which we have discussedthose listed above. As such informationis released for public distribution,we shall, of coiu-se, be glad towork it into outline and render whateverassistance we can in connectionwith that phase of the Civil DefenseProgram.As soon as time permits, we hope tomeet with the various local sanitationpersonnel and, if possible, develop orformulate more concrete plans basedon the above outline.NORTH CAROLINA NURSES IN CIVIL DEFENSELouise P.EastChairman, Committee on Resources for CivilMilitary Nursing NeedsN. C. State Nurse's AssociationandNurses in North Carolina are takingand teaching courses related to CivilDefense. Widespread information isneeded regarding defenses against theeffects of an atomic bomb; how to keepdisease from spreading and how to protectour food and water supplies. Eachhome owner should know how to safeguardthe home. Thousands of individualsneed to be taught safe methodsof Fii'st Aid and Home Nursing.As long as the world is in its presentchaotic state we will need Civil Defense,for modern warfare is directedas much against the home front asagainst the military. The home frontcan not retreat! It is insurance againsttotal confusion and inadequacy shouldwar come. We are told on good authoritythat our enemy is strong, thatenemy planes could reach every majorcity in the United States and that theycould carry atomic bombs, nerve gasand biologic warfare to everyone's doorstep. General Hoyt Vandenburg, Chiefof Staff of the U. S. Air Force believesthat seven out of every ten enemyplanes, attacking the United States,could get through to their targets inspite of our defending Air Force and

12 The Health Bulletin December, 1951anti-aircraft installations. That is whyCivil Defense is imperative. We can notprevent enemy attacks from happening,but we can prevent the enemy fromcompletely demoralizing us.Nurses in North Carolina, as well asnurses in all of the States, have begunthe job of instructing all nurses in theState in "Nursing Aspects of AtomicWarfare." The course includes basicinformation about policies, responsibilities,communications, organization,etc. for many civil defense services andhow nursing service would fit in withthe total over-all program.The present day Civil Defense programfor nurses is based on atomicwarfare. What will happen if atomicbombs fall on our cities? Why is anatomic bomb so destructive? How tosurvive under attack? What type of injurieswould result from an atomic attack?What is radiological contamination?In addition to information regardingatomic warfare the course includesinformation on special weaponsdefense such as biological and chemicalwarfare.Six North Carolina nurses were appointedby Governor Kerr Scott in January,1951 to attend a teachers' courseat Emory University, Atlanta, Ga.,which was given under the auspices ofthe National Security Resources Boardand the U. S. Public Health Service.The six nurses returned home and immediatelycontacted the State MedicalSociety, the N. C. State Nurses' Associationand the State Civil Defenseauthorities. A teaching manual wasformulated which was mimeographedand used in teaching two days institutesin Elizabeth City, Fayetteville,Wilmington, Durham, Wilson, Raleigh,Greensboro, Winston-Salem, Charlotteand Asheville. Three hundred and thirtythree nurses received instructionwhich prepared them to teach in turnother nurses. To date approximatelyeight hundred nurses have had thisinstruction. Many classes are beingtaught during the Pall and Wintermonths and will continue until all ofthe approximately eight thousand registerednurses in North Carolina havehad an opportimity to enlist in thisundertaking, which will be a safeguardto themselves and to the citizens of ourState. Where classes have been taughtin Hospitals, the instruction has beengiven, not only to registered nurses, butalso to practical niirses, nurses' aidesand to student nurses. Niu-ses have, inmany places, shared this informationfreely with civic groups, P.T.A. organizationsand others. The Army trainingfilms used have been shared with physicians,members of fire departments andpolice departments.Civil Defense means that you protectyourself and others if trouble comes.We dare not wait until total disasterstrikes to train personnel because ittakes time and energy and funds. Theniirses of North Carolina are indebtedto the N. C. State Nurses' Association,the State Civil Defense organizationand the State Board of Health for theirsupport in making this instruction possible.The nursing committee whichguided the program is grateful to allnurses who have given their time andtalent in teaching the classes. The jobis not complete and no one knows howmuch time is left. Instruction given atthe institutes is only a beginning andtime will bring changes in Civil Defenseplanning and development.Nurses and all interested personsshould keep up-to-date by ordering newreference material from the Superintendentof Documents, U. S. GovernmentPrinting Office, Washington 25,D. C. Local, State and National agenciesare also releasing informationwhich will help in understanding thenation's civil defense activities on alllevels and to interpret them to others.The pamphlets which the U. S. Governmenthas published and will continueto publish are especially helpfuland, since they are "official," nursescan use information from them freely;there need be no question about theirauthority. The North Carolina StateNurses' Association has a State -wideCommittee on Resoiurces for Civil andMilitary Nursing needs, and twenty-twodistrict committees. Some of the functionof these committees are

December, 1951 The Health Bulletin 131. To formulate a program for nursesin Civil Defense that is coordinatedwith medical and allied services.2. To plan for the instruction ofnurses to carry out the program.3. To secure from the twenty-twodistricts a complete roster ofnurses, both active and inactive.4. To stimulate the recruitment ofinactive nurses and arrange for refreshercourses for them.5. Recruitment of nurses for Militarynursing needs.Civil Defense is here to stay!Without Civil Defense our State andNation would be helpless should warcome.NUTRITION AND FOOD IN THE CIVILDEFENSE PROGRAM*Bertlyn BosleyChief, Nutrition SectionN. C. State Board of HealthNutrition services are defined in theUnited States Civil Defense Manualand in the Health Services and SpecialWeapons Defense Manual as being "responsiblefor planning emergency dietsand food priority systems. These dietsand food priority systems would be visedas guides for that branch of the welfareservice responsible for supply foodin an emergency period, following acivilian wartime disaster. Milk rationingwould be the most urgent consideration.""The duty of the nutrition servicesis to recommend types and amounts offood whch should be available foremergency feeding of the general populationand of special groups such asinfants, children, pregnant women, theaged and patients with illnesses requiringspecial diets. The nutrition servicewould also recommend emergency dietsfor essential Civil Defense workers."The Manual suggests further thatthe type of food served provide 2,000 to2,200 calories a day, that it "be designedto allay himger and maintain morals,that it be cheap, easy to prepare, of thekind customarily eaten by the populationand that at least one food beserved hot.These general instructions providedthe basis for the formation of a Foodand Nutrition Advisory Committee ofthe State Civil Defense Program withthe approval of the State Civil DefenseDirector.There are many groups In NorthCarolina that can contribute to nutritionand particularly to food service.The Advisory Committee was formedto permit all such organized groups interestedin Nutrition and Food to plantogether for this phase of the Civil DefenseProgram. The Committee consistschiefly of state associations, witha few exceptions. These exceptions aremade to include persons who couldprovide valuable assistance but whomight not be members of a state associationallied with food interests. Representativesappointed from the followingstate associations and agenciesare members of the Advisory Committee:Home Economics AssociationHospital AssociationHotel AssociationDietetic AssociationRestaurant AssociationSchool Food Service AssociationState Home Demonstration ServiceState Board of WelfareState Board of HealthThe American Red CrossPresented at the North CarolinaPublic Health Association Meeting onSeptember 13, 1951.

14 The Health Bulletin December, 1951College Food and Nutrition DepartmentThe North Carolina Association forHome EconomistsRepresentatives of several other groupsare to be invited to assist this Committee.It was planned that each associationor agency represented on the AdvisoryCommittee be a member of the CivilDefense Committee in his respectivestate organization, thereby becomingthe liaison agent between the AdvisoryCommittee and the State Association.The primary fvmction of the StateAdvisory Committee is to serve (1) asa clearing hovise for the various matterspertaining to nutrition and foodservice, (2) to coordinate the plans ofthe various associations, to preventduplication of effort and to provide amore efificient and effective service forthe State and (3) to provide guidancein nutrition and food matters as requestedby the State Civil DefenseDirector.The Committee can report the followingplans in progress:1. A guide on planning for food andnutrition service has been preparedfor the use of local civil defensechairmen. This is availableto civil defense chairmen throughthe oflace of the State Civil DefenseDirector.2. A register of trained dietitians isbeing secured by the Dietetic Association.(a) This group will also prepare asuggested menu guide for visein hospitals and emergencyfield centers for the injured.3. A register of Home Economistswith knowledge of quantity foodservice is being prepared by theHome Economics Association.4. The State Board of Public Welfareis preparing a register of trainedfood service managers known ineach county.5. The Restaurant Association hasappointed a committee which willgather information about suitablefood centers and personnel.6. The School Food Service Associationwill secure similar informationas it relates to school lunchrooms.(These registers will be checked forduplication and given to the StateCivil Defense Chairman. They maybe used as a beginning register bylocal directors or to supplementregisters of local directors.)7. The Red Cross has offered cooperationthrough its canteen committees.8. The State Board of Health,through a committee will help setup nutrition standards.(a) It will also provide menuguides for state hospitals andinstitutions for feeding personsimder restricted conditions,as for example if waterand fuel are not available.The Committee plans to make availablematerials which will be useful tolocal Civil Defense Directors. Requestsshould be sent to the Office of theState Civil Defense Director.THE ROLE OF THE HEALTH EDUCATOR INCIVIL DEFENSEMiss Elizabeth LovellState Board of Health, Raleigh, North CarolinaFaced with the challenge of preparingfor civil defense, public health educatorshave been somewhat like thenewcomer to a rural community whojoined the volunteer fire department.One particularly pitch-black night thealarm clanged and the new volunteerrushed to the fire. The fireman gatheredat a small house and leisurely unloadedthe fire equipment. The new

December, 1951 The Health Bulletin 15volunteer grabbed a hose and begandragging it toward the house. It wastoo dark to see much, but he couldsmell plenty of smoke. "Quick," heshouted, "turn on the water".One of the old-timers among thevolunteers called back, "Easy therefella, let the fire burn up bright beforewe go to work on it. Cain't hardlysee what we're doin' in this dark".As with the volunteer fireman, wehave ceKtainly been aware of the"smoke," and for many months therehas been a growing awareness on thepart of public health educators of theirown need for assessing their individualand collective potentials for Civil Defense.They have felt the necessity ofworking with Civil Defense leaders Inorder to acquire an accurate vmderstandingof the total Civil Defense pictureand to establish ways by whichpublic health educators may fit in thatpicture.Over the past year public health educatorshave seen themselves increasinglyinvolved in Civil Defense activities.The Director of Public HealthEducation for the North Carolina StateBoard of Health has been assisting authoritiesin Asheville in the developmentof a coordinated program involvingwide citizen-participation in planning.Public health educators are beingcalled upon almost daily by lay andprofessional community groups in connectionwith Civil Defense—for informationon CD, to help with filmshowings and discussions on CD, forthe preparation of visual aids on CD,and to organize training courses forCD. Furthermore, many public healtheducators, working in groups whichthey themselves had helped to organizefor action, have begun to see the potentialof those groups in the totalCivilDefense effort.The public health educator movementbegan in the State in 1941 whenNorth Carolina was chosen—primarilybecause of the vast cantonment areasin the State—for the first pioneer demonstrationof public health educationas a Civil Defense measure. The blockplan utilized by Civil Defense forcesthroughout the nation was first developedby a public health educator inFayetteville, North Carolina.There are today some eighty professionallytrained public health educatorsscattered throughout NorthCarolina and employed in local healthdepartments, schools, colleges. TuberculosisAssociations, the American CancerSociety, the Health PublicationsInstitute, the State Medical Society, theParent-Teachers' Association, etc. Otherpublic health educators in the Statenot currently employed professionallywould be available and willing to servein Civil Defense.State-wide, regionally, and nationallythe past fifteen months have markedthe participation of North Carolinapublic health educators in a nimiber ofhalf-day discussion sessions with CivilDefense leaders and public health educatorsfrom all over the country. Healtheducation involvement in various aspectsof Civil Defense has been citedand accented in these sessions.The role of the health educator hasbeen projected by the Research Committeeof the N. C. Association ofPublic Health Educators as follows:"After we have finished oxn trainingcoiu"ses, most of us will be starting outto interest others in doing the CivilDefense job. We will want to help peoplebecome thoroughly involved. Wewant to stimulate them to action. Wewant to give them the right kind ofinformation.As we begin, we are convinced that ifour Democracy is worth defending, itis worth defending democratically. IfCivil Defense is thrown at people, orthey are scared into doing what oneperson or a select group of personsthinks they should do, the Civil Defensestructure may be weak, autocratic,and short-lived."We have been forwarned by the CivilDefense authorities that Civil Defensemay well be a program of many years'duration.People are more likely to come outwith the most important, long-lastingplanning and action in Civil Defenseif they are introduced first to the whole

16 The Health Bulletin December, 1951picture of county needs, weaknesses,strengths and resources.Many people involved in Civil Defensein the last war considered it awaste of effort because this countrywas not actually attacked, and becausethey were not helped to see preparationfor defense as a basic means ofstrengthening their communities andcounties for democracy as well as foremergency.By using our best techniques, we canhelp people to take a look at the wholeof what needs to be done to fortify acounty or community. Then, if disasterand emergency needs disappear, peopleare not left just hanging. They stillhave reason to unite for constructive,community action. If war does notcome, they will still be geared to moveahead.The emergency of national securityand preparedness is acute. We mightfind a correlary in the story of UncleBen, a native of western Carolina.Uncle Ben had a long white beard anda car almost as old as the beard. Bendrove the jalopy with all the trust ofa doting father, but one day, as hedashed down a mountain road, thebrakes suddenly failed. It was a questionof steering the difficult trail orjumping. Uncle Ben didn't desert theship.The car flew down the mountainsidein a roaring cloud of dirt and dust.Miraculously, Ben maneuvered it downto a level road and the car shudderedto a halt, as the tires screeched andtwo blew out as a fitting end to the episode.Ben pulled what was left of hisnerves together and got out of the carto survey the damage. Just then aforester came up. "Uncle Ben," he saidsternly, "you were going too fast, doyou know that?"Uncle Ben looked his friend in theeye and replied "I never was one tohold with dilly-dallyin'."We have started the roll down themountain and when public health folksare faced with an emergency the'venever been known to hold with dillydallyin'.The people we know—ourselves included—inthis atomic era need to cultivatesufBcient courage, unity, andinitiative to meet all challenges of theage. We feel the public health educatorscan help—by helping people tocome together on their common problems,by helping people to obtain informationthey need, by working withpeople as they take steps necessary toresolve their problems, by helping themto see that only as they help themselvesand each other can democracy survive.We believe that in making our contributionto Civil Defense we can, at thesame time, build a stronger citizenryand State. We believe that Civil Defensecan be far more than an emergencystructure, that it can strengthenDemocracy itself.