SMALLPOX: 141 cases in 27 counties with no deaths. The counties reporting smallpox present were: Bartholo-

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1 MONTHLY BULLETIN Indiana State BoardofHealth [Entered as second-class matter at the Indianapolis Postoffice] [Acceptance for mailing at special rate of postage provided for in Section 1103, Act of October 3, 1917, authorized August 9, 1918.] VOLUME XXIII. INDIANAPOLIS, AUGUST, Number 8 HUGH A. COWING. M. D. t PRESIDENT Muncie JOHN H. HEWITT. M. D VICE-PRESIDENT Terre Haute FREDERICK HENSHAW, D. D. S Indianapolis J. N. HURTY, M. D., Phar. D., SECRETARY Indianapolis CHAS. BRUCE KERN, M. D Lafayette WM. F. KING, M. D., ASST. SECRETARY AND DIRECTOR BUREAU OF VENEREAL DISEASES. H. R. CONDREY ACCOUNTANT H. M. WRIGHT REGISTRAR-STATISTICIAN WM. SHIMER, A. B., M. D..SUPT. BACTERIOLOGICAL LABORATORY J. P. NICODEMUS, M. D ASSISTANT BACTERIOLOGIST I. L. MILLER, A. B. STATE FOOD AND DRUG COMMISSIONER AND CHEMIST. V. C. STARNER, B. S ASSISTANT CHEMIST JOHN C. DIGGS, B. S SANITARY ENGINEER EDWARD C. HELWIG, M. D DIRECTOR DIVISION OF SCHOOL HYGIENE ADA E. SCHWEITZER, M. D., DIRECTOR, DIVISION OF INFANT AND CHILD HYGIENE H. W. McKANE, M. D DIRECTOR DIVISION OF TUBERCULOSIS LEO J. RAIL STATE INVESTIGATOR The MONTHLY BULLETIN will be sent to all health officers and deputies in the State. Health officers and deputies should carefully read and file each copy for future reference. This is very important, for we expect to print instructions, rules and general information, which it will be necessary for officers to preserve. CONTENTS. Page Births for August.85 Abstract of Mortality Statistics for August 85 Summary of Morbidity and Mortality for August 85 Health Officers, Attention. 86 Report of Bacteriological Laboratory for August 86 Outfits Prepared and Sent Out During August 87 Things of Interest from the Laboratory 87 Report of Food and Drug Department for August 88 Report of Division of Tuberculosis for August- 90 Report of Division of Infant and Child Hygiene for July Report of Division of Infant, and Child Hygiene for August.. 90 The Public Health Nurse and the Schools 91 Summary Weekly Disease Reports 92 Chart Showing Geographical Distribution of Deaths 93 Table 1, Deaths and Births in Indiana by Counties 94 Table 2, Deaths and Births in Indiana by Cities 95 Weather Bureau Report 96 BIRTHS FOR AUGUST," Total births, 5,537 (stillbirths excluded); State rate, Males numbered, 2,845; females, 2,692. White males numbered, 2,764; white females, 2,627. Colored births, 146; males, 81; females, 65. Stillbirths, 156; white, 147; colored, 9. The Northern Sanitary Section, population 1,042,514, reports 2,041 births; rate, The Central Sanitary Section, population 1,219,131, reports 2,283 births; rate, The Southern Sanitary Section, population 686,443, reports 1,213 births; rate, The highest birth rate, Lake and Vermillion Counties, The lowest birth rate, Ohio County, The total births to date for 1920, 43,587. The total births to date for 1919, 37,785. ABSTRACT OF MORTALITY STATISTICS FOR AUGUST, Total deaths reported, 2,397; rate, 9.8. In the preceding month, 2,538 deaths; rate, In the same month last year, 2,388 deaths; rate, 9.7. Deaths by important ages were: Under 1 year of age, 354, or 14.7 per cent of total; 1-10, 214; 10-20, 99; 65 and over, 834, or 34.7 per cent of total. SANITARY SECTIONS: The Northern Sanitary Section, population, 1,042,514, reports 790 deaths; rate, 9.1. In the preceding month, 888 deaths; rate, In the same month last year, 982 deaths; rate, 9.1. THE CENTRAL SANITARY SECTION: Population, 1,219,131, reports 1,055 deaths; rate, In the preceding month, 1,118 deaths; rate, In the same month last year, 1,069 deaths; rate, THE SOUTHERN SANITARY SECTION: Population, 686,443, reports 552 deaths; rate, 9.6. In the preceding month, 532 deaths; rate, 9.3. In the same month last year, 527 deaths; rate, 9.2. REVIEW OF SECTIONS: The Central Section presents the highest death rate, which is.6 higher than the rate for the entire state. The Central Section also presents the highest death rate for whooping cough, influenza, and cancer. The Northern Section presents the highest death rate for diphtheria, scarlet fever, lobar and bronchopneumonia, cerebro-spinal fever, poliomyelitis, and external causes.' The Southern Section presents the highest death rate for tuberculosis, typhoid fever, diarrhea and puerperal septicemia. RURAL: Population, 1,701,179, reports 1,223 deaths; rate, 8.6. In the preceding month, 1,321 deaths; rate, 9.3. In the same month last year, 1,232 deaths; rate, 8.7. URBAN: Population, 1,246,909, reports 1,174 deaths; rate, In the preceding month, 1,217 deaths; rate, In the same month last year, 1,156 deaths; rate, The cities named present the following death rates: Indianapolis, 11.6; Fort Wayne, 12.0; Evansville, 14.5; South Bend, 10.2; Terre Haute, 11.5; Gary, 8.8; East Chicago, 12.1; Muncie, 16.7; Hammond, 11.2; Richmond, 13.2; Anderson, ll.8; New Albany, 11.7; Elkhart, 11.6; Kokomo, 9.6; Michigan City, 8.7; Lafayette, 16.6; Logansport, 8.3; Marion, SUMMARY OF MORBIDITY AND MORTALITY FOR AUGUST, 1920 Gonorrhea was reported as the most prevalent infectious disease. The order of prevalence was as follows: Gonorrhea, scarlet fever, syphilis, smallpox, tuberculosis, diphtheria, typhoid, measles, pneumonia, influenza, poliomyelitis, meningitis. SMALLPOX: 141 cases in 27 counties with no deaths. The counties reporting smallpox present were: Bartholo-

2 86 MONTHLY BULLETIN, INDIANA STATE BOARD OF HEALTH. mew County, 1; Benton, 1; Cass, 4; Clay, 6; Daviess, 6; Decatur, 9; Elkhart, 14; Floyd, 1; Gibson, 1; Grant, 6; Greene, 4; Hancock, 4; Huntington, 2; Jackson, 1; Johnson, 3; LaGrange, 4; Lake, 6; Lawrence, 5; Marion, 13; Miami, 2; Shelby, 3; Spencer, 1; Steuben, 10; St. Joseph, 25; Tipton, 1; Vigo, 5; Wabash, 3. TUBERCULOSIS: 212 deaths, of which 179 were of the pulmonary form and 33 other forms. The male tuberculosis deaths numbered 105 and females 107. Of the males, 14 were married in the age period 18 to 40 and left 28 orphans under 12 years of age. Of the females, 39 were married in the same age period as above and left 78 orphans under 12 years of age. Total number of orphans made in one month by this preventable disease, 106. Number of homes invaded, 200. PNEUMONIA: 75 deaths; rate, 30.5 per 100,000. In the preceding month, 85 deaths; rate, In the same month last year, 47 deaths; rate, 19,1. Males numbered, 42; females, 33. INFLUENZA: 10 cases in 1 county, with 6 deaths. In the preceding month, 13 deaths reported. In the same month last year, 41 cases in 10 counties, with 17 deaths. TYPHOID FEVER: 69 cases in 37 counties with 32 deaths. In the preceding month 56 cases in 24 counties with 18 deaths. In the same month last year 134 cases in 43 counties with 38 deaths. DIPHTHERIA: 77 cases in 26 counties with 9 deaths. In the preceding month, 96 cases in 22 counties with 16 deaths. In the same month last year, 88 cases in 33 counties with 14 deaths. MEASLES: 63 cases in 14 counties with no deaths. In the preceding month, 274 cases in 44 counties with 4 deaths. In the same month last year, 31 cases in 14 counties with no deaths. POLIOMYELITIS: 6 cases in 5 counties with 1 death. In the preceding month, 1 case in 1 county with 1 death. In the same month last year, 4 cases in 4 counties with 3 deaths. SCARLET FEVER: 159 cases in 41 counties with 4 deaths. In the preceding month, 215 cases in 43 counties with 7 deaths. In the same month last year, 109 cases in 54 counties with 3 deaths. SYPHILIS: 154 cases in 30 counties with 8 deaths. In the preceding month, 140 cases in 23 counties with 14 deaths. GONORRHEA: 200 cases in 29 counties. In the preceding month, 154 cases in 29 counties. EXTERNAL CAUSES: 187; males, 151; females, 36. SUICIDES: 27; males, 21; females, 6. Suicide by poison, 6; by hanging or strangulation, 6; by drowning, 4; by firearms, 8; by cutting or piercing instruments, 1; by jumping from high places, 1; by crushing, 1. ACCIDENTAL OR UNDEFINED: 147; males, 118; females, 29. Poisoning by food, 1; other acute poisonings, 4; burns, conflagration excepted, 4; absorption of deleterious gases, 1; accidental drowning, 13; traumatism by firearms, 4; traumatism by fall, 11; traumatism in mines, 7; traumatism by machines, 5; railroad accidents and injuries, 25; street car accidents and injuries, 4; automobile accidents and injuries, 30; injuries by other vehicles, 6; motorcycles, 2; injuries by animals, 4; lightning, 4; electricity, lightning excepted, 4; fractures, cause not specified, 3; other external violence, 15. HOMICIDES: 13; males, 12; females, 1. Homicides by firearms, 11; homicide by cutting or piercing instruments, 1; homicide by other means, 1. HEALTH OFFICERS, ATTENTION. Delayed Birth and Death Returns. Each month the statistical department receives certificates for births and deaths that have occurred during the preceding month, which are not sent to this department in time to be tabulated with the report for the current month. With the report for, August, the following counties named below were delinquent in this matter: BIRTHS. Adams, 4; Allen, 13; Benton, 2; Blackford, 1; Boone, 5; Carroll, 5; Clark, 7; Clay, 5; Crawford, 2; Daviess, 7; Decatur, 1; Dekalb, 9; Delaware, 72; Dubois, 1; Elkhart, 3; Floyd, 5; Fountain, 5; Franklin, 2; Fulton, 1; Gibson, 6; Grant, 13; Greene, 8; Hamilton, 9; Hancock, 2; Harrison, 3; Hendricks, 1; Henry, 10; Howard, 1; Huntington, 2; Jackson, 4; Jasper, 1; Jefferson, 1; Knox, 4; Kosciusko, 3; Lake, 52; Laporte, 2; Lawrence, 3; Madison, 1; Marion, 7; Monroe, 6; Montgomery, 3; Morgan, 3; Newton, 3; Noble, 3; Orange, 4; Porter, 2; Randolph, 6; Ripley, 3; Shelby, 1; Spencer, 2; Starke, 1; St. Joseph 3; Sullivan, 8; Tippecanoe, 3; Vanderburgh, 6; Vermillion, 3; Vigo, 46; Wabash, 1; Warrick, 7; Washington, 2; Wayne, 1; Wells, 3; White, 1; Whitley, 1. DEATHS. Boone, 1; Carroll, 1; Cass, 1; Clark, 6; Clay, 2; Crawford, 2; Decatur, 1; Dekalb, 4; Delaware, 43; Elkhart, 1; Fountain, 4; Franklin, 1; Fulton, 1; Gibson, 1; Grant, 4; Greene, 1; Hamilton, 4; Hancock, 1; Harrison, 4; Hendricks, 1; Henry, 2; Howard, 1; Jackson, 1; Jay, 1; Jefferson, 2; Kosciusko, 1; Lake, 2; Laporte, 3; Lawrence, 4; Madison, 2; Marion, 10; Martin, 2; Miami, 1; Montgomery, 1; Morgan, 1; Noble, 5; Owen, 2; Pike, 1; Porter, 1; Randolph, 5; Ripley, 5; Spencer, 1; Sullivan, 2; Vermillion, 2; Vigo, 1; Wabash, 1; Warrick, 1; Washington, 2; Wayne, 3; Wells, 1. REPORT OF BACTERIOLOGICAL LABORATORY INDIANA STATE BOARD OF HEALTH FOR AUGUST, Will Shimer, M. D. Superintendent. Sputum for tubercle bacilli t Urine for tubercle bacilli Spinal fluid for tubercle bacilli Abdominal fluid for tubercle bacilli Pus for tubercle bacilli Throat cultures for diphtheria bacilli Unsatisfactory

3 MONTHLY BULLETIN, INDIANA STATE BOARD OF HEALTH. 87 Widal tests for typhoid fever......' Wassermann tests for syphilis Anticomplementary Brains for rabies Dogs:... Rotten Hogs: Blood for counts Blood for malaria plasmodia Pus for gonococci Females: Unsatisfactory Males: Unsatisfactory Sex not given: Pathological tissues Carcinoma: Carcinoma of breast ; Carcinoma of stomach Carcinoma, location not given Sarcoma: Sarcoma of nail Miscellaneous tissues Gasserian ganglions Urine for general analysis.... Feces for dysentery bacilli Feces for typhoid bacilli Intestinal worm for identification Total number examinations Guinea pigs inoculated for tuberculosis,....,, ,,,.. OUTFITS PREPARED AND SENT OUT DURING AUGUST, Tuberculosis... Diphtheria Widals Wassermans Malaria... Blood counts... Gonococci Total number. REPORT ON "NEOSALVARSAN" SENT TO THE CLINICS DURING THE MONTH OF AUGUST, 1920 U.S.P.H.S. CLINICS Anderson Brazil Columbus East Chicago Evansville Fort Wayne Hammond Indianapolis Clinic Indianapolis Hospital. Jeffersonville Kokomo Madison Marion Michigan City, Muncie New Castle South Bend Terre Haute Total to Clinics... Miscellaneous sent Total THINGS OF INTEREST FROM THE LABORATORY. The part played in the incidence of typhoid fever in Massachusetts by typhoid bacilli carriers is unknown, but the number of typhoid bacilli carriers found each year is increasing, although typhoid cases reported annually in the state are decreasing in number. The axiom of "once a carrier, always a carrier," is a good one for health officials to stand by. A series of negative fecal and urinary examinations for the typhoid bacillus should mean nothing to a board of health who are safeguarding the public health, if typhoid bacilli have been found in the excreta of a person three months or more after having had typhoid fever. It is true that occasionally the removal of a gallbladder results in negative findings. However, the mere fact that it is not true in all instances indicates that there is a chance that the bacilli are lurking in other places than the removed gallbladder, and that the person may remain a carrier indefinitely. The small number of typhoid cases reported in recent years makes the investigation of individual cases easier than formerly when the number of cases was twice as large. A more careful investigation of the individual case for the purpose of locating the source of infection is needed in order to lower the existing morbidity and mortality rate. Intensive work in studying individual typhoid fever cases and obtaining an epidemiologic case record for each case was started in Massachusetts in These investigations have been made by the local boards of health, state district health officers, nursing assistants and the epidemiolo-

4 88 MONTHLY BULLETIN, INDIANA STATE BOARD OF HEALTH. gist. By careful questioning, the data on the case records have proved of great value in most instances, although there is an opportunity for more conscientious gathering of detailed information on the case records by some boards of health. From the case records of the past three years, it is evident that more than half of the typhoid fever cases in Massachusetts are due to carriers. The clinical case caused 12.3% of our typhoid cases in 1918 and These far too numerous secondary cases were caused in households because physicians did not insist on administering, the typhoid-paratyhoid vaccine to contacts. In the search for carriers it has been surprising to find the number of carriers who have no recollection of ever having had typhoid fever. This is particularly true of older persons. However, in 1919, of the 13 carriers found, only three gave a negative typhoid history. Before the carrier campaign was started it was rather unusual to find a carrier unless he was involved in an outbreak of typhoid, but this has changed, for housewives are now proving to be the most common carriers found and usually cause only one or two cases. We know that typhoid carriers caused 132 cases, or 7.9% of the 1,665 typhoid fever cases studied in the state in 1918 and In addition many cases and small outbreaks were suspected of being caused by carriers, but were not proved. The first carrier located in Massachusetts was found in 1910 and the "carrier list" now contains 51 known carriers which are given in the accompanying table. Typhoid Cases Infected by Carriers. The 51 carriers were apparently responsible for 493 cases of typhoid fever. Of the 51 carriers, 21, or 41%, transmitted the infection to others by milk and 18, or 35%, were food handlers, infecting others probably by food. The remaining 12 carriers, or 24%, were in such occupations that they could have caused the cases associated with them, by food or contact. The intermittent nature of the carrier danger is manifest in several carriers. For instance, carrier 42 caused no known cases in 1909, 1910, or the period 1914 to 1918 inclusive, yet in 1919 there were 29 cases on his milk route and for the first time, typhoid bacilli were insolated in his excreta. Similarly, carriers 8, 21 and 29 show the same peculiarity and indicate the grave menace a carrier is during his lifetime. Milk Infection Minimized. There would be practically no milk outbreaks of typhoid fever if we could locate the carrier before the milk was infected. For this reason it would seem advisable to have all milk handlers submit to at least three agglutination tests, fecal and urine bacteriological examinations, even though they give no history of having had typhoid fever. The hunt for carriers, from a financial or health standpoint, would certainly pay from an economic point of view. Once a survey of employes was completed, it would be little trouble to keep the new employes checked up. Pasteurization. Pasteurization has undoubtedly prevented outbreaks of disease, but an outbreak of septic sore throat occurred in Massachusetts on a route on which pasteurized milk was supplied, because the milk was infected after pasteurization. There is an opportunity for infection in the process of capping the bottles and it would seem desirable to have employes doing this work examined in order to discover whether they are carriers. Summary of Carriers and Cases They Infected. Milk handlers Food handlers Cooks Maids Housewives. Nurses Icemen Nonfood handlers Total Number of Carriers. Typhoid Cases. Occupations. It is rather startling to find typhoid carriers among nurses, but two were found. One who handled milk caused 6 cases and the other infected her patient. In recent years it is the houseworker, the maid, waitress, cook or wife who causes the carrier cases and it is a good indication of the activity of the local boards of health along the line of communicable disease prevention that such carriers have been found. Length of Carrier State. The question is often asked in regard to the length of time a person may be a carrier and the only answer is "always." One carrier had typhoid 44 years prior to the first case traced to him, and others 20, 18, 16 years and shorter periods. The time interval was not obtained for all carriers because of the inability of the carrier to supply reliable data. Release Cultures in Clinical Cases. A system of examining the urine and feces of each typhoid patient at hospitals and requiring three negative findings on three specimens taken at least 48 hours apart before the discharging of the patient, brought to light three carriers in two hospitals during 1918 and This method of "release cultures" should prove of the greatest value in locating carriers before they cause infection rather than after, as does the present method. Checking of Carriers. At four-month intervals investigations are made to determine whether each typhoid carrier in the state has "kept faith" and is not engaged in an occupation in whicli food is handled or in an occupation whereby the public health would be endangered. Up to the present time, no typhoid carriers have been known to have caused an infection, since being proved carriers. REPORT OF THE DEPARTMENT OF FOOD AND DRUGS FOR THE MONTH OF AUGUST, I. L. Miller, State Food and Drug Commissioner. Inspection of refreshment stands at the county fairs in Indiana, by representatives of the Food and Drug Division. of the Indiana State Board of Health, has disclosed a vastly improved sanitary condition, generally, in these places, it was reported to I. L. Miller, Food and Drug Commissioner. Mr. Miller was informed that the state inspectors have visited practically every county and local fair in the state and that the old abuses have, for the greater part,

5 MONTHLY BULLETIN, INDIANA STATE BOARD OP HEALTH. 89 been eliminated by concessionaries. Especially was an improved condition noted at the state fair, according to the inspector's report of their activities there, Mr. Miller is advised. During the month of August Food and Drug Inspectors investigated 1,069 food-handling establishments, and of this number only two were classed as "bad," an exceptionally small percentage. Of the places directed to make immediate improvements or suffer condemnation and a denial of further commercial privileges were 41 cream stations, 6 bakeries, 6 confectionaries, 15 hotels and restaurants, and 8 soft drink parlors in the total of 100 such places. Three drug stores of the 146 inspected were graded "excellent" and 8 "poor." Of the 38 follow-up inspections of places inspected and criticized for specific delinquencies the month before 21 were found satisfactory and the cases dismissed, but 17 will be given a limited time in which to again undertake to follow out the direction of the inspectors. Of the 127 condemnation notices issued during the month, 11 were directed to bakeries, 76 to cream stations, 12 to restaurants and 7 to drug stores. Of the total 88 were found to have been improperly constructed, thus creating insanitary conditions about the premises. Of the 67 legal food samples analyzed 19 were ice cream samples, 21 "pops" and of the 39 illegal samples 9 were ice cream and 8 milk. A total of 106 analyses were made of food samples during the month. Four of the 20 drug samples were found illegal. State Inspectors co-operated during the month with representatives of the Bureau of Chemistry, United States Department of Agriculture in the seizure of drug samples which will be analyzed for violations of the federal pure food and drug law. The seizures were made in Indianapolis and Terre Haute. Apricot verdial, blackberry cordial and rye cordial were ordered withdrawn from the market because they were found to contain benzoate of soda, an unlawful preservative. One ice dealer was convicted on evidence presented by state inspectors and he was fined $10.00 and costs. The following tables indicate the work of the Food and Drug Division during August. SUMMARY OF SANITARY INSPECTIONS MADE DURING THE MONTH OF AUGUST, 1920 CLASSIFICATIONS Number Number Number Number Number Number Inspected Excellent Good Fair Poor. Bad Bakeries Bottling Works. Canning lactones... Confectioneries Creameries Cream Stations Dairies Drug Stores Fish Stores Fruits and Vegetables. Flour Mills Groceries Hotels and Restaurant Ice Cream Factories.. Ice Cream Parlors... Meat Markets Milk Plants Poultry and Produce.. Slaughter Houses Soft Drink Parlors Vinegar Plants Total v. Total Follow-up Total SUMMARY OF FOLLOW-UP INSPECTIONS MADE DURING THE MONTH OF AUGUST, 1920 Bakeries Canning Factories Cream Stations Groceries Hotels and Restaurants.. Ice Cream Parlors Meat Markets Poultry ana Produce Total Number CLASSIFICATIONS Number Number Not Inspected 0. K. Satisfactory- SUMMARY OF CONDEMNATION NOTICES ISSUED DURING THE MONTH OF AUGUST, 1920 CLASSIFICATION. No. Issued Bakeries -. Cream Stations Drug Stores Groceries Grocery and Meat Market. Hotels Ice Cream Plants Meat Markets Milk Plants Poultry Houses Restaurants Slaughter Houses Soft Drink Parlors Total Reasons for Condemnation Unsani- Improper No No. taiy Con-. Health Bread Con- struc- Certifi- Labels ditions tion cates ANALYSIS OF FOODS DURING THE MONTH OF AUGUST, 1920 Beverages Pop Lemonade Orangeade Coffee Extract- Vanilla Flour Fruit Products Jelly, Maise or Peanut Oil Maple Syrup Margarine Meat Products- Hamburger. Milk Products Milk (Dairy) Milk (Mothers) Cream Ice Cream Ice Cream Powder... Pie- Apple Blueberry Cherry Rock Candy Syrup Sugar Vinegar Total. Orders complied with and cases closed Number Number CLASSIFICATION Legal Illegal Total ANALYSIS OF DRUGS DURING THE MONTH OF AUGUST, 1920 Alcohol (Denatured) Elixir Lactated Pepsin Glycerine Linseed Oil Miss Price's Compound Morphine Sulphate Scotch Snuff Spirits Camphor Stock Tonic Tincture Ginger Unknown Drug Extract. Total Number Number CLASSIFICATION Legal Illegal Total

6 90 MONTHLY BULLETIN, INDIANA STATE BOARD OF HEALTH. LIST OF PROSECUTIONS DURING THE MONTH OF AUGUST, 1920 Names and Addresses Date Final COUNTIES of Defendants Why Prosecuted of Dis- Trial position Clark.. Geo. Oritz, Jeffersonville, Indiana. Selling ice without weighing.. Goods Ordered Withdrawn From Sale During the Month of August, bottles Apricot Cordial Contains Benzoate of Soda 1 bottle Blackberry Cordial Contains Benzoate of Soda 1 Old-69-Rye-O Cordial Contains Benzoate of Soda REPORT OF DIVISION OF TUBERCULOSIS FOR AUGUST, Dr. H. W. McKane, Director. The Tuberculosis Division was represented in Scott and Lawrence Counties during August by the automobile display, moving and stereopticon pictures, instrumental and vocal music, and lectures. On special invitation by Charles Blackburn, Field Agent of the Anti-Tuberculosis Association of Lawrence County, fifteen days were spent in that county. By request of Dr. Jas. H. Morrison, Health Commissioner of Bartholomew County, two days were given to the Columbus Fair, where many thousands visited the Tuberculosis Display and saw the moving pictures at night. Three thousand pieces of circular matter were taken. During the month there were nineteen public entertainments, twenty-one lectures to 10,000 people and 5,000 pieces of literature distributed. Two hundred eighty positive tuberculosis persons were visited or investigated. REPORT OF DIVISION OF INFANT AND CHILD HYGIENE FOR THE MONTH ENDING JULY 30, Dr. Ada E. Schweitzer, Director. This Division was busy every day of the month including Sundays. The notable event for the Division for the month was the visit to Winona Lake. The Division spent the entire week ending July 20, comprising a part of the Chautauqua carried on at that place by the Winona Lake Assembly. One hundred and thirty-seven children were examined by the Child Hygiene staff, assisted by local and visiting doctors. Most excellent help is herewith acknowledged, which was given by Mrs. Geo. B. Killen. The children examined represented 30 Indiana towns, 4 Pennsylvania towns, 3 towns each in Illinois and Ohio, 2 in Oklahoma, 1 each in California, Massachusetts, Missouri, Florida, Kentucky and New York. Four of the children examined were born on the west coast of Africa. The ages ranged from 15 years to two weeks; 4.6 per cent of the boys and 3 per cent of the girls were found below minimum standards. However, below the average there were found 14 per cent of the boys and 17 per cent of the girls; 27 per cent of the boys and 26 per cent of the girls were found above average weight. Only 2.3 per cent of the boys and 6 per cent of the girls were found to be perfectly proportioned. Women on local committees from Winona Lake and Warsaw came to assist in the work and physicians examined the children. Doctors Van Dyke and Stevens were especially helpful in this work. The director was invited to make the child, health week at Winona an annual feature of the program. Summary of the Work Done. Meetings attended Talks given by doctor By nurse By dietitian. Audience numbered Organizations addressed, Exhibits shown, days, Towns visited, Counties, Conferences held Moving picture film shown. Local talent on program times Hospitals visited... Children examined Doctors assisting Teachers and others Preachers assisting.. Homes surveyed Meetings in hotel Meetings in schoolhouse Meetings in moving picture houses. Meetings in auditorium Meetings out of doors, pictures Mileage Pamphlets distributed Charts loaned, sets Lantern slides, loaned, boxes of fifty. REPORT OF DIVISION OF INFANT AND CHILD HYGIENE FOR THE MONTH ENDING AUGUST 30, Dr. Ada E. Schweitzer, Director. The Division was active all but four days during the month. At Stilesville the evening of August 9 a lecture was given in the public square to a large audience of not less than 200. It is believed a good impression was made. At Plainfield, August 13, moving pictures and lectures were given at the Chautauqua to an audience of 500. On August 24 and 25 the Division was at Greensburg, where a carnival was held. A rest tent was established under the charge of nurses McBee, Thomas and Johnston. Visitors, 500. Dr. Schweitzer talked to the county institute; audience, 40. The Division also visited Portland, August 26, where Dr. Schweitzer gave talks in the forenoon and afternoon. Special talks were given to the County Teachers' Institute. Conference was held with the committee on child hygiene. Audience, 250. The evening talk to district doctors. A conference was held with the school authorities and health officers. The most intensive work done during the month was in Hendricks County. The campaign was undertaken on the request of the Home Economics Club. The County Demonstration Agent arranged the schedule and appointed local committees to co-operate in each township. At Brownsburg a moving picture show was used one night and the next night the schoolhouse. At Pittsboro the screen was hung on a building at the side of the public square and the health pictures were shown before and after a band concert. Pictures and talks were given also at Lizton. At the Chautauqua at North Salem and Plainfield, the direc-

7 MONTHLY BULLETIN, INDIANA STATE BOARD OF HEALTH. 91 tor, although not on the program, was given a place and also presented health pictures one evening. Talks were given at Plainfield and pictures were shown at Hadley and Clayton. Doctors Jas. C. Carter, Jas. H. Taylor and Walter Hoskins assisted the director and local physicians in examining 76 children. Several homes were surveyed at Plainfield. Health posters were designed by local artists and placed in conspicuous places to announce the coming of the Child Hygiene Division. Two and one-half days were given to child hygiene work and the examination of children at Danville. A baby contest was held under the direction of the Division Director at the County Fair and moving pictures were shown in the assembly room. Summary of Work Done. Meetings attended Talks given Audience '. Towns visited Car mileage Children examined.... Doctors assisting examinations Dentists assisting examinations Teachers and others assisting, many. Homes surveyed Literature distributed Form letters sent out Loans, slides Charts loaned Folding panels, loaned. Meetings in churches Meetings in schoolhouses Moving picture hall County court house meetings. Meetings in Masonic Temple Meetings in hotel Salem County Fair rest tent, nurse, vis Baby Legion Carnival, Greensburg, rest days, 500, by nurse and three assistants Talked to mixed audiences Talked to Teachers' Institute District Medical Societies. Moving pictures shown eight times. Number of films shown THE PUBLIC HEALTH NURSE AND THE SCHOOLS. The progress which a child makes in school depends upon his physical condition as well as his mental. Often defects of eye, ear or throat may be so serious as to retard him in his studies, and to class him as a backward child. The solution of this problem of the health of school children depends in a large measure upon the work of the school nurse. She supplements the school physician, assisting him in the physical inspection of school children, carrying his advice into the homes and explaining to the parents what the trouble is and how it can be remedied. Under the supervision of the school doctor, she carries out routine treatment of minor ailments and looks after those who have been excluded from school for purposes of treatment, and to insure an immediate return when well, so that no time may be lost from their studies. She inquires into absences in order to learn the nature of the illness, to give nursing care and to be able to report to the proper authorities if absences are caused by a contagious disease. She is invaluable in teaching children to form healthful habits to take plenty of exercise in the open air, to eat slowly and chew thoroughly, to brush the teeth regularly, to keep the body clean and to get enough sleep in well ventilated rooms. She instructs in health laws; organizes and develops health leagues, and teaches girls in the higher grades the proper care and feeding of babies, and the simple rules of hygiene. She watches the ventilation, heating, lighting and other conditions around the school buildings, and reports insanitary conditions to the superintendent of schools. When the schools are closed, she uses the summer vacation in doing infant welfare work or some other kind of community health supervision. There is a known shortage in the United States today of several thousand Public Health nurses, and one of the important phases of any health promotion programs, is to arouse the interest of qualified young women in taking the training necessary to fit them for this vital and absorbing calling. FLORIDA AUTOMOBILE TOURISTS. The Florida State Board of Health has recently adopted rules to prevent the spread of thrash and the growing of insanitary conditions through Florida by automobile tourists. This is certainly a comment upon the cleanliness of the tourists. Decent and clean tourists will not leave marked signs oi where they have camped or stopped by the roadside. The spreading of thrash and the making of insanitary conditions does not belong to and will not be done by high grade people at any time anywhere. Slovenly tourists in Florida will certainly find themselves before the courts of that state, for the rules speak with no uncertain tone. THE UNIVERSITY OF CALIFORNIA, LOCATED AT BERKELEY, CALIFORNIA, published the following syllabus of a lecture course in industrial hygiene as given at the said university. For the past six years the department of hygiene has provided a two-unit lecture course in industrial hygiene, consisting of twenty-eight lectures, supplemented with study and surveys. Following herewith is the syllabus above named. THE NURSING BOTTLE A SIGN OF NATIONAL DECAY. The bulletin of the Chicago School of Sanitary Instruction expresses the opinion that the nursing bottle is a sign of national decay. The bulletin quotes Dr. John M. Foote, who says: "Whenever a nation becomes the seat of a rich and degenerate autocracy where wealth accumulates and men decay, not only infanticide increases, but maternal nursing is replaced by artificial food and some form of the nursing bottle appears." Dr. Foote adds that the nursing bottle might well be made an ideograph for reason that the wet nurse has always been an important figure in the history of infant feeding. And among the wealthy nations of antiquity, as wet nurses become more and more in demand, men and women cast about for some mechanical means of giving food to the infant in order to replace or supplement breast feeding." After thinking over this matter, we will all probably conclude that Dr. Foote is right. "The nursing bottle is a sign of national decay."

8 92 MONTHLY BULLETIN, INDIANA STATE BOARD OF HEALTH A FOUR MONTHS' COURSE in public health nursing: The University of Colorado in a recent pamphlet announces it will give a four months' course in public health nursing under joint auspices of the University of Colorado School of Medicine and the Colorado Fuel and Iron Company. We take it that it is a sign of progress when a great commercial corporation joins with an educational institution in promoting nursing. This proves the commercial and practical value of nursing, because successful business men do not act hastily. The managers of the Colorado Fuel and Iron Company evidently understand it is good business for them to promote public health nursing. In other words, it is money in their pockets. Of course, not directly, but still it is profitable. The university will present through its professors the following subjects to the nurse students, and it is indeed worth while for anyone to read over and think about the titles as given: The Modern Public Health Movement and History of Public Health Nursing. Community Health Problems. Community Organization and Activities. Social Problems and Relief. Psychology Applied to Health. Communicable Diseases. Tuberculosis Problems. Industrial Hygiene and Occupational Diseases. Dispensary Social Service. Infant Feeding. Principles and Methods of Case Work. Medical Legislation and Vital Statistics. Child Welfare. Food and the Family Budget. Public Health Nursing in Practice with Round Table Discussion of Field Work. Moderation and regularity in eating make for both health and comfort. Chicago Bulletin. The two best tests of the degree of civilization which a country has attained are the state of its education and the attention it devotes to public health. The London Daily Chronicle. It costs the people of the United, States $180,000,000 every year to feed the country's rat population. This is exclusive of the damage and destruction caused by rats, which annually amounts to many millions more. Chicago Bulletin. August, Summary of Weekly Disease Reports From Health Officers. August, 1920 Tuberculosis Diphtheria Influenza Measles Meningitis Poliomyelitis Pneumonia Scarlet Fever Smallpox Typhoid Syphilis Gonorrhea August, 1920 Tuberculosis Diphtheria Influenza Measles Meningitis Poliomyelitis Pneumonia Scarlet Fever Smallpox Typhoid Syphilis Gonorrhea Adams Allen Bartholomew.. Benton Blackford Lawrence Madison... Marion Marshall... Martin.. Boone Brown Carroll. Cass Clark Miami Monroe Montgomery Morgan Newton Clay Clinton Crawford Daviess Dearborn Noble Ohio Orange Owen Parke Decatur Dekalb Delaware Dubois Elkhart Perry Pike Porter Posey Pulaski.. Fayette Floyd.: Fountain Franklin Fulton Putnam Randolph Ripley Rush Scott... Gibson Grant... Greene Hamilton Hancock Shelby Spencer. Starke Steuben St. Joseph... Harrison Hendricks Henry... Howard Huntington Sullivan... Switzerland.. Tippecanoe.. Tipton Union... Jackson Jasper Jay Jefferson Jennings Vanderburgh Vermillion... Vigo Wabash Warren Johnson Knox Kosciusko Lagrange Lake Laporte Warrick Washington.. Wayne Wells White Whitley Totals.... Totals.. Totals.. Totals..

9 MONTHLY BULLETIN, INDIANA STATE BOARD OF HEALTH. 93 CHART SHOWING GEOGRAPHICAL DISTRIBUTION OF DEATHS FROM IMPORTANT CAUSES FOR AUGUST, NORTHERN SANITARY SECTION. Total population Total deaths Death rate per Pulmonary Tuberculosis rate per Other forms of Tuberculosis rate per Typhoid Fever rate per Diphtheria and Croup rate per Scarlet Fever rate per Measles rate per Whooping Cough rate per Lobar and Broncho-Pneumonia rate per Diarrhoea and Enteritis (under 2 yrs.) rate per Cerebro-Spinal Fever rate per Acute Anterior Poliomyelitis rate per Influenza rate per Puerperal Septicemia rate per Cancer rate per External causes rate per Smallpox rate per CENTRAL SANITARY SECTION. Total population. Total deaths Death rate per Pulmonary Tuberculosis rate per Other forms of Tuberculosis rate per Typhoid Fever rate per Diphtheria and Croup rate per Scarlet Fever rate per Measles rate per r Whooping Cough rate per Lobar and Broncho-Pneumonia rate per Diarrhoea and Enteritis (under 2 yrs.) rate per Cerebro-Spinal Fever rate per Acute Anterior Poliomyelitis rate per 100,000 Influenza rate per Puerperal Septicemia rate per Cancer rate per 100,000. External causes rate per Smallpox rate per SOUTHERN SANITARY SECTION. Total population Total deaths Death rate per Pulmonary Tuberculosis rate per Other forms of Tuberculosis rate per Typhoid Fever. rate per Diphtheria and Croup rate per Scarlet Fever rate per Measles rate per Whooping Cough rate per Lobar and Broncho-Pneumonia rate per Diarrhoea and Enteritis (under 2 yrs.) rate per Cerebro-Spina! Fever rate per Acute Anterior Poliomyelitis rate per Influenza rate per Puerperal Septicemia rate per Cancer rate per External causes rate per Smallpox rate per INDIANA

10 TABLE 1. Deaths and Births in Indiana, by Counties and Sections, During the Month of August, (Stillbirths Excluded.) STATE AND COUNTIES. Estimated Population, Total Deaths Reported for August, Total Deaths Reported for August, Total Deaths Reported for the Year 1920 to Date. Total Deaths Reported for the Year 1919 to Same Date. ANNUAL DEATH RATE PER August, This Year. August, Last Year. IMPORTANT AGES. Under 1 Year. Age 1 to 10. Age 10 to Years and Over. Pulmonary Tuberculosis. Other forms of Tuberculosis. Typhoid Fever. Diphtheria and Croup Scarlet Fever. DEATHS FROM IMPORTANT CAUSES. Measles. Whooping Cough. Lobar and Broncho- Pneumonia. Diarrhoea and Enteritis (under 2 years) Cerebro-Spinal Fever. Acute Anterior - Poliomyelitis. Influenza. Puerperal Septicemia. Cancer. External Causes. Smallpox. Institution Deaths. Total Births. BIRTHS Rate per 1,000 Population. State of Indiana.. Northern Counties... Adams Allen Benton Blackford Carroll Cass Dekalb Elkhart Fulton '.' Grant Howard Huntington Jay Jasper Lagrange Kosciusko. Lake Laporte Marshall Miami Newton Noble :.. Porter Pulaski Starke Steuben St. Joseph Wabash Wells White Whitley Central Counties Bartholomew.- Boone Brown Clay Clinton Decatur Delaware Fayette Fountain Franklin. Hamilton Hancock Hendricks Henry Johnson Madison Marion Monroe. Montgomery Morgan Owen Parke Putnam. Randolph Rush Shelby. Tippecanoe Tipton Union Vermillion Vigo Warren Wayne Southern Counties Clark Crawford Daviess, Dearborn Dubois, Floyd Gibson Greene Harrison Jackson Jefferson Jennings Knox Lawrence Martin Ohio Orange Perry Pike Posey Ripley Scott Spencer Sullivan Switzerland Vanderburgh Warrick Washington

11 TABLE 2. Deaths and Births in Indiana, by Cities and Groups, During the Month of August, (Stillbirths Excluded.) STATE AND COUNTIES. Estimated Population, 1920, Total Deaths Reported for August, Total Deaths Reported for August, Total Deaths Reported for the Year 1920 to Date. Total Deaths Reported for the Year 1919 to Same Date. ANNUAL DEATH RATE PER August, This Year. August, Last Year. Under 1 Year. IMPORTANT AGES. Age 1 to 10. Age 10 to Years and Over. Pulmonary Tuberculosis. Other Forms of Tuberculosis. Typhoid Fever. Diphtheria and Croup Scarlet Fever. DEATHS FROM IMPORTANT CAUSES. Measles. Whooping Cough. [Lobar and Broncho- Pneumonia. Diarrhoea and Enteritis (under 2 years) Cerebro-Spinal Fever. Acute Anterior Poliomyelitis. Influenza. Puerperal Septicemia. Cancer. External Causes. Smallpox. Institution Deaths. BIRTHS. Total Births. Rate per 1,000 Population. State of Indiana. Rural.. Urban Cities of First Class Population 100,000 Indianapolis Cities of the Second Class Population 45,000 to 100,000 Fort Wayne Evansville South Bend Terre Haute... Gary..'. Cities of the Third Class Population to East Chicago Hammond Muncie Richmond Anderson New Albany Elkhart Kokomo Michigan City Lafayette Logansport Marion Cities of the Fourth Class Population 10,000 to 20,000. Mishawaka Vincennea New Castle Laporte Peru Bloomington Crawfordsville Shelbyville Huntington Elwood Bedford Brazil Jeffersonville Cities of the Fifth Class Population 5,000 to 10,000. Frankfort Columbus Goshen Wabash Connersville Clinton Whiting Washington Linton... Valparaiso! Lebanon.. Madison.. Princeton Hartford City Seymour Kendallville Mt. Vernon Greensburg... *Failed to report. Mortality of Indiana, August, (Stillbirths Excluded.) DEATHS AND ANNUAL DEATH RATES PER 100,000 POPULATION FROM IMPORTANT CAUSES. POPULATION BY GEOGRAPHICAL SECTIONS AND AS URBAN AND RURAL. State of Indiana... Northern* Counties Central Counties.. Southern Counties All Cities Over 100,000 45,000 to 100, ,000 to 45, ,000 to 20,000.. Under 10,000 Country Estimated Population Diarrhoea., D Pulmonary Other,.. Diph-, Whoop- Lobar and and Cerebro-Acute e Puer- Tuber- Forms Typhoid theria Scarlet. Measles. ing Broncho- Enteritis Spinal Anterior Influenza. peral Cancer. External Smallculosis. Tuber- Fever and Fever Cough. Pneumonia. (Under Fever. Polio- Septi- Causes. pox. culosis. Croup 2 Years.) myelitis. cemia. DeathRate. Death Rate,

12 96 MONTHLY BULLETIN, INDIANA STATE BOARD OF HEALTH. U. S. Department of Agriculture, Weather Bureau. Condensed Summary for Month of August, TEMPERATURE-IN DEGREES FAHRENHEIT. Section Average. Departure from the Normal. Temperature extremes. Station.* Highest. Date Station.* Lowest. Date. Hobart. Wheatfield.. PRECIPITATION IN INCHES AND HUNDREDTHS. Section Average. Departure from the Normal. Station.* Precipitation extremes. Greatest monthly Amount. Station.* Least monthly Amount. Jeffersonville.. Frankfort.., Always use plus sign (+) before positive departures. When more than one station reports the same, state, infigures,the number of stations, lf more than one date, use the earliest placing a dagger after it. The two best tests of the degree of Civilization which a country has attained are the state of education and the attention it devotes to the public health. The London Daily Chronicale. Right habits of living are always exchangeable at par for good health. Chicago Bulletin. It costs the people of the United States $180,000,000 every year to feed the country's rate population. This is exclusive of the damage and destriction caused by rate, which annually amounts to many millions more. Chicago Bulletin. Moderation and regularity in eating make for both health and comfort. Chicago Bulletin.