ITH the opening of the numerous army cantonments throughout the United States, there arose sanitary and health problems of great magnitude, for never before in our history have so many large bodies of men been suddenly brought together from all walks of life and, as it were, thrust upon civil communities. The nearby towns rapidly increased in population, often to more than twice their normal size, and new villages sprang up almost over night. The great influx of strangers taxed the housing accommodations to the utmost and through the congestion resulting, the danger of introduction of contagious diseases was enormously increased. Not only were the soldiers likely to bring infection to the camp, but the large force of laborers required. for construction work and other strangers incident to the camp were an even greater menace to the health of the community. On the other hand the potential danger to the men of the new army from impure water and food supplies or other bad sanitary conditions in the zone around the camp was very great.

These dangers were early recognized by the sanitary authorities throughout the country and prompt measures were instituted to protect the soldiers from acquiring infection from sources without the camp and also to pro

tect the citizens of the extra-cantonment zone from the unusual dangers to which they were exposed by reason of the establishment of a cantonment in their midst.

City, state and national health authorities, working in harmony with each other and with the military authorities, have striven to maintain sanitary and health conditions in the region surrounding the cantonment up the highest possible standard.

The United States Public Health Service at the request of the different state and city authorities has detailed medical officers to most of these zones, in either an advisory or an administrative capacity, with a view both to aiding the local health authorities in meeting the emergency conditions and also to developing a health organization of the highest order to remain after the emergency shall have ceased to exist.

The direction of sanitation around Ohio's great cantonment (Camp Sherman) was turned over to the United States Public Health Service by the state, October 27, 1917. At this time the state authorities had developed a health organization and, with the aid of the American National Red Cross, which had contributed a sanitary unit, had sanitary measures well under way.

The present health organization consists of: two commissioned

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medical officers, one acting assistant surgeon and one scientific assistant detailed from the United States Public Health Service; the Chillicothe board of health with a part-time health officer and sanitary officer; an American Red Cross sanitary unit composed of one bacteriologist, two sanitary inspectors, four public health nurses, and one clerk. A bacteriological laboratory equipped by the state. and maintained by the Red Cross. is an invaluable aid in the work.

The city was found to have an excellent sanitary code but some revising was needed. Amendments have been made requiring: (a) that all privy vaults shall be screened against flies, (b) that all wells shall be adequately protected against pollution and that both public and private wells when found polluted may be condemned by the sanitary authorities, (c) that manure shall be kept in tightly constructed bins and removal effected twice weekly from March 1 to November 1, (d) that all food handlers or workers in dairies shall be subject to medical examination and protective inoculation against typhoid fever at the discretion of the board of health.

Water Supply

The city water supply is pure and abundant, coming from deep wells which are adequately protected against contamination, and the reservoir is admirably located, well constructed to prevent pollution from surface drainage and carefully policed. Repeated bacteriological examinations have shown total absence of B. coli. Notwithstanding this adequate supply of pure water, a large number of the citizens have preferred

to use water from private and public wells and cisterns. Many of these, because of insufficient safeguards against contamination from privy vaults and from surface pollution, have become badly infected. A large number have been examined bacteriologically and this work will be continued as rapidly as possible. Of the public and semipublic wells and cisterns thus far tested 54.5 percent have been found infected with B. coli and condemned. Of the purely private wells 18.1 percent show contamination. Two cases of typhoid fever. in one family undoubtedly resulted from the use of water from a well in close proximity to a defective privy vault. This well showed a high degree of pollution.

Milk

Nearly all the milk used in Chillicothe is furnished by six large distributing firms which receive their milk supply from about 100 producers. Thirty-five per cent of the milk is furnished by one company which pasteurizes the milk before distribution. Frequent bacteriological examination is made of all milk and the dairy farms are inspected and scored. In only one instance has the bacterial count and sediment test shown impure milk, and by process of elimination this. trouble was traced to one particular dairy farm and found to be due to improper methods used in milking. By insistence upon the proper precautions being employed this milk quickly conformed to the required standard. With the advent of warm weather still greater care will be necessary in order to make sure that the proper standard of purity is being maintained.

Hotels and Restaurants

One of the most difficult and at the same time most important of the problems of extra-cantonment sanitation is the regulation of eating places. There are about sixty of these in the zone around Camp Sherman, a large proportion of which have sprung up since the opening of the camp. Unless these places are kept under strict supervision not only the sanitary but also the moral conditions would fall to a low plane. Every effort is being made to keep these places up to the standard required by the sanitary code. All have been furnished with copies of sanitary regulations and frequent inspections and ratings are made.

In conjunction with the military authorities the following plan has been put in force: To all eating places which fulfill the sanitary requirements a certificate of approval is issued, which must be posted in a conspicuous place, and instructions have been given all soldiers to eat in no place which does not possess this approval certificate. To obtain one of these certificates a restaurant must not only reach the usual standards of cleanliness but all employes handling food destined for public consumption must have been examined by officers of the United States Public Health Service and found free from communicable diseases. For the examination of female employes, a female physician has been appointed. Not many cases of communicable diseases have been found but this in all probability is due to the fact that many so afflicted have left their places of employment when notified that a physical examination would be required, and now that all those seeking employment in restaurants are required to

produce a certificate of health, those who know they can not pass do not apply.

The barber shops are also required to conform strictly to the regulations prescribed in the city sanitary code as are the ice cream

and soda water establishments.

Frequent inspections, scoring and issuance of approved certificates being the means employed for this purpose. Military guards for the prevention of patronage by soldiers have at times been necessary to produce the desired results in restaurants and barber shops. Disposal of Garbage and Night Soil

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The collection and disposal of garbage has heretofore been one of the functions of the Health Department. Four men with horsedrawn carts collect the garbage from residences twice weekly, and three times a week from taurants and hotels. The garbage is dumped a short distance beyond the city limits. The defects of this method are readily apparent and steps have been taken either to have the removal of garbage turned over to the Service Director or an increased allotment of funds to the Board of Health in order that motor garbage wagons can be purchased and the garbage taken a sufficient distance from the city and burned.

A sanitary survey of the city in regard to privy vaults has been completed and shows the following:

Total number of houses in
the city...

3,810

About one-third of the houses unconnected with sewers could be connected if the owner chose to do so but the remainder are not accessible to a sanitary sewer. Orders have been issued to the property owners to clean, fill and abandon privy vaults and make sewer connections where this is possible. Those having sewer connections already and still retaining the old privy vaults are ordered to clean, fill and abandon these vaults. Those not accessible to sewers who have insanitary vaults are ordered to clean existing vaults and replace with cement water-tight vaults. These orders are being complied with as rapidly as the weather conditions permit.

Contagious Diseases

The lack of hospital facilities renders the control of contagious diseases a difficult matter, as when one of these diseases appears in a family, strict isolation in the home is often not maintained, and other members of the household. are very liable to be attacked. All cases are visited by a medical officer for the purpose of confirming diagnosis and collection of epidemiological data. The houses are placarded and contacts isolated for the period of incubation. Frequent visits are made by the nurses who give instruction in prophylaxis and report other suspicious illness among other members of the family or contacts and in emergencies give bedside care.

An unusual number of cases of measles and German measles have occurred, but scarlet fever and diphtheria have been kept well within bounds, and only two cases of cerebro-spinal meningitis have been reported. The American Red Cross laboratory has been of great

aid in controlling diphtheria as swabs are taken from all suspicious looking throats among school children and contacts, and a few carriers have thereby been found, quarantined and treated until they ceased to be carriers. The inspection of school children is performed by nurses of the Social Welfare League employed by the board of education for this purpose aided in cases of threatened epidemic by the Red Cross nurses.

Smallpox appeared the latter part of October but was held in check by isolation of patients and isolation and vaccination of contacts. An order was also issued requiring vaccination of all school children who had not been recently successfully vaccinated. Nearly 400 children were vaccinated under this order. A few isolated cases have occurred in the city and country districts since, but at no time has an epidemic threatened. The total number of cases in Ross County including Chillicothe since October 27 is eleven. A circular letter has been addressed to all

physicians urging upon them the importance of reporting every case of chickenpox in view of the difficulty often experienced in differentiating this disease from mild smallpox.

Eight cases of typhoid fever have been reported, three of which were in one family and two in another. Prophylactic inoculation against this disease has been urged

and offered free to all but this offer has not been taken advantage of. However it may later be required of all handlers of food and workers in dairies.

Venereal Diseases

The control of venereal diseases is of prime importance in extracantonment work both as regards

the effectiveness of military organizations and the serious after-effects these diseases entail.

With a view to lessening these evils a venereal clinic has been opened, where carriers of venereal diseases among the civil population will be given free treatment and hospitalized if necessary until they cease to be a menace to society. Physicians will be supplied with salvarsan and other venereal remedies without cost for use in their private practice under prescribed regulations and serological and bacteriological tests will be made upon request.

Flies and Mosquitoes

Camp Sherman is fortunate in being located in a malaria-free region, making the fight against mosquitoes of minor importance. As yet no anopheles have been found but careful search will be made for the larvae of this genus with the advent of spring. A constant and strenuous warfare against flies will be necessary, careful attention being given to the eradication of breeding places such as manure piles, garbage, etc. Manure will be required to be kept in tightly constructed bins raised one foot from the ground and removal effected twice a week.

Rural

The character of the population and the sanitary conditions in the rural districts are much above the average for country districts, but efforts will be directed toward improving conditions when necessary in regard to surface privies and water supplies unprotected from pollution. All cases of contagious disease are visited and quarantined for the required time.

There are twenty-five rural

schools in the five-mile zone around the camp and these are visited and inspected by a medical officer and a nurse. The hygienic and sanitary conditions of the schools and physical condition of the pupils are noted and steps taken to improve them when defective.

The most serious condition thus far noted has been an almost total lack of protection against smallpox, not more than one-tenth of the pupils ever having been vaccinated against this disease. Measures will be taken to produce as far as possible a smallpox-immune population in the extra-can

tonment zone.

Notification of Diseases

It goes without saying that the first essential in disease control is an accurate knowledge of the existence of disease. To secure this, all the physicians of the county have been furnished notification cards and franked envelopes and requested to report every case of communicable disease occurring in their practice, and they have cooperated very heartily in this work. Daily interchange of information as to the occurrence of communicable disease within and without the camp is maintained between the army medical authorities and the Public Health Service.

The board of health of Chillicothe has measured up to the requirements of the altered conditions in a most commendable manner and has at all times given its undivided support to any new health measure which has been recommended for adoption.

Editor's Note: Dr. Robinson's article was prepared about February 1, and all statistical information contained must be considered as of that date.