Before touching upon the more detailed methods of prevention, the subject of the transmission of scarlet fever through milk must be touched upon. A comparatively large number of outbreaks transmitted in this way have been recorded. I know of no such instances in Ohio, but I think this is rather due to the fact that my investigations have included a rather small number of scarlet fever outbreaks, than because milk has not been a medium of transfer in our state. Local health departments should check off against each dairyman the number of cases of typhoid fever, diphtheria and scarlet fever occurring among his patrons. By this method any unusual prevalence upon a milk route will be instantly detected and measures taken accordingly. The laws of Ohio require that each case of scarlet fever shall be quarantined until the attending physician certifies to the health officer that the patient is no longer capable of communicating the disease. The health officer must then disinfect the house, and the quarantine must remain for ten days following disinfection if there are inmates who are of susceptible age who have not had the disease. Children who are exposed but live in other homes must be quarantined for ten days from the last possible exposure, if they are not immune by reason of a previous attack. When a case is quarantined the working members of the family need not be confined if the patient is properly isolated and the work engaged in does not necessitate contact with children or the milk supply. In isolating a case particular attention should be paid to the discharges of the mouth and nose, and all articles contaminated by these discharges should be disinfected or destroyed before being removed. Terminal disinfection with formaldehyde should be practiced. (This is probably useless, but is still required.) The use of gowns, proper disinfection of the hands and thermometer, and similar precautions should be taken by physicians attending cases. "The physician may find the necessary precautions and disinfection to be irksome, but they should not be shirked in justice to his other patients and the community." (Rosenau). Personal prophylaxis may be dismissed briefly. Contact with cases and with children with sore throats should be avoided. Children should be taught to avoid the common drinking cup, the towel used in common, and the error of placing articles other than food in the mouth. The use of vaccines made from cultures of the streptococcus isolated from cases have given good results in protecting children from the disease. Moser's polyvalent antistreptococcus serum has been used in the treatment of the disease but no conclusions as to its efficacy can be drawn at the present. The treatment of scarlet fever may be dismissed with a word of warning as to the disastrous results that may occur if the patient is allowed to get up too early. In such cases dangerous complications such as nephritis are more liable to occur. In a contagious disease hospital I attended for several months, great care was taken to see that the patients remained in bed until convalescence was assured, and the attending physicians were equally solicitous as to the measures to prevent nephritis and disease of the ear drum. Six weeks in bed was not unusual for an ordinary case of scarlet fever. The laws of Ohio do not specify any minimum period for the detention of scarlet fever cases. Some city health departments require four or five weeks as a minmum, and thirty days is acceptable, providing desquamation is complete and there are no mucous complications. It is to the interest of patients as well as to the public at large to enforce detention for at least this period. Finally, no campaign for the prevention of scarlet fever can be successful without the aid of a well-organized system of school inspection. This should be carried out by physicians or by public health nurses in charge of physicians. By this means and with the cooperation of the teaching force, not only will the success of the general campaign be assured, but interruptions to school work will be avoided. To sum up, the prevention of scarlet fever depends upon the following factors: 2. 3. 4. Skillful and conscientious physicians. Public health nurses to visit cases. 8. Skill and care in the treatment of cases to avoid the various The physician is intimately concerned with nearly all these factors and it is with pleasure that Í acknowledge the high stand taken by various medical societies of Ohio in furtherance of the campaign to improve the public health. The increasingly accurate and prompt reporting is an evidence of the cooperation of physicians and the effectiveness of health departments. HEALTH OFFICERS WANTED. The California State Board of Health does not stop at the state's border line in seeking district health officers. The examination set for June 30, 1917, was open to "all American citizens between the ages of 21 and 60" who meet the requirements laid down by the board. Secretaries of boards of health throughout the country were requested to call the examination to the attention of any physicians who might be interested. The state civil service commission will have the United State Public Health Service conduct the examination as a board of special examiners. The successful applicants will constitute an eligible list from which to fill six positions as dictrict health officers. The salary is $3000 a year. Candidates are required to be holders of a degree in medicine, sanitary engineering or public health work, and must give their entire time to the work. THE OHIO PUBLIC HEALTH JOURNAL. 247 THE SANITARY ASPECTS OF SWIMMING POOLS. L. H. VAN BUSKIRK, Director Division of Hygienic Laboratories, Ohio State Department of Health. Swimming has always had a fascination for a large proportion of the population and few boys at least grow to manhood without acquiring the ability to swim. Boys, wherever they are located, will attempt to find a suitable "swimming hole" where they may practice the arts of swimming and diving. Few communities are located on lakes or upon streams where suitable bathing places are available, for with the development of cities and the manufacturing industries, the problem of contamination by sewage and manufacturing waste is encountered. Since large volumes of these wastes are disposed of by dilution, conditions favorable for bathing are not obtained and other means of furnishing this form of recreation must be secured. The encouragement of bathing is an important health problem. It must not be considered, however, that the ordinary swimming bath can be considered a very effective means of cleansing the body. Hot soap baths must be utilized for this purpose. Swimming baths are considered as being beneficial more from the standpoint of athletics and exercise than from their ability to cleanse. After having seen boys swimming in the Cuyahoga River at Cleveland, Mill Creek at Cincinnati, the Maumee River at Toledo, and the Scioto River at Columbus, all of which streams are more or less seriously contaminated, the demand for municipal and free bathing resorts suitably located and protected is realized. It is difficult to so locate natural bathing resorts so that they may at all times be free from contamination. The desire also for all year swimming has brought into existence the indoor swimming pool. Such pools can be supplied with a water of satisfactory sanitary quality. It must not be thought however that by installing swimming pools which can be supplied with a pure water supply, that all danger of infection is thereby obviated. Extreme care must be used in the construction and the operation of all such conveniences. The problem is not small, owing to the fact that swimming pools ars now being constructed in practically all the gymnasia, in many hotels, clubs and schools. Some of these are constructed under cover, while a few are not. In the natural bathing places it is necessary to protect particularly against sewage contamination, altho the pollution of the water due to the bathers themselves is not to be neglected. In the ordinary. swimming tank or pool, however, practically the only source of contamination is from the material which is carried to the pool by the bathers. Practically all communities where such pools are used are provided with a satisfactory public water supply, from which the pools are filled. When the pool is first placed in operation the water is of satisfactory sanitary quality and is not only fit for bathing but can also be considered as suitable for drinking purposes. As soon as use is made of the pool the water begins to receive its contamination and this contamination is increased as long as there is no attempt made to either disinfect the contents of the pool or to replace the water. The impurities introduced by the bathers ordinarily consists of hair, particles of skin, fibers from the bathing costume, soluble organic matter and salts, bacteria and other microscopical organisms. The insoluble matters on settling, accumulate in the bottom of the pool and give it an unclean appearance. The salts and certain other materials which are soluble are probably harmless in themselves but provide an excellent medium for the development of bacteria and other micro-organisms. Unquestionably the bacterial content of the water is of most importance since these bacteria may directly affect the health of the persons using the pool. It has been demonstrated that bacteria are commonly introduced into the water by the bathers, and also that there is a very marked multiplication of the bacteria when the pool is not in use. Numerous reports have been made of infectious diseases which it is attributed have been caused by an infection received in the swimming pools. Skutch reports an epidemic of vulvo-vaginitis that spread to two hundred and thirty-six girls who used the swimming pool at Posen. Hertzka and Sticker demonstrated experimentally that bacillus prodigiousus can pass into the vagina of a woman while swimming. In 1908 Cobb reported certain cases of nasal infection which he claimed to have traced directly to the use of swimming pools. Burrage states that epidemics of colds and sore throat are apparently traceable to the use of the swimming pool at Purdue University. Bunker states that at Brown University no epidemic of any sort can be attributed directly to an infection of the pool, but that affections of the nose and ear were occasionally found among the members of the swimming team. Lewis has noted a prevalence of grippe, colds, sore throat and some cases of pneumonia at Northwestern University, which appeared to be restricted to the users of the swimming pools. Whipple notes that similar infections were found among the users of the Brooklyn Polytechnic swimming pool. Fehr and Schultz reported cases of conjunctivitis. Fehr, Schultz, Cobb, Jager, Pfuhl, shafter, Linhartz, Cline, Schultz, Gresher, Witte, Kirchner, Hartog, Bassin, Maier, and Baginsky have all reported cases of typhoid fever. When it is realized that approximately three-tenths of one per cent of a population are typhoid carriers it will not be surprising to find that a large number of cases of typhoid fever can be attributed to an infection which may be secured in swimming pools. As it has been realized that many infections are carried probably thru swimming pools, there has been an attempt made to secure a more satisfactory construction and also a safer plan for the operation of such pools. Many pools have been constructed of reinforced. concrete, unlined. These were dark colored and it is with difficulty that one can observe the physical condition of the pool. With modern construction, however, practically all the pools are constructed with reinforced concrete, lined with a white tile. At the upper edge of the pool a trough is provided in order to catch any wash water from the floor surrounding the pool, to care for any overflow and which is also used for the expectoration of the bathers. Mannheimer who has examined thirty-five such pools, has found only fifteen provided with such troughs. In a questionnaire sent out by the Ohio State Board of Health to all the other State Departments of Health it is interesting to note that there were received a total of thirty-six replies from the total of forty-eight states. Information was desired from each health department regarding the transmission of various diseases thru the use of the swimming pool. Twenty-five states replied that they possessed no information concerning the subject. Eleven states reported information concerning various infections which may be classified as follows: Two State Departments of Health have found ear infections; two, throat infections; one, typhoid; three, eye infections; and three, skin eruptions. Certainly with this information at hand and the reports of infections as given by the various observers cited above, more serious consideration should be given to the question of swimming pool sanitation. Now various methods are in use as regards the maintenance of swimming pools. Certain pools are filled but four times a year, others are emptied and refilled twice each week and at least one is refilled and cleaned each day. Most equipments which are installed at the present time provide for the continual removal of a portion of the water which is treated with a coagulant, passed thru a filter and returned to the tank. Mannheimer states that of thirty-five swimming pools from which he obtained statistics, one was refilled every day, twenty-six were refilled at intervals of from two to seven days, six at intervals of from two to three weeks, one only once in twelve weeks, while in another the water was never changed. From analytical data which has been secured at Brown University, University of Pennsylvania, Ohio State University, Purdue, Northwestern University, University of Wisconsin, and from various other universities, it is evident that some method for purifying the water is necessary and that all pools should be provided either with filters whereby the water from the pool can be reused, or the pool should be refilled each day. In the case where the water is filtered it is probable that some means of disinfection should also be included. Owing to the expense attached to the use of fresh water for refilling, it is undoubtedly advisable to install with the original equipment, some sort of filter. The filters may be used either with or without the use of coagulants and are more or less effective in removing organic matter and color from the water. Filters are not at all times effective, however, in producing a water satisfactory as regards bacterial removal, and the use of disinfectants is being depended upon in order to insure safe bathing conditions. The question of disinfection has been studied from various angles and various substances have been used in order to maintain a low bacterial content in the water. It is easy of course to apply the disinfectant intermittently, but the efficiency of this system has been questioned by some who are of the opinion that whatever may be applied to the water should be added continuously. It has been sug |