can very readily see the impossibility to do thorough work or to get satisfactory results in all cases. To the good, intelligent women and through their organizations, the city is largely indebted for the nurses that we now have, and they have a promise of two more which we surely need and I beg for the earnest support of this society collectively and individually toward this end.

Nineteen fifteen is the first year the vaccination of the school children has been placed in the hands of the school physician and I believe this is the proper place for it, for the reason that we are in the schools daily throughout the year and are prepared to vaccinate, whenever the occasion requires. While the medical inspection of school children is comparatively a new activity, still it has been in force long enough to have convinced the most skeptical of its tremendous value both in the prevention of epidemics, of disease, and the arrest of disease in its incipiency, and the most difficult thing to understand is, the reluctance which some of our municipalities display in providing adequately for this work. The way we are constituted to-day it would appear that we place far greater value on property than we do on health or life. Millions are spent annually for the detection and punishment of petit larceny, but to prevent disease there is quite an epidemic of indifference. We have men among us who decry vaccination, they are about on par with the men who belittle education and we have to blush in acknowledging that during our campaign to carry schools to the illiterate districts of our State, opposition was met from some few men who blamed education for all the ills and crimes of the cities and towns. Of course such opposition is born of ignorance. How men of education can honestly hold out to-day in the light of all the proof and experience, against the vaccine immunizing practice is beyond the comprehension of a normal, logical brain. And when people will not be convinced by the overwhelming proof of past experience, there is nothing left but compulsion, and Kentucky may be thankful and proud of the fact that we have laws both for compulsory education as well as vaccination.

Quite a stir was created in this city last winter when the newspapers heralded the fact that several United States surgeons were here to go through the schools to search out trachoma. The reporters made the most of it and some sensational articles appeared, so that not only the layman was made uneasy, but the ophthalmologists as well, naturally feeling that their diligence and skill in diagnosing especially this one disease had been challenged, when it was published that two per cent. of

trachomatous eye-lids had been found in the schools. It was my duty as one of the school inspectors to accompany the United States inspector on his rounds. This was not a new experience for me by any means as I had the opportunity of examining the eyes of three hundred and fifty children mostly from the mountain districts of our State where the means and manner of living were not of the best and where trachoma has long been prevalent; these children are the wards of the Masonic Widows and Orphan's Home, on whose staff of physicians I am, and in assisting Dr. John R. Wright, the ophthalmologist, 1 had ample opportunity to become familiar with follicular conjunctivitis, granular conjunctivitis or trachoma whichever the infection may develop. There are constantly under treatment at the Home from twenty to forty cases; when they are chronic and catarrhal and do not yield to treatinent, they are operated on. It was my privilege and pleasure to be present at a meeting of the Eye, Ear, Nose and Throat Society several months ago where a very able paper was read on Trachoma, and very fully discussed. There were five boys ranging in age from five to eight brought into the room. They were from the Industrial School of Reform and brought 10 the hospital for treatment. The United States Government Surgeon pronounced all five cases trachoma. the essayist of the evening pronounced all five cases follicular conjunctivitis. I was led to conclude from the paper read and the discussion following, that there was very probably an arbitrary and hasty diagnosis made by both gentlemen. The concensus of opinion and positive conclusion reached by all was, that trachoma is a specifie infection the bacteria of which has so far not been isolated, therefore the only positive means of diagnosis was the chronicity of the disease and consequent destruction of conjunctival tissue, or the stubborn persistence of the disease not yielding to simple treatment, whereas folliculitis or follicular conjunctivitis will yield quickly to treatment and frequently get well without any treatment at all. The lesson I learned at this meeting was a very valuable one to me, it taught me to be very cautious about writing trachoma on the diagnosis card of the child notwithstanding all the experience of the Masonic Home and the ten thousand children I examined with the United States Government surgeon, and again I am not so very jealous of my prerogatives or ambitious to insist on a positive. diagnosis, especially where there is no harm to come from a watchful waiting. Therefore I am now marking my diagnosis cards where I find a mild conjunctivitis-for observation.

If the disease persists I mark the card follicular conjunctivitis and send notice to the parents to take the child to their ophthalmologist for treatment.

If I find my warning goes unheeded and the disease growing worse, I then change the diagnosis to trachoma or granular conjunctivitis, and insist on the attention of a specialist. If still neglected the child is excluded from school, to impress on the parents of the child that we are in earnest about our work. The nurse is then put on the case, visits the home to find the cause of inattention and if poverty is found to be responsible for conditions, she secures treatment through one of the several avenues she has to choose from. This is about the procedure followed in all the chronic ailments such as enlarged tonsils, adencids, defective vision, hearing, teeth, anemia, eczema, nervous diseases, etc.

However there is another side to this picture, there frequently arises the occasion the occasion when the medical inspector of school children must thoroughly understand his work, be postive of his diagnosis and have the courage of his convictions and see to it that his directions are carried out, and that is when the communicable diseases and infections are in question. The more acute contagious diseases are not very often diagnosed in the school. Scarlet fever, diphtheria, measles, smallpox, chickenpox. whooping cough, etc., for the very good reason that the

prodromal

symptoms are so pronounced that the mother is the first to notice them, keeps her child at home and sends for the family doctor. But such conditions as scabies, pediculi, impetigo contagiosa, acute catarrhal or suppurating trachoma, where the child must be excluded for the protection of the other children, or a suppurating discharging, foulsnelling otitis media or ozena, these are the conditions most frequently found, and naturally more often among the children whose parents cannot pay a physician. These are the cases that give us the most concern and are the great majority of all the cases found, for our interference, the school nurse in most of these cases must accompany the child to the hospital for treatment. We meet with parents who are overly sensitive and unreasonable about the possibility of their child having the itch, nits or pediculi and resent the diagnosis, and exclusion from school, and I am sorry to say that sometimes a physician is found who will so far forget his obligation to the community that he will yield to the wishes of the family who may be his patients and deny the diagnosis. This is unfortunate for the family doctor alone, because when a child is excluded, the diagnosis is so positively

demonstrated to the teacher and principal of the school, that a mistaken diagnosis is well nigh impossible. At least we insist that the child remain away from school until it is cleaned up and the disease cured, and although our diagnosis may be denied our directions are carried out and the child returned to school clean.

All kinds of subterfuge is resorted to, to avoid vaccination, by those who do not understand, or are afraid, or do not believe in it. ("I have been vaccinated and it did not leave a scar"), ("I have had the smallpox, but there are no pits visible"), ("My ma is going to have me vaccinated by our family doctor next week")-but next week drags into months. ("The doctor says my blood is not in condition," etc., etc.) until we are convinced that an evasion only is aimed at, and then must come exclusion for refusal of vaccination. Again it is to be regretted that the family doctor will too readily lend himself to the wishes of his patients and sign a certificate of successful vaccination when there is no sign of a scar or a pit, as this is the only evidence of successful vaccination that the school inspector has to go by, he, in all honesty to himself and to the community must insist on revaccination until successful. The cause of most of the unsuccessful vaccinations is that the points or vaccine have not been kept in the ice-box, for when exposed to a temperature of seventy degrees or over, for four or five days, it becomes perfectly sterile. In summing up I wish to emphasize what seems to me to be the cardinal principles of the medical inspection of schools and school children. The detection of contagious, infectious and communicable diseases, the exclusion of those so suffering for the protection of others. The detection of insidious and chronic diseases, to call them to the notice of parents or guardians and refer them to their family physician, the finding of physical defects with the same reference as above. If the families afflicted, are unable to help themselves to put into motion such measures as will insure them aid, free of expense. To encourage the teaching of the practice of hygienic living both at school and at home and where practicable talk to the children along that line, a general supervision of the sanitary condition of school rooms and grounds. This may seem quite a large contract for the number of physicians employed, but if the plan is adopted to make every teacher and every principal your assistant, which they most willingly become when they understand what is wanted, the work becomes a pleasant task and the great improvement so quickly noticeable in the appearance of the children after treatment is a powerful

incentive to renewed effort for more and better work.

Help us get more school nurses, our children need them and at last that is where the greatest good to the greatest number is to be looked for, the nurse is the one that is entrusted with the duty of following the case to the homes, the clinics and watch them until a conclusion is reached. All this takes tact. patience and a great deal of time, so you can understand very readily how badly we are hampered in our work, two nurses among forty-two thousand children.

DISCUSSION.

S. G. Dabney: The teaching of hygiene and better modes of living to children and, through them, their families, is, I believe, one of the most decisive steps for the betterment of community life that has been taken for a long time.

Dr. Rosenham is not alone in the difficulty he finds in diagnosing trachoma. The border line is sometimes exceedingly hazy. Dr. J. M. Ray, in a recent paper, pointed out the fact that, of ten modern text-books, not a single one gave a satisfactory means of differentiating trachoma from follicular conjunctivitis. It is generally accepted now that the pathology of the two diseases is almost, if not absolutely, identical. although this is disputed by some. I believe that, until the laboratory men come to the aid of the elinical observers and discover a bacteriological cause for trachoma, we are all going to make a good many mistakes

Speaking to the practical side of the subject, I believe that many mild cases-call them traehoma or follicular conjunctivitis--are not infectious-are not in a stage where they are likely to be communicated. Eye diseases are rarely communicated unless there is secretion, and until there is some discharge from the mucous membrane, it is not necessary to exclude them from school, nor is operative treatment demanded.

Still another group is composed of those cases in which we all agree that an operation is indicated, although the diagnosis can only be determined by the microscope. I do not admit that when such a case is relieved by a single operation without leaving a scar, it is evidence that the condition was not trachoma, because we know that the expression operation will sometimes cure trachoma.

Perhaps when we come to know more about trachoma we will find that it has many stagessome communicable and some not communicable; some, perhaps, self-limited. This is true of other diseases and there seems to be no reason why it should not be true of this one. Some of these cases recover without scars while others, in spite of all forms of treatment, will have pronounced

scars.

Bert Gribble: The Public Health Service recently sent here by the Government to examine our school children found that from 1 1-2 to 2 per cent. of the school children in Jefferson County had trachoma. Under this head they included all suspicious cases. One of the gentlemen, Dr. Moore, has had a very wide experience along this line, having been in Government service more than fifteen years, doing quarantine duty at Ellis Island, where he examined a great many immigrants for trachoma. Whether the cases he had diagnosed here are trachoma or follicular conjunctivitis remains to be seen.

Adolph O. Pfingst: The evolution of the old school-house, with its poorly ventilated, dark rooms, roller towels, wooden buckets, with tincups, etc., into the beautiful modern, hygienic school building of to-day, is, I believe, largely due to the untiring efforts of the medical profession. Soon after the introduction of medical inspection in schools in this country, Dr. Luckett, of Minneapolis, pointed out that, of the twenty-odd million school children in the United States, something like eight million were afflicted with some form of eye, ear, nose or throat disease, and that children deficient in these respects soon become mentally and physically deficient and went to form a great portion of the idle poor and crimmals. He later introduced, at a meeting of the American Medical Association, a resolution urging the legislatures of the various states to enact legislation providing for the medical examination of school children, and I believe such legislation is in effect in practically every state at the present time.

Passing over the question of the diagnosis of trachoma, I think Dr. Dabney struck the keynote when he said that every case in which there is a secretion should be excluded from school, while those of a milder type should be treated by their family physician, or at clinics, but allowed to remain in school.

In the agitation about trachoma, we should not overlook the fact that there are frequently other conditions in school children, which demand attention; for instance, myopia, or near-sightedness, which is present in a large percentage of children and progresses rapidly during the school term. Therefore, I think it is an important part of the medical inspector's duty to see that the vision of school-children is up to normal.

S. C. Frankel: When the medical inspection of school children was first begun, the inspectors encountered many difficulties in the discharge of their duties. To many of the children, especially the younger ones, the mere mention of the name "doctor" was sufficient to frighten them almost into hysteries. Again many of the older children, especially girls, objected to being examined. The principals and teachers of the schools were not enthusiastic about it because it necessitated con

siderable extra work. Furthermore, the parents of many of the children objected to their being examined, and frequently sent messages by the children to the effect that they were able to pay for medical attention, and that if any examinations or treatment were necessary, their family physician could do it. What was most surprising was the fact that many doctors opposed it, probably under the impression that the inspectors were administering treatment. Necessarily, therefore, our first few months of work were mainly devoted to educating the children, teachers, parents and, to a less degree, doctors, as to the object of our work and its scope. We were considerably handicapped at first by the fact that we had no nurses to follow up the cases in which we discovered physical defects. It was only after about eighteen months that we were able to have nurses to follow up these cases and to ascertain what results were being secured. While I was doing this work I constantly advocated the need of more nurses for this purpose. Since that time the facilities have been increased and parochial schools have been added to the list and I am sure that this has very much improved the work.

C. J. Rosenham, (Closing): I would simply add that, at the present time, the principals and teachers are in hearty accord with the work, and are giving us their earnest support.

Red Cross Work in the Ladrones.-Prompt action taken by the American Red Cross in 1915. in response to an appeal transmitted to the Navy Department, kept from starvation a number of destitute persons on the Island of Rota in the Ladrones Group in the Pacific. On receipt of the appeal the American Red Cross, through the cooperation of the Navy Department, authorized by cable the loading of relief stores on the U. S. S. Supply at Manila, this vessel being ordered to stop at Rota and discharge the food sent by the Red Cross. After taking this action, the American Red Cross notified the Japanese Red Cross of the receipt of the appeal and thus the conditions in Rota were brought to the attention of the Japanese government. Through the American Ambassador at Tokyo, Japan, the government sent the American Red Cross a draft covering the original expense in Rota, together with thanks for the action taken.

Human energy produces wealth. The inherent power of production of one person may be greater than that of another, but the producing power of all persons is reduced, and often stopped altogether, by disease. It is the object of health boards to maintain at its maximum efficiency the producing power of the public, and to conserve it by lengthening life.

ACTIVE AND PASSIVE IMMUNIZATION; THE ESSENTIAL DIFFERENCE BETWEEN VACCINE AND SERUM THERAPY.*

By J. D. ALLEN, Louisville.

The object of both vaccines and sera is to cure and prevent infective diseases, by helping nature in the production of a state of immunity. We all know it to be a fact that nature is the most successful of all physicians and that infections can be cured only by nature. We all appreciate the value of drugs in helping nature to put forth her best efforts. We appreciate the value of the mechanical aid rendered by the surgeon, in removing the products and results of infections. But on the other hand we all appreciate the fact that not one, nor all the drugs mentioned in the materia medica can immunize a patient against typhoid fever or smallpox, and not one, nor all the surgeons can cure diseased appendix. The curative and preventive features rest with nature and the remedy which nature uses is immunity. The only reagents at our disposal for causing nature to produce a state of immunity are vaccines and sera, and although these two reagents ultimately produce the same results, they are entirely different in their makeup and in their mode of action. They both produce immunity, the former an active, the latter a passive immunity.

Immunity, like pathogenicity is more or less a relative term, and might be defined as an animal's ability to overcome or prevent an infection; in other words what we term resistance. The serum of all animals recovering from infective diseases contains some substance or substances, the result of cell activity, which are detrimental to the growth of the bacteria, and the products of the bacteria causing the infection, to such an extent that these same bacteria in moderate quantities cannot infect the recovered animal; such an animal is spoken of as immune, and its condition as one of immunity. Of course we all understand that these substances are chemical products generated by the animal cells for protection, when irritated by bacteria or other foreign proteids, and in bacteriological terms are named according to their mode of action. The irritant (the bacteria or other foreign proteid) which stimulates the body cells to action is called the antigen. The product thrown off by the animal cell which splits the bacteria is called a lysin. The product which agglutinates the bacteria is called

*Read before the Jefferson County Medical Society.

an agglutinin. The product which neutralizes the toxin of the bacteria is called an antitoxin. The product which prepares the bacteria for cell digestion is called an opsonin, and all of these products which are the result of cell activity are included under the general term of amboceptor or antibody. The product which is found in the blood of all animals at all times, necessary to complete the reaction between the antigen and the antibody is call. ed the complement. All of these products except the complement are specific, according to the antigen which stimulates their production. In other words the lysin which is stimulated by the presence of the staphylococcus will not split the streptococcus. In order to produce a complete reaction, necessary for the destruction of the antigen or bacteria, three of these products must always be present, the antigen (the bacteria or its toxin) the antibody and the complement. The final destruction of the bacteria, however, is due to the phagocytes which destroy or digest the bacteria after they have been prepared by these chemical products. As a matter of fact an excess of these chemical products are thrown off by the animal cells and are not utilized in the destruction of the bacteria but remain in the blood, ready to attack this same bacteria when it again puts in its appearance. This excess of these chemical products in the blood of an animal, generated by the animal cells for the destruction of bacteria,-constitutes what we call acquired immunity.

Acquired immunity may be either active or passive, according to whether or not the animal generates these products as the result of his own cell activity or receives these products in the blood of another animal which has been previously immunized. Active immunity then is due to the direct participation of the organism concerned and depends upon increased cell activity. Such immunity is gained at the expense and often at the risk of the organism concerned. Immunity to smallpox for instance, may be obtained either by an attack of the disease or by the commen method of vaccination. However, in each and every case, the immunity depends upon a specific reaction on the part of the cells and tissues of the individual organism. Passive immunity on the other hand involves no active generation of the protective substances by the immunized animal. The latter is simply the recipent of the substances formed in the blood of another animal and transferred to the indi

vidual to be protected. In the preparation of the diphtheria antitoxin antitoxin for instance, the horse is actively immunized by the injection of increasing doses of diphtheria toxin, and the blood of the horse comes to contain a pro

tective substance, the so-called diphtheria antitoxin, which if injected into another animal renders that animal passively immune to diphtheria. The horse then is actively immunized and produces its own antibody, the animal which receives the horses serum is passively immunized, receiving the antibody already formed.

HOW ACQUIRED IMMUNITY IS PRODUCED.

We have just seen that acquired immunity is either active or passive according to whether or not the animal which is to be immunized plays any part in the production of the immunity.

Active immunity can be produced, first by overcoming an infection, such as the immunity following typhoid fever; second, by the incorporation into the animal body of live but attenuated bacteria (that is bacteria which have lost their virulence to a certain extent), such as the well known vaccination against smallpox; third, by the incorporation of the products or toxins of bacteria, such as the immunity produced in the horse, in the preparation of diphtheritic antitoxin, by injection of the toxin of the diphtheria bacillus; fourth. by the incorporation of dead bacteria.

Passive immunity on the other hand can be produced only by the injection of the serum of an actively immunized animal, such as the immunity produced by antitetanic and antidiphtheritic sera. The method most used in the production of active immunity, both for prophylactic and curative purposes is the injection of dead bacteria which includes all of our well known vaccines.

The object then of both vaccines and sera is to produce a state of immunity, by causing the presence in the blood of the animal or patient, of this chemical substance, the result of cell activity, which we call an antibody. The vaccines cause the production of the antibody -the sera supply the antibody already produced.

HOW VACCINES AND SERA RESPECTIVELY PRODUCE AN ACTIVE AND PASSIVE IMMUNITY.

Vaccines which are simply a saline suspension of dead bacteria contain no antibodies or other substances which are detrimental to the growth of the bacteria and products of bacteria causing the infection. They produce immunity, by the same process which disease produces immunity and that is by irritating the animal cells and causing the cells to throw off an excess of protective substances, or antibodies, which substances remaining in the circulation combine with the specific baeteria which are the antigens, in the presence of the complement, which is in the patient's blood, when and where ever they come in con