nished by railroads, interurban trolleys, and the automobile, has greatly increased the tendency of communicable diseases to spread from city to city and from State to State. The duties and powers of the local health officer or board of health should be specific and clearly defined by law and pertain only to the business of improving and protecting the public health. They should include all measures necessary for the reduction of sickness and disease and the improvement of the general sanitary status of the community. As a basis for the activities of the health authorities, a sanitary code or set of rules and ordinances or regulations/ should be promulgated. These regulations should be prepared with extreme care and permit of intelligent application and enforcement. Too many of these codes today are amusing relics of ancient and antiquated ideas, hastily written a generation or more ago, incapable of enforcement or application to conditions as they exist at the present time. In many of the smaller places there is found to exist only a board of health, composed mainly of busy practicing physicians who take their turn at placarding or fumigating or attempting to abate a few petty nuisances that are brought to their attention. They may receive a small monetary compensation. No records of any value are preserved and nothing real is accomplished in disease prevention. With the growing tendency to appoint health officers who are made the executive agents of the boards of health, it is reasonable to delegate to the boards only legislative and advisory functions. Local boards of health are too often perfunctorily appointed bodies and owe even their existence to some mandatory clause in the city or town charter. The principal functions of a local board of health are briefly : may be necessary for the protection of the public health. 2. To adopt and promulgate such rules and regulations as may be necessary in maintaining the health and sanitary condition of the community. 3. To secure adequate appropriations and approve expenditures. 4. To consult with and advise the health officer in problems of special importance or of an emergency nature as they may arise from time to time. The function of the local health officer and the local health department is the prevention and eradication of communicable or preventable diseases. It has been estimated that nearly one-quarter of all deaths in the United States are the result of communicable diseases many of which are essentially community diseases whose prevalence in a community is an index of the adequacy and efficiency of the local health organization. Where local boards of health are established, the local health officer generally should be the executive officer of the board, empowered to enforce its rules and regulations. His tenure of office. should depend upon his ability and efficiency. He need not necessarily be a physician, but he should have either thorough experience or previous training and a good working knowledge of sanitary principles and practice. It is absurd to require that he be a resident or a voter in the community he is to serve, because our sanitary science is really in its infancy, and trained sanitarians do not grow up over night in every community. Also a person without local ties will often make a more efficient public esrvant. The Local Health Officer. The most important function of the local health officer is the control of preventable diseases. To secure the best results, his efforts must be directed along three lines: 1. He must keep constantly informed concerning the prevalence and geographic distribution of preventable diseases within his jurisdiction (morbidity reports). 2. He must secure complete and definite knowledge of the various conditions responsible for this prevalence (epidemiological studies). 3. He must devise and institute remedial measures to control these diseases and reduce their prevalence (corrective measures). The importance of morbidity reports.-The complete reporting of all cases or suspected cases of communicable diseases is the most important factor in their control and too much emphasis cannot be placed on this point. While it is true that notification of cases of sickness is satisfactory in isolated instances, generally speaking, our morbidity returns are far from satisfactory. Without a knowledge of the existing cases of communicable diseases in his community the health officer cannot intelligently investigate their epidemiology or institute measures for their control. Nearly all states have laws regarding the reporting of communicable diseases, but few, if any, are consistently enforcing them. The importance of morbidity reports is being dismissed with apparently little discussion, but notification must be recognized as the cornerstone upon which is built up our defense against communicable disease. Epidemiologic studies.-In modern sanitary procedures, epidemiology, as a science, deals not only with epidemics but with usual or unusual prevalence of disease. Its function is to determine the origin, distribution, and means of spread. In common practice it is. the local health officer that must assume the role of epidemiologist, because he is the man on the spot and best acquainted with local conditions. Given prompt and fairly complete case reports, he must study each individual case, check and tabulate his findings, and draw his conclusions as to the factor or factors responsible for the prevalence of the disease under investigation. Personal visit to each known or suspected case should be made by the health officer immediately upon learning of its existence, in order to establish the diagnosis and determine, if possible, the cause or probable cause of the infection. A suitable blank form should be used, and for each case notation should be made of the findings in regard to the date of onset, the personal habits, environment, water and milk supply of the patient, method of disposal of excreta, the possibility of contact infection, and so forth. Proper blanks or cards not only make the collection of data easier, but facilitate tabulation and filing for future reference. If the data are properly indexed and tabulated, a great deal can be learned concerning the real or probable cause of the disease studied. Chronological charts and spot maps, showing dates of onset of cases with their distribution, are of invaluable assistance in following the progress of a disease. This discussion of the value of epidemiologic study is brief, but it is desired to emphasize its importance as the foundation upon which must be based any intelligently applied remedial measures required to control or eradicate disease. It is unfortunately true that many boards of health and local health officers, especially in rural sections, do not devote much, if any, time to the epidemiologic study of the prevalence of disease in their communities. The one-man, part-time health department, with no clerical assistance, asks how he can be expected to collect and study these data. No elaborate equipment is necessary, and in rural communities, at least, comparatively little time. is required to keep the information up to date at all times. Control of disease--Corrective sanitation.-Having studied carefully the findings in each case reported or discovered during investigations, the evidence at hand will in most instances point to the steps necessary to control the situation, and much needless expenditure of energy and funds will usually be avoided. Without this information. of the cases and the conditions under which they are occurring, the health authority will be working in the dark and wasting his available ammunition against an enemy of unknown numbers and haunts. Funds usually appropriated for health work are so limited that it equires wisdom and discretion born of training and experience to expend them to the greatest advantage. LATEST CANCER STATISTICS. Mr. Frederick L. Hoffman, chairman of our Committee on Statistics, expects to publish shortly in the "Spectator" newly tabulated data showing the mortality from cancer in thirty-five American cities. for the period, 1906-16. Mr. Hoffman is now able to report that against an average recorded cancer death rate of 87.8 per 100,000 population for the five years ending with 1915, the rate for 1916 has risen to 92.1. It further appears that every form of cancer shows an increase with a single exception of cancer of the buccal cavity for which the rate has remained unchanged. At first glance, however, there seems to be striking evidence of decreases or but slight increases in the local caner death rates in many cities where the activities of the Society for the Control of Cancer have been most pronounced. Interpretation of these figures must be deferred until the publication in detail of Mr. Hoffman's new data, which will be awaited with interest. DIPHTHERIA ANTITOXIN PRODUCTION. J. GILBERT GEORGE, B. S. Antitoxin Chemist, Ohio State Board of Health. The discovery and isolation of the Bacillus Diphtheriae, the specific cause of diphtheria, by Loeffler in 1884, prepared the way for a mninute study of the disease, which resulted in a thorough knowledge and demonstration of obtaining a toxin from the diphtheria bacillus in broth culture. This was followed by the work of Frankel in 1890, who succeeded in obtaining immunity by means of toxin injections. In the same year Behring and Kitasato published the results of their experiments on diphtheria and tetanus and in this publication they announce that an animal immunized against tetanus or diphtheria produced in its blood substances which were capable of neutralizing the toxin; that the blood serum, when injected into other animals before the toxin, can prevent the toxic action, and when injected even after the onset of symptoms can save the life of an animal. An antitoxin, therefore, is an antibody formed in an animal through the stimulus of a specific toxin. The usual method of producing an antitoxin is by the repeated injections of increasing amounts of toxin into a susceptible animal. The strongest antitoxins are obtained from animals that are very susceptible to the toxin, but all animals by no means produce antitoxins, although repeatedly injected with the appropriate poison. A guinea pig is very susceptible to diphtheria and will not form diphtheria antitoxin, even after the repeated administration of diphtheria toxin. In other words, the guinea pig, a susceptible animal, lacks the mechanism of antitoxin formation which is possessed in such a high degree by horses and other animals. Antitoxin produced by the. horse or other animal when injected into the guinea pig will protect it. Horses are selected for the production of diphtheria antitoxin on account of their size, their relative endurance to the treatment with toxin, they furnished large quantities of blood, the serum of the horse is the blandest (most mild) blood serum of any known species, and finally the horse furnishes antitoxin in higher potency than any other known animal. Normal, vigorous and healthy horses from 5 to 12 years old, purchased under a guarantee of soundness, are employed in preference to other animals. Even though purchased under such a guarantee the animal is kept under observation for a few weeks and tested for glanders and tuberculosis. No animal is retained until it is proven that there is no latent or active disease present. Horses as a rule, are free from diseases which affect man, are relatively large, easily handled and always available. There is a very great difference in the ability to produce antitoxin even among different individuals of a suitable species. Thus, some horses have this power developed to such an exquisite degree that they produce a high grade of antitoxin for prolonged periods. Other horses cannot be stimulated to antitoxin production. As far as the efficiency of the immune serum is concerned, it is entirely dependent on the animal. Horses vary greatly in their individual predisposition toward the production of an effective serum; some animals even completely fail to do so, not that the latter are not actively unized, for they are, but because they contain very little antitoxin within their serum. The difference among horses is well known to manufacturers, who have no means of knowing beforehand which horses will be profitable. There is absolutely no way of judging which horses will poduce the highest grades of antitoxin. The only practical method at present known is to discard those animals which refuse to respond to the stimulation of toxin injection. Roughly estimated, those horses that are extremely sensitive and those that react feebly are the poorest, but there are exceptions even in these cases. The "Romer Test" has been suggested by some laboratory workers, as a means by which one might determine whether an animal be usable for the production of antitoxin. The only reliable method, therefore, is to make "test bleedings" of the horses at the end of ten weeks or three months and test their serum. If only high grade serum is wanted, all horses that give less than 200 units per c. c. should be discarded. The present adopted method of producing toxin for injection purposes is as folows: A virulent culture of diphtheria bacillithat known as Park and Williams' No. 8-is grown in specially prepared toxin bouillon under conditions best suited to the greatest production of toxin. The culture after six to ten days' growth at incubator temperature is removed, and rendered sterile by the addition of a 5% solution of carbolic acid. The toxin is stored for several days in a refrigerator and the sterile culture is filtered through asbestos wool or paper pulp and finally through a Berkefeld filter. If the preliminary tests show that the toxin has the required toxicity, it is allowed to "age" or "season" for several weeks at a low temperature protected from light before being used for injection purposes. Before injecting the horse with diphtheria toxin, its minimal lethal (fatal) dose is established by inoculating a series of guinea pigs of known body weight (250 grams or about 8 ozs.) with graduated doses of toxin. The toxin is so potent that about (1/2000) 0.002 c. c. is generally sufficient to kill a 250 gram guinea pig within four days after inoculation. Having determined the relative strength of the toxin it is now ready for use. The object primarily is to establish in the animal a "basic or partial" immunity and then to increase the immunization until the antitoxin is present in the blood in high concentration. As the injection consists of toxin from which the killed bacilli have been removed the horse does not contract diphtheria, for the disease can only be conveyed by the living bacteria. Injections are made subcutaneously and with all possible precaution to preclude bacterial infection. The first dose is a fraction of a c. c. and is injected under the skin of the horse in the region of the shoulders, of the thorax or side of the neck. |