measuring it. Just as the man who begins to sleep out of doors says as he pounds himself on his chest, "I feel a hundred per cent better," without being able to describe just how he is better, so the public is coming to realize that it pays to clean up and enforce sanitation regulations, even though we have not yet established a standard of measurement for the benefits resulting therefrom.

California and the It would undoubtedly be a good investment for Cholera Situation. California to apply the "fire-drill" system to her public health control. Discipline made dependable through frequent drills based on hypothetical fires has saved many a life in times of the real emergency. Similarly, the sham battles of the militia and the regular army are considered well worth the cost. It is even more important that this principle should be applied to the wargame with disease, since all the fighting forces are untrained militia with only here and there a trained officer. The expense of printing and distributing brief well-worded pamphlets for boards of health, the salaries of instruction nurses, and the many other expenditures incident to developing community coöperation in fighting disease are sound investments and should be extended and systematized.

Cholera has become such a rare disease that the present generation of Californians know nothing of it. The possibility of the disease appearing here seems remote, but this is not the case. Since cholera appeared in Russia and Italy in 1910 there have come to our state from the infected areas 2,200 immigrants. It is theoretically possible that any one of these might have been a cholera "carrier" or a patient who escaped the vigilance of the health inspectors both in Europe and at the port of entry in America. To safeguard our state as far as possible, each of these immigrants has been under surveillance from the time he planned to leave his native country. The following letter is sent out from this office as soon as he leaves the quarantine port in the United States en route for California:

Health Officer,

California.

DEAR DOCTOR: I have to-day received word from the immigration authorities that' an immigrant named from is en route to California, having given the following as his destination: This locality is within your jurisdiction.

The State Board of Health, in coöperation with the United States Public Health and Marine Hospital Service, is doing everything possible to safeguard the State from the importation of cholera. This immigrant was held at the port of departure in the above named country for five days, and has been under observation on shipboard, again being inspected at the immigration port in this country. Notwithstanding these precautions, there is a possibility that some cholera-carrier may reach his final destination in this state. Consequently, it is desired that you inform yourself of the arrival of this immigrant, and that you arrange to be promptly notified if he develops any illness. It is also desirable that you request physicians in your jurisdiction to notify vou promptly of any illness suggestive of cholera which may occur among residents in the vicinity of this immigrant's residence or place of employment. Should a possible case of cholera develop within your jurisdiction, you are requested to promptly notify the State Board of Health, in order that we may send to your aid an expert from our laboratory to thoroughly investigate the matter. Very truly yours,

(Signed) WILLIAM F. SNOW, M.D. Secretary California State Board of Health.

But suppose all these precautions fail and one of these immigrants minating cholera "germs" with his bowel discharges, reaches an

inland town in California, and gets a job on some construction work with camps on the banks of a city's water supply. The construction company's toilets are built over the stream, and these cholera "germs" find in this arrangement their opportunity to transfer themselves from this man who has won his personal battle with them to many susceptible victims in the city. This is one of the very possible ways in which the old world epidemic of cholera may at any moment become the source of one or more foci of the disease on this western coast of the New World.

And if this supposition should come true, then what? How many of our citizens know what to expect of their health officers and what is expected of themselves in the control of the disease and the prevention of panic? The first great world epidemic of cholera recorded occurred from 1817-1823; the second appeared in 1826 and lasted till 1837; the third appeared in 1846 and continued till 1862; the fourth began in 1864 and lasted till 1875; the fifth began in 1883 and lasted thirteen years in spite of the fact that the "germ" causing the disease was known all of this time; the sixth began in 1902 and lasted till 1906; the seventh began in 1910 and will last-how long? Probably the turning point in the battle of the nations against cholera was reached in the Hamburg outbreak in 1892, when the disease within the space of ten days attacked over 17,000 in a population of 600,000, killing 50 per cent of them, and extended its attacks to 269 other places in Germany before the defensive forces of the country could be marshaled for the battle. Within nine weeks after the intelligent direction of the fight began, the disease was practically driven out of the empire. In contrast to this victory the disease continued to rage in European Russia, causing the death of over 800,000. In 1894 cholera renewed its attack on Germany, and entered 157 towns, but the people and their officers were fully trained for the battle and only 490 persons died before it was again driven out. Since that date it has been unable to get past the closely guarded ports of entry of Germany, France, and England.

Fortunately, cholera has not succeeded in gaining a foothold in the United States since 1873, when it appeared in the Mississippi Valley, and caused serious panics and grave anxiety for the success of the Centennial Exposition which was in course of preparation at Philadelphia. In spite of the fact that during the past ten years the prevalence of cholera in Japan, China and the Philippines has seriously threatened the Pacific coast through the increasing transpacific travel, California has not had any cases of cholera since 1850. It is probable that vigorous measures at our ports of entry will protect us, but cholera is a subtle enemy and it behooves us to organize a health militia and hold ourselves in readiness. Since June 13, 1911, the surgeon general reports twenty-five cases of cholera which have developed at sea or after arrival at the New York port of quarantine. Of this number three have escaped detection until after release for entrance to this country. Two of these were held in detention from June 20th to 27th. When released one went to Brooklyn, where she was discovered July 2d, and died July 4th; the other went to Auburn, N. Y., developing the disease June 30th and dying July 1st. The third man was a quarantine employee who left the station after having served as a guard over supposedly well passengers. He developed the disease June 13th on Staten Island, and died July 14th. The fourth case of cholera to occur within the lines of our quarantine defense has

just been reported from Boston. The city health officer reports the death (July 20th) from cholera of a woman who had taken into her home as lodgers two sailors from the crew of a vessel arriving from an Italian port. The sailors were also taken ill, but disappeared and have thus far not been located.

Under date of July 19th, the following order was issued by the United States Government:

CHOLERA-BACILLUS CARRIERS.

(1911. Department Circular No. 47, Bureau of P. H. and M. H. S.)
TREASURY DEPARTMENT,

OFFICE OF THE SECRETARY,
WASHINGTON, July 19, 1911.

To National, State, and local quarantine officers, collectors of customs, shipowners and agents, and others concerned:

In accordance with the act of Congress approved February 15, 1893, and to further prevent the entrance of cholera into the United States, the following regulation, in addition to those contained in Quarantine Regulations of the Treasury Department issued October 20, 1910, and in Department Circular No. 45, July 6, 1911, is hereby promulgated, and shall remain in force until otherwise ordered:

All steerage passengers arriving at ports in the United States from ports or places infected with cholera shall be subjected to bacteriological examination and shall not be admitted to entry until it has been determined by said examination that they are not cholera-bacillus carriers.

FRANKLIN MACVEAGH, Secretary.

This order covers the greatest factor in the control of cholera. If a focus should be developed in California it will be essential to examine the bowel-discharges of every individual in the community, who can not be absolutely excluded as a carrier by other information. Equipped with the information thus obtained the health officer can proceed with definite administrative measures directed intelligently against the enemy. If the public understands the necessity for such a measure and is prepared to coöperate with the health officer when the real emergency arises there will be no alarm and only small loss of life before the threatened epidemic is fully under control.

The Schools and the

California has a new vaccination law. It is New Vaccination Law. a lonely waif. Nobody really likes it-the doctors say it is a distinct step backward; the anti-vaccinationists say it is only a half-step forward; the uninformed public considers it an unmitigated nuisance; and the health officials look suspiciously on it as a weakling which will be of little use in their battle against smallpox. The teachers befriended it because it relieves the schools of the serious friction resulting from the old-law discrimination between the public and the private school. The State Board of Health and the Antivaccination League agreed to endorse it as a fair compromise between their divergent points of view. And now the question is being asked, "Just what is this law?''

When Johnny Jones enters school this fall his teacher will say: "Johnny, have you your certificate of vaccination with you?" And Johnny hands over his certificate showing that he has been successfully vaccinated within the past seven years of his young life; and thereupon his troubles with the vaccination law cease. Or, Johnny fails to hand over this certificate, whereupon his troubles begin. For Johnny must then be vaccinated or present bona fide statement from his doctor that is temporarily not in condition to be vaccinated, or convince his

parents that they must go on written record as being conscientiously opposed to vaccination. If he succeeds in securing one of these "testimonials" he will be permitted to remain in school as long as smallpox stays out of the school district. His "temporarily-not-in-condition" certificate is void as soon as he recovers from the condition specified by his doctor, and his "conscientious objection" certificate must be renewed each year. Both are void during the presence of smallpox in the district.

The administrative detail of the new law is simple. The teacher collects a certificate from every child and turns these over to the local health officer with a certified list of her enrollment. The health officer goes over these certificates and classifies them according to the three types provided. He makes such investigations as he deems necessary and returns to the teacher for return to their owners the certificates of successful vaccination. Those certificates which he keeps constitute the list of provisional attendants. Upon the appearance of smallpox in the district he will require their withdrawal from school, and, of course, compliance under the general public health act with any other regulations he may consider that the seriousness of the situation warrants.

In the September issue of the Bulletin the full text of this law and a review of the arguments for it will be printed. Time alone can show the wisdom or fallacy of its provisions. In the mean while it is the intention of the State Board of Health and the Antivaccination League to enforce it in all good faith. These two organizations have little use for each other's opinions, but they respect the integrity of their members in attempting to eliminate the deception which has attended the enforcement of the old vaccination law. An accurate knowledge of those who are not immune is the most valuable information the health officer can have at the outset of an epidemic of smallpox. The right to send their children to the public school when smallpox is not in the community is the essential demand of the opponents of vaccination. Both these needs are met by the new law.

A Day With the Secretary's

Correspondence.

**

Many people wonder what the secretary of a State Board of Health can find to occupy his time. The extracts printed below from a few of the letters now awaiting reply as these comments are written may suggest a point of view.

These are but types of the daily correspondence of the Secretary's office. On an average forty to fifty important letters each day are received, and must be answered with accuracy and care, if the local health officials or citizens are to be genuinely aided. Before assistance is possible many of these requests must be investigated by correspondence with local officers or by personal trips of the Secretary.

It is the policy of the State Board of Health to do nothing for a local community which it can and should do for itself, but the number of intercounty matters, and of intracounty matters which the local officials are not equipped to cope with are beyond the resources of the Board's staff. The recent legislature increased the administrative office force of the Secretary, but as yet the Board is without field men for obtaining direct information on the many problems presented to it for solution or advice.

A DAY WITH THE SECRETARY'S CORRESPONDENCE, CONTINUED.

EDITOR'S NOTE.-The following letters have been selected as illustrating one phase of the State Board of Health's work. Many of these letters will require much time in searching records or in laboratory investigation before final answers can be given. Next month extracts from the monthly reports of the "Movements of the Secretary" will be printed in illustration of another phase of the routine work of the Board: July 20, 1911.

[Southern California City.]

Dr. W. F. Snow, Secretary State Board of Health, Sacramento, California. DEAR DOCTOR: Inclosed you will find letter from directed to the Mayor, relative to the insanitary conditions of certain canneries. The matter is respectfully referred to you for investigation and reply.

Yours very truly,

Acting Health Commissioner.

[Respectfully referred to California State Board of Health.]

[A Bay City.]

Cal., July 24, 1911.

Doctor Long, U. S. Marine Hospital Service, San Francisco, Cal. DEAR SIR: Under instructions from the North Side Improvement Club of, I beg to bring to your attention the fact that persons on board ships, as well as persons on the shore, are recklessly throwing refuse, such as old clothing, furniture, dead animals, etc., into the estuary of Oakland harbor. This refuse does not float out to sea, but is driven to the Alameda shore by the current, and there becoming decayed causes a nuisance, both unsightly and dangerous to health. The

Association, on account of the large area of their shipping plant, are the greatest sufferers. We know that you will take the necessary steps, as far as your jurisdiction will permit, to abate the nuisance.

I am advising the city authorities as well, but I permit myself to suggest that a word from you to them as regards people on shore would help along materially. Thanking you in advance, I remain,

Respectfully yours,

DAY LETTER.

Secretary.

THE WESTERN UNION TELEGRAPH COMPANY.

LOS ANGELES, CAL., July 24, 1911.

Dr. W. F. Snow, Sec'y State Board of Health, Sacramento, Cal. Has State Board power to disinter and examine body; died here July 14; diagnosis yellow fever. Returned from Mexico six days prior death. Will Board pay undertaker's expenses, such procedure? Think it important to clear up such diagnosis. If Snow away, telephone message to Gardner for opinion. Answer promptly.

3:30 P. M.

WM. LEMOYNE WILLS.

DEAR DOCTOR: Replying to your letter relative to the epidemiology of the plague case which occurred near Lafayette, Contra Costa County, I beg leave to quote from Dr. McCoy's final report as follows:

"The patient was a boy, nativity Contra Costa County, age 7 years, name Horace Flood. He gave a clear history of having hunted squirrels on a number of days during the past month. These squirrels were chased into cracks in the earth, dragged out with a hooked wire and killed by a dog. The dead squirrels were then carried home to be fed to a captive bobcat. A few days before the boy became sick, he was bitten on the left hand by a wood rat.

On Friday, July 21st, the boy became ill with fever and chilliness. The temperature when seen by a physician on that day was 105 F. The following day a swelling was found in the right axilla, and the shoulder and surrounding areas were painful and tender. Nose bleed occurred several times.

The case when I saw it was clinically undoubtedly one of plague. Fluid drawn from the gland with a hypodermic syringe showed pest-like bacilli in smears and a pure culture of B. pestis was secured on media. Two guinea pigs inoculated with the aspirated fluid died on the sixth day with the usual lesions of plague. The bacteriological examination therefore confirmed the clinical diagnosis.

Dr. Leech, under whose professional care the boy was, advises me that the boy died on the 26th instant.

Anti-pest serum was used without benefit."

My preliminary report of clinical diagnosis was made pending the bacteriological examination, and was sent in as soon as I had received it from Dr. McCoy, who saw the case in consultation with Dr. Leech, the family physician.

Yours sincerely,

RUPERT BLUE. Surgeon, in Command.

[A Northern California City.]

I want to report a case and ask your advice concerning same.

We have a county charge in the person of an ex-sea captain, who is about 68 years of age, and gives a varied and suspicious history, having lived from time to time in many different ports of the world. The case looks very much like one of leprosy, though no diagnosis has been made as yet.