located to watch closely. The men are constantly moving from one to the other, and are particularly apt to move on when a case of smallpox appears. One case has come to our attention where the party left the camp he was in for another, after he began to feel the symptoms of the disease. It is quite possible that the move cost him his life. The present form of the disease is by no means light, quite a large percentage dying.

The law requires that health officers report all cases at once to the State Board of Health, and that means be taken to control it. This should be observed closely, as the fear that knowledge of its existence will cause notoriety and injure the locality is foolish. It is bound to be known, and at the present time what people want to know is, that every effort is being made to control it. If it is they are satisfied, but if there is an effort to suppress the fact of its existence they are at once suspicious, and the imagination multiplies the cases.

As far as we are informed, and our information reaches most of the cases, none having the disease were ever vaccinated. In one town a physician who had never been vaccinated is down, while the others who were equally exposed are free.

This emphasizes the need of universal vaccination, and it may not be amiss to review briefly the advantages of the operation, the amount of good it has done, and the small danger attending it.

Before the introduction of vaccination smallpox was the worst scourge in existence. It was conservatively estimated that in Europe alone over 200,000 died each year from it, and that great numbers were left blind or otherwise maimed for life. It was a disease of childhood and few attained to adult life without having had it. The protective influence of vaccination was first made known in 1798 and more or less extensively adopted during the next few years. Immediately following this there was a sudden decrease in the extent and mortality of the disease. This has often been credited to the improved sanitary conditions; but the fact that other contagious diseases, and especially filth diseases, decreased only in a very limited degree, proves this ground to be not well taken. Indeed, in cities where the growth was large and sanitary conditions worse, the mortality from smallpox decreased in the same ratio as in places where better sanitation prevailed.

Fortunately, careful records were kept in various countries, and from these it is easy to prove the effect of vaccination.

In Sweden, during the twenty-eight years preceding vaccination, 2,050 died annually from smallpox in every million population; during the forty years following vaccination, only 158 per million. In Prague, for the seven years before vaccination, one twelfth of the total deaths were from smallpox; during the thirty-five years after, the ratio was only 1 to 457. In Copenhagen, for fifty years before vaccination, the smallpox death-rate was 3,128, and for the fifty years after, 286. In Berlin, for twenty-four years before, the smallpox death-rate was 3,422, and for the next forty years only 176.*

Figures might be multiplied, but it is useless, for the experience of almost all physicians and all hospitals proves the protecting power of vaccination. That the protection in all cases extends throughout a long life is not claimed, but even if later in life the disease is contracted,

*Figures taken from Welch and Schamberg's "Acute Contagious Diseases." (Philadelphia and New York, 1905.)

it is much lighter and is seldom fatal. Every one, however, should be re-vaccinated, when the protection is almost perfect.

The danger attending the operation is very small, and when compared with the danger attending the disease, sinks into insignificance. Every wound, no matter how slight, may become infected with disease-producing germs unless proper care is taken to prevent such an occurrence, and it is almost entirely from this cause that deaths occur after vaccination. In Germany Voight estimated but one death in 65,000 vaccinations, and in his own practice of five years he vaccinated 100,000 people with but one death. Compare. this with the deathrate before vaccination, when from one in every twelve to twenty died with smallpox, and the life-saving effect of vaccination will be evident. The dangers from vaccination may be classed as follows: 1st. Careless operation. 2d. Impure virus. 3d. Wound infection.

To avoid these, 1st. Employ none but a careful physician, who does his operation in an aseptic manner. 2d. Use only virus which is produced by manufacturers whose products are known to be pure or are examined and certified by the United States Government. The danger from impure virus is, at the present time, very small. Almost no humanized virus is used, and only healthy calves are used to produce the bovine virus. They are tested for tuberculosis and other diseases, and the virus produced is carefully examined by making cultures before it is sold. 3d. The wound must be kept clean and aceptic. In this class of wound-infection come almost all the deaths. Frequently no care whatever is taken of the wound. It is left to be rubbed and irritated by the clothing which may be none too clean, and often the child is allowed to play in the dirt of streets and stables. When dressings are put on, not infrequently they are allowed to become dirty and a source of danger. Nature does her best to protect the sore by a scab, but this is often scratched or rubbed off by the clothing, thus leaving a most excellent chance for infection. The scab should always be carefully guarded and never removed until it drops of itself.

There is also occasionally a case where the child or person is in such a physical condition that no careful doctor would care to vaccinate. These, of course, should not be vaccinated until the disease causing the disability has been removed.

It is often charged that vaccinia produces other diseases. This is as impossible as it would be to inoculate with measles and produce scarlet fever or plant corn and raise potatoes. That other diseases follow at once after vaccination is due to coincidence only. Among the millions vaccinated, it would be strange indeed if in some cases it did not immediately precede the development of some other disease, not as a cause, but merely by chance. With humanized virus it might be done, with pure bovine virus never.

The conclusions reached by a vast majority of medical men, and especially by those who have had exceptionally good chances of observation and study, are:

1st. That vaccination and re-vaccination will protect from smallpox, and that the lessened mortality and the changing from a disease of childhood to one of adult life is the result of this operation.

2d. That if proper care is observed the evil results of vaccination will be almost nil.

There seem to be two classes who oppose vaccination. First, a small class who seem to dislike to obey law or to do anything not dictated by their own will. To these we have only to say that the constitutionality of the compulsory vaccination law has been upheld by the Supreme Court of the United States. The other class, good, law-abiding citizens who want to obey the laws and to do right, but who honestly believe that there is danger lurking in the operation. They hear of a death following vaccination, and although it was as far from being the cause, and perhaps farther, than the breakfast eaten that morning, it gets the credit. To this class we earnestly appeal to study, in an unprejudiced way, the whole question and weigh the evidence for and against. It is a question of too great moment to be hastily decided from prejudice arising from a death following vaccination a death which was not caused by the vaccination, but was rather the result of an inoculation which might as easily have been received through any other wound of the skin that was not kept clean and aseptic. Compare the death-rate from smallpox before vaccination was practiced, and now, taking into account that where vaccination is not practiced the death-rate is now as great as it ever was.

It is not a disease of filth, but attacks the clean and sanitary the same as the dirty and foul. Good health or fine houses do not protect, and if to some they seem immune, it is because they are thoroughly vaccinated. The charge that physicians urge it for the fees they get is too foolish to discuss. It would be on the same par as if the physicians in turn charged that the opponents were too stingy to pay for the protection. Vilification and abuse have no place in this important matter. The medical profession has given to the world an easy, simple, and practically harmless method of avoiding the most terrible scourge that has ever devastated the world. Accidents have followed its application, so have bad men crept into the most sacred societies; but both evils can be eliminated, and neither good thing should suffer from the experience. No other way of controlling the disease is known. Quarantine is unscientific, costly, and ineffective, for contagion will not be hedged in. Besides, very many cases of smallpox are never seen by a health officer, and they are met, not infrequently, on the cars or street.

WORK OF THE STATE HYGIENIC LABORATORY.

The experience of the eight months during which the laboratory has been in operation has shown that it is possible to actively coöperate in Berkeley, with health officers in far distant cities, in the work of repressing diphtheria. The laboratory has made examinations of diphtheria cultures from epidemics in Sacramento and Ontario, with a few scattering cases from other towns. In all, two hundred and forty-one serum cultures have been examined for diphtheria.

The value of a bacteriological examination is by no means restricted to the matter of diagnosis. The laboratory furnishes an accurate means for determining the duration of quarantine. The convalescent with virulent diphtheria organisms in his throat is quite as dangerous a source of infection as a case in which the membranes are present. Owing to the great variation under different circumstances, in the time required for the diphtheria organisms to disappear from the throat,

no definite period of quarantine is just to all. Some may be released early; others drag on for months. Occasionally, in these latter instances, the organisms in the throat lose virulence, and such a circumstance warrants releasing the quarantine. Upon request by the health officer or physician, the laboratory will make an examination for virulence by guinea-pig inoculation of cultures from cases that have been under quarantine for a month or over.

When the first culture is sent from a case, and the report is desired for deciding a doubtful diagnosis, it may be possible in certain cases to render a report more promptly than usual. When such doubt exists, the physician is requested, after inoculating the serum tube, to again smear the swab against the membrane to gather as much material upon the swab as possible. Mark "swab examination" on the upper right-hand corner of the report card, and when the specimen arrives at the laboratory a direct microscopic examination will be made from the swab. If diphtheria organisms are found, a positive report will be telegraphed immediately; if not, the report will be deferred. until the culture may be examined. Experience elsewhere has shown that half of the cases reported positive after examination of the serum may be reported positive from an examination of the swab. The special swab examination should not be requested in cases for release from quarantine.

The work of the laboratory has by no means been restricted to work on diphtheria. About a hundred other bacteriological examinations have been made of sputum, suspected typhoid blood, and public water supplies.

Through the courtesy of Professor M. E. Jaffa, of the Agricultural Experiment Station, the laboratory has been able to respond to requests for examinations of foodstuffs with reference to the presence of preservatives and to make a number of important toxicological analyses. Professor G. E. Colby has made analyses of waters and septic tank effluents.

The request by the Board of Supervisors of the City and County of San Francisco that the laboratory participate in a complete investigation of the milk supply of the city in its relations to public health, has occasioned an extensive amount of work upon milk.

ARCHIBALD R. WARD, Director.

GERMANY'S WORK IN COMBATING TUBERCULOSIS.

By F. M. POTTENGER, A. M., M. D., in Southern California Practitioner. No nation in the world is going at the tuberculosis problem with so much earnestness as Germany. It is really fitting that this should be so, for this is the home of Koch, the discoverer of the tubercle bacillus. Here also lived Brehmer, that far-seeing humanitarian who was the father of the sanatorium idea, founding the first institution for the cure of tuberculosis half a century ago. He was so much in advance of his confreres that they thought him insane for persisting in his belief of the curability of this disease, which had baffled medical skill during all the ages. Largely through the labors of these two men, the one demonstrating tuberculosis to be a germ disease that can be prevented and the other that it can be cured, have the forces of the entire civilized world been directed against the great white plague.

Not only have many of the scientific problems connected with this disease been worked out in Germany, but here also has the prevention of the disease received its greatest support.

Imbued with the Brehmer idea, Germany has erected many sanatoria for the care of her people. She has 75 people's sanatoria with 7,085 beds, and 31 private institutions with 2,028 beds, and still more in the course of construction.

There is one class of persons which still deserves the earnest attention of those who are building institutions of this kind, and that is the class which is not able to enter a private institution and above accepting charity, and this class was considered at the last meeting of the Central Committee for erecting sanatoria, and it was urged that institutions be erected where a nominal sum would be charged to meet the needs of this worthy class.

The permanency of results in the sanatoria seems to be increasing. With wider experience, some of the mistakes of the earlier days of sanatorium work are being remedied and better and more lasting results are being obtained. The statistics of the Prusso-Hessian Railway Company for 1905 show that 53.61 per cent of their workers who had been discharged five years were still able to do full work. This is a gain of 4.54 per cent over the statistics of the preceding year. The statistics of Friedrichsheim Sanatorium show of patients dismissed three and four years, 70 per cent of the I stage, 55 per cent of the II stage, and 23 per cent of the II stage are still able to work.

Great as is the humanitarian movement which prompts the erection of the German sanatoria, where the poor afflicted with tuberculosis in its early stages can be restored to their earning power and to the bosom of their families, it can not compare with that other great work which has been instituted in Berlin-I refer to the "Fuersorgstelle,' or helping stations. In different sections of Berlin, the committee in charge of the tuberculosis relief work has rented apartments where the poor who suspect that they have tuberculosis can come and receive aid. These apartments are very simple and are run in a very practical and economical manner. There is no attempt whatever at show. There are two rooms, one for a waiting-room, the other for examinations. The floors are bare, the walls plain, no curtains at the windows, no furniture, except a few chairs and a table. There are one, two, or three nurses attached to each one of these stations, whose duty it is to keep a careful record of every case, take the history of the patient, especially inquiring into the conditions under which the patient lives, give instructions to each patient, visit their homes, and instruct them in the proper care of the sick, especially with reference to preventing the spread of the disease. In case anything is needed to increase the patient's chances of a cure or in order to prevent the spread of the disease, this is furnished by the station. In this way patients are sent to sanatoria while they are in the early stages. Advanced cases are directed to hospitals and homes, if there is room for them; if not, they are sometimes taken away from their densely crowded quarters where there is danger of infecting their family and placed in more commodious quarters which are provided. Sometimes pillows, blankets, or even beds are furnished to add to the comfort of the afflicted. Food is also given and flasks for the care of the sputum are always provided. The nurses make regular visits, seeing that the rules are being obeyed and giving new instructions when necessary.