CONFERENCE ON 
TUBERCULOSIS ISOLATION CONFERENCE 
ON 
TUBERCULOSIS ISOLATION 
Sponsoretl hy tke 
Calif ornia State Department of Public Health 
Held at Los Angeles 
Alarck 20, 1943 FOREWORD 
All agree that the isolation of communicable cases of 
tuberculosis is an important part of the control program. The 
concept of forcibly isolating the recalcitrant cases has not 
been accepted widely in California. In Los Angeles County, 
however, under the leadership of the late John L. Pomeroy, Health 
Officer, and Dr. Percy K. Telford, Chief of the Division of 
Tuberculosis, a policy of enforced isolation, when indicated, 
has been followed for more than ten years. More recently, other 
county and city health departments in the state have adopted a 
similar program. 
Because of the success of the program in Los Angeles County, 
and because of the great need for a careful study of this prob- 
lem by all interested parties, Dr, Edward Kupka, of our department 
suggested that health officers, tuberculosis control officers, 
sanatorium superintendents, representatives of the State Attorney 
General1s Office, and others meet for the purpose of a round- 
table discussion. Plans were laid and the meeting held at the 
State Building in Los Angeles on March 20, 19^3• 
There was general agreement that the statutes in effect at 
the present time are sufficient to provide proper legal backing. 
Particularly valuable was the recital by various discussants of 
the difficulties which face the health officer in conscientiously 
i carrying out isolation, and the solutions or suggestions evoked. 
The chief barrier to a more active isolation program seems to be 
a general lack of appreciation of its importance and necessity. 
Once this has been made clear, health officers, district attor- 
neys, and judges will feel less hesitancy in compelling the 
isolation of the recalcitrant tuberculous in suitable institutions 
or other locations where protection will be assured. 
The free discussion at the meeting was recorded. The pro- 
ceedings were moderately abridged and slightly edited; irrevelant 
material and some case histories were omitted. The resulting 
text follows. The appendix contains Mr. Martin’s legal analysis, 
pertinent sections of the Health and Safety Code, and the recent- 
ly adooted tuberculosis regulations of the State Department of 
Public Health. 
WILTON L. HALVERSON, K. D. 
Director of Public Health 
ii SUMMARY OF 
GENERAL CONCLUSIONS OF CONFERENCE 
1. The local health officer is authorized to quaran- 
tine or isolate a person with communicable tubercu- 
losis; he may do this without consultation with or 
direction from the State Health Department. 
2. The local health officer must be prudent in the 
selection of suitable cases for coercive action; 
he must be able to show that reasonable cause 
exists. 
3. Enforced isolation is to be resorted to only after 
thorough trial of persuasion and explanation has 
been made. 
4-. A person who breaks tuberculosis Isolation is guilty 
of a misdemeanor, for which he can and should be 
prosecuted, 
5» Recalcitrant tuberculous frequently present complica- 
ting factors such as chronic alcoholism or borderline 
psychosis. 
6. The experience in Los Angeles County has shown the 
practicability of enforced isolation of the tuber- 
culous, 
7. A campaign of education on the occasional necessity 
of enforced tuberculosis isolation is in order. ACTIVE PARTICIPANTS IN ORDER OF SPEAKING 
ELMER BELT, M. D. , President of the State Board of Health 
P. K. TELFORD, M, D. , Chief, Division of Tuberculosis, 
Los Angeles County Department of Health 
K. L. WYNNS, M. D., Chief, Bureau of Epidemiology. 
State Department of Public Health 
W, A, POWELL, M. D. , Health Officer, Contra Costa County 
JOSEPH L. ROBINSON, M. D., Medical Director, Clive View Sanatorium 
CHSSLEY BUSH, M. D., Medical Director, Arroyo del Valle Sanatorium 
EDWARD KUPKA, M. D., Chief, Bureau of Tuberculosis, 
State Department of Public Health 
MR. EVERETT W, MATTOON, Assistant Attorney General, Los Angeles 
MR. ALLEN L. MARTIN, Deputy Attorney General, San Francisco 
MYRNIE GIFFORD, M. D., Assistant Health Officer, Kern County 
JOHN C. SHARP, M. D., Medical and Health Director, Monterey County 
F. M. POTTENGER, SR., M. D., Vice-President, State Board of Health 
CHARLES F. BLANKENSHIP, M. D., U. S. Public Health Service 
CHARLES L. IANNE, M. D., Director of Tuberculosis, Santa Clara Co. 
JOHN D. FULLER, H. D., Health Officer, Santa Cruz County 
EDWARD LEE RUSSELL, M. D., Health Officer, Orange County 
WARREN F. FOX, M. D., Health Officer, Riverside County 
MISS ZDENKA BUBEN, Director, Bureau of Medical Social Service, 
Los Angeles County Health Department 
MR. C. 0. HARVEY, Quarantine Officer, Los Angeles Co. Health Dept. 
S. F. FARNSWORTH, M. D., Health Officer, Alameda County 
ROY 0* GILBERT, M. D. , Assistant Health Officer, Los Angeles County 
MR. W. FORD HIGBY, Executive Secretary, California Tuberculosis Ass’n. 
iv CONFERENCE ON TUBERCULOSIS ISOLATION 
DR. BELT: The meeting will come to order. The objective of 
this gathering is to discuss thoroughly the matter of enforced 
isolation of recalcitrant tuberculous patients. There are present 
here representatives of the Attorney General1s Office, of the State 
Department of Health, as well as county health officers, sanatorium 
directors, social workers, and officials of several tuberculosis 
associations. Will the following please come and sit at 
this table, to act as an advisory board of experts to whom ques- 
tions may be addressed: Dr. Pottenger, Dr. Bush, Dr. Telford, 
Dr. Cohn, Dr. Wynns, Dr. Kupka, Mr. Mattoon, Mr. Martin and Mr. 
Higby. 
The first item on the program is a paper by Dr. Telford which 
will relate the experience of Los Angeles County in the matter of 
enforced isolation of the tuberculous and which will serve as a 
basis for subsequent discussion. I hope this discussion will be 
as free as possible. Dr. Telford. 
DR. TELFORD: Of prime importance in considering the subject 
of isolation of tuberculosis is the fact that in the dozen years or 
so that we have been engaged in the work, of all the difficulties 
and criticisms that we have encountered, no one has ever expressed 
the opinion that such isolation was not desirable from a medical or 
epidemiological standpoint, if the procedure was found practicable. We have, therefore, a sound medical and public health basis for our 
attempt to segregate the spreaders of this disease. 
There were a number of circumstances that persuaded us to 
embark on this attempted isolation. In the first place, it was 
realized that the incidence of the disease has been reduced to a 
low enough level that we could begin to consider the possibility 
of exercising control over the most dangerous cases, at least. 
That this procedure was becoming possible at this time was due 
largely to the great increase in institutional beds devoted to the 
care of the tuberculous patient. In the early period of the rapid 
and widespread development of tuberculosis sanatoria, their prime 
purpose usually stated as being particularly for the care of 
early, minimal cases that could be expected to be improved by 
institutional treatment. The proportion of minimal cases found 
in clinic work and surveys became a fetish and an obsession. It 
soon dawned on us that we were sending many minimal cases to the 
institution that were not active, and repeated studies of the fate 
of the minimal cases discovered showed that the care of minimal 
cases was not a major part of the campaign against tuberculosis. 
We found that the minimal cases that stayed at home had a better 
record than those that went to the institution—which fact could 
not be accepted at its face value, because, of course, the worst 
cases were more easily induced to go to the sanatoria, and the 
cases that remained at home as a consequence were likely of a less 
serious nature. But the finding was significant enough to point 
2 out the fallacy of the original idea of establishing public sana- 
toria primarily for minimal cases. 
It was also found that when the insignificant minimal lesions, 
which proved to have no activity, were eliminated, there was a 
certain maximum of new active minimal cases that could be discover- 
ed on any sort of survey. The institutions were found to contain 
from two-thirds to three-quarters of advanced cases. The conclu- 
sion, therefore, soon followed that a comparison of the mortality 
rates in the institutions and of discharged institutional cases 
with mortality rates of patients without sanatorium care failed to 
demonstrate advantages in treatment that were worth the trouble and 
expense. The greatest advantage of institutional care for tubercu- 
losis accrued from the segregation of advanced patients from the 
rest of the population, particularly from the intimate contacts in 
the homes. If that separation of the patient from those he was 
likely to infect was to be effective, certainly some legal control 
over the movement of the patient had to be established, and not 
left entirely to the voluntary cooperation of the patient. 
Another situation arose in which we had to go forward with a 
widespread public education program of the danger of the spread of 
the disease, or else acknowledge as a Health Department we were 
incapable of coping with the situation. For many years we made the 
rounds of all the schools in the County, tuberculin testing child- 
ren and X-raying the positive reactors, and in later years attempted 
to examine in the same manner all household contacts of positive 
3 reactors. Wo had one physician employed full time holding confer- 
ences with some responsible adult member of the positive reacting 
students to explain the communicability of tuberculosis. These 
parents, guardians and relatives were exercised over the evidence 
of live bacilli in the student and eagerly absorbed the information 
given to them orally and in pamphlet form. It was emphasized to 
them that the child was infected because the sputum of a person ill 
with tuberculosis had gotten into the mouth of the child, that such 
exposure continued in later years could result in chronic second- 
ary infection, and that they had a right to demand of the Health 
Department that they be protected against such infection. In this 
situation what could we do but enforce isolation of known danger- 
ous cases? 
As a corollary and necessary contributing legal function, we 
had to also require by legal order the examination of refractory 
household contacts and reasonably suspected cases. As you may 
interpolate, no such arbitrary action as we have been carrying out 
in the control of tuberculosis is possible without the support of 
the general population, and the education accomplished in our 
school surveys created, not only a permissive attitude in our people, 
but an enthusiastic support of our segregation of dangerous cases. 
i 
This is evidenced by the fact that in the many hundreds of arbitrary 
legal actions that we have instituted, there has never been any 
popular objection voiced to the Courts, the Health Officer, the 
Supervisors, or the press. The greatest obstacle we have encountered has been a reluc- 
tance, or a fear, of officials to embark upon a new and untried 
legal procedure because of the theoretical responsibilities involved. 
Even- Dr. Pomeroy, who was our County Health Officer at that time, 
and who was particularly interested in tuberculosis and gave us 
hearty support in any reasonable activity in the suppression of 
tuberculosis, gave his approval to the procedures with great trepi- 
dation and remained fearful for years of some embarrassing reper- 
cussion from these activities, I can remember several Instances, 
early in our experience, where the patient made such vigorous 
protest to Dr. Pomeroy he summarily cancelled our order, and in- 
variably these orders had to be reissued at a later date with Dr. 
Pomeroy’s support. The evidence of grossly positive sputum, and 
oftentimes new cases developing in the family in contact with such 
a patient, is a challenge to any Health Officer who has the means 
at his disposal to suppress such spread. 
Our experience in court in the many instances of prosecution 
for violation of isolation orders for tuberculosis has Impressed us 
with the almost universal wholehearted support of the Justices. 
The only criticism expressed by these Judges has been related to 
the vigorous objection of patients isolated in some of our private- 
ly operated institutions housing public patients, where the care is 
known to be inadequate. It is going to become necessary to restrict 
our legal isolations to placements in public institutions approved 
by and subsidized by the State Department of Health, Satisfactory 
5 isolation is not always necessarily in an Institution, for we have 
many patients who arc adequately isolated at home. All other 
variables from these typical situations, such as the chronic in- 
fected and more or less healed persons with rare tubercle bacilli 
in the sputum, or with insignificant cases with infection in the 
sputum demonstrable only by gastric lavage, are dealt with con- 
sistently with the facts in the individual case and the restric- 
tions and supervision are modified as indicated. 
The widespread activities of health agencies in surveying 
various groups of students, industrial workers, of inductees and 
enlistments in the combat forces and contact surveys, are of small 
avail if wo exorcise no effective control over those who are known 
to be spreading the disease. It is comparable to be forever bailing 
the boat without making an effort to plug up the leak. It would be 
interesting to review the activities of the various health agencies 
in the past generation that have accomplished so much, and brought 
us to the point where we now stand where it is possible to exercise 
adequate control over the great majority of the persons who are the 
source of all of our new cases. The percentage of unknown, danger- 
ous cases is becoming smaller constantly as a result of all these 
activities, and will become still smaller, as the dangerous afflict- 
ed persons become more conspicuous by their rarity. Statistics, 
tables, percentages and all sorts of tiring figures have been 
scrupulously avoided in this discussion, but a request has been 
received for a statement of these activities in figures as experi- 
6 enced by the Loo Angeles County Health Department. The Los Angeles 
City Health Department has been equally active, but its figures are 
not included here. The first order of isolation was issued May 1, 
1931, and the present legal form instituted November 11, 1931. 
During this period of twelve years there wore 1,436 orders of isola- 
tion in Institutions, 1,125 examination orders served, and there 
were instances of the officer inducing the person to comply 
without serving the order. Arrests and convictions for violation 
of any of these orders amounted to 233* One case was lost and we 
felt that it was due to the prejudice of the jury against conditions 
in a small rural institution. One complaint was refused because it 
would mean life imprisonment for an habitual criminal and one or 
two other complaints were refused for reasons not pertinent to our 
study. Evasion of orders by desertion numbered 191. Those ore the 
significant figures and there is no need to burden you further. 
There arc many other activities incidental to this work,such as 
transfer of place of isolation, miscellaneous investigations and 
inspections, and office work of recording, filing, and termination 
of orders because of healing or death or return to legal residence. 
There have been comparatively few isolations in homes in the past, 
but increasing requests arc being received from the health dis- 
tricts. A majority of those now in force are instances of transfers 
from institutions to homes. These transfers must be made on demand 
of patients when they have secured proper places of isolation in 
some home. 
7 In conclusion it might be in order to advise caution against 
misuse of this power. Any evidence of any worker using this author- 
ity as punishment for insults, as a threat or to secure consent to 
treatment indicated, is summarily suppressed. There are some situa- 
tions that are on the borderline of dangerous spread when other 
factors influence the decision such as minors experiencing neglect 
or treatment by flagrant quackery. This responsibility of review 
and decision must be the responsibility of one individual in each 
organization, and he must exercise all the judgment he possesses. 
(Dr. Telford continued extemporaneously as follows:) 
I might say from our experience that what justices would like 
would be a statement as to the attitude of the State Health Depart- 
ment regarding the need for isolation in tuberculosis. We need such 
a statement to cover the question of whether the patient complies 
with the orders that are placed upon him by the health officer or 
by the deputies of the health officer, because in the Code these 
are already well defined, and the authority of the health officer 
is clearly laid down, together with the penalty for violation of 
his orders. 
Tuberculosis is listed among the many contagious diseases in 
which he may take action, but tuberculosis is buried in a long list 
and seems a little obscure to the justices. In no place have we 
something definite to point to stating it is the attitude of the 
health department that it is necessary to isolate patients with 
g dangerous numbers of tubercule bacilli in the sputum. 
Communicability of tuberculosis varies in individuals, and it 
is vastly different from the danger that exists in other diseases. 
Wo know that it takes a long, continued exposure in a. home in the 
usual circumstances before it is spread among other members of the 
family, and that home is the place where it is usually acquired. 
On the other hand, however, we do heave individual cases that are 
quickly and dangerously affected. ’We had a person of teen age last 
week we had X-rayed the year before and found negative who now has 
acute miliary tuberculosis with meningitis. 
DR. BELT: Dr. Wynns, will you tell the audience about the new 
regulations concerning tuberculosis? 
DR. K. L. WYNNS, Chief, Bureau-of Epidemiology, State Depart- 
ment of Public Health; We have prepared new regulations that fall 
well within the lines that this meeting is taking. The old regula- 
tions were passed many years ago and had practically no teeth. 
Whatever activity was undertaken in the matter of tuberculosis was 
done under the General Health Laws and not under the tuberculosis 
regulations. It might be well to read the sections that we have 
written and which may be adopted with certain revisions, of course, 
depending somewhat on the tone of this meeting and, of course, the 
final consideration of the Board. At the present moment the sug- 
gested regulations are: 
Part A. “Patients with positive sputum shall be considered as 
fulfilling the requirements of isolation a„s long as they are under 
9 adequate medical supervision and observe the instructions issued by 
the health officer. If there are any young children in the house- 
hold, the degree of isolation for the patient shall be such that the 
children are adequately protected and shall conform to the require- 
ments of the health officer." 
This first section is not a great deal different from the 
corresponding passage in the present regulations. In the past the 
individual who obeyed instructions of his physician and health 
officer was considered as fulfilling the requirements of isolation. 
Section B we now have is—"Persons with a grossly positive 
sputum shall not engage in any occupations involving the handling 
of foods or come in close contact with children or young adults. 
Also, persons suspected of having an open case of tuberculosis shall 
not engage in any of these specified occupations until it has been 
determined to the satisfaction of the health officer that the sus- 
pected case is not a communicable case of tuberculosis." 
Part C—this is the part that we are quite interested in. We 
would like to have everyone’s reaction to this section. "Tubercu- 
lous patients with positive sputum who refuse to observe the health 
officer1s instructions and thereby expose others needlessly to in- 
fection shall be placed in quarantine, including the placarding of 
the premises, until such time as the health officer feels that such 
quarantine is no longer necessary for the protection of the public, 
and in the event that such quarantine proves inadequate for the 
protection of members of the household or community, the patient 
10 shall be placed in isolation in quarters designated by the health 
officer until such time as such isolation is no longer necessary for 
the protection of the public.” 
This paragraph, of course, allows for the old quarantine which 
there has been very little criticism over or objection to—quaran- 
tining a case in the home. However, all health officers have come 
up against the problem of quarantining an individual in the home 
along with two or three or four small children, and quarantine under 
those circumstances is unsatisfactory because those children are 
still exposed to an open case of tuberculosis. I know of one in- 
stance in which the individual wont so far as to say that they were 
his children and if he wanted to spit in their soup and give them 
tuberculosis that was his business—not the health officer's! That 
is the type of individual we are dealing with. We are not dealing 
with the usual case of tuberculosis who is quite willing to follow 
regulations. 
Under the above circumstances, a quarantine and placarding of 
the home may protect the public, but it does not protect other 
members of the household. So, the health officers in some instances 
have been able to remove the ill member from the household to other 
quarters. It would usually be a tuberculosis hospital. And I think 
that is what we are all most interested in. That has been done in 
this part of the State. Unfortunately, I don’t think we have very 
many instances of that being done in other parts of the State. 
11 I think that covers the proposed regulations. The actual word- 
ing, as I have given it, may be changed, but the section on enforced 
isolation should remain. 
DR. BELT: The meeting is now open for general discussion. 
DR. W. A. POWELL, Health Officer of Contra Costa County, 
Martinez; Suppose we proscribe an area of isolation and put up 
quarantine signs for an uncooperative tuberculous. Our county is 
a rural county, as are most of the communities, and, of course, the 
man breaks the isolation and goes around. Wo catch him somewhere 
else, eating in a public place maybe. We take him into the court. 
In one or two instances we have suggested to the court beforehand 
that this man, after he has been given a six months’ sentence say, 
that he be suspended, provided he was sent to the county sanatorium. 
The man goes to the county sanatorium, gets drunk about a week 
after he gets there, or he doesn’t like the way they treat him under 
present regulations of all sanatoria—and that is where I think the 
center of control should be. Ho is allowed to go to that office 
and sign out. Here is an infectious disease that is allowed to go 
and say, ’’Pooh” and out ho goes. Ho comes back to us. We put him 
then in contempt of court. I don’t know what the legal name is, but 
anyway the judge will say, ’’You have got to go to jail and spend six 
months.” 
We have an isolation ward in the county hospital. It is un- 
fortunate that our tuberculosis sanatorium is at Weimar, which is 
about one hundred miles up in the foothills, and shared by thirteen 
12 counties. So it isn’t in our county. We can’t, pick him up then and 
put him in the isolation ward, and we can’t put him in the open 
tanks in the county Jail, so we are right back whore we started. 
It seems to me that there is a legal side. When this man comes 
up to the sanatorium he carries an infectious disease. The State 
Board of Health, in cooperation maybe with the local authorities, 
could appoint the superintendent of that hospital as a deputy health 
officer. When this man gets into Placer County, where Weimar is 
located, and if the State Board of Health has regulations which say 
this man will be confined in that hospital unless he carries out 
other recommendations, the health officer, who in this instance is 
the superintendent of the hospital, says that he must stay there, and 
then if he comes and wants to sign out, the superintendent of the 
institution will say, ’’I’m sorry, but the State law won’t permit.” 
You will say well he gets drunk and goes off anyhow. It seems 
to me that could be overcome in that institution by having a special 
ward whore ho would be given treatment Just like anywhere else. Put 
a barbed wire fence around it and put him in there. Give him every 
consideration that the others have, except that he can’t get through 
the gate. It seems to me something like that is going to be the 
solution of this problem. In the city where you have plenty of 
policemen and where you have your own tuberculosis sanatorium, it 
is different from in our own community. 
Here, too, undoubtedly, as the doctor has said, you have 
arrangements whereby the sanatorium doesn't allow these people to 
13 go home unless there are facilities for adequate isolation of this 
patient in the home. That, of course, is an ideal condition. I 
frequently have arrangements like that with our sanatorium. That 
would be ideal. But this positive patient can leave. The other 
day we had a man in the county hospital, suffering from hemoptysis, 
who had been out of the sanatorium three months. He had signed out. 
In their large turnover, they had lost track of the man, and we 
didn't know he was oven out. We had no idea where he was. He was 
simply going all around the country. 
There arc other points I would like to mention, but I think 
the secret of this thing, especially for those who are in counties 
with the sanatorium in another county, and there are other counties 
in the same fix, is for legal machinery to be set up. Maybe I am 
wrong on this. A case of diphtheria couldn’t go out. A case of 
this type can’t go out of the isolation ward unless there are facil- 
ities for isolating it at home, and I don't see why we can't do the 
same with tuberculosis. 
DH. BELT; If Dr. Robinson will tell us how Olive View treats 
the person who wants to go home and who is under isolation, then we 
will go back to Dr. Telford for the Department of Health viewpoint, 
DR. JOSEPH L. ROBINSON, Clive View Sanatorium, Olive View: I 
think the remarks Just made are extremely pertinent. Here in Los 
f 
Angeles where you think perhaps we have good facilities for taking 
care of these people, there are about 2,300 beds for tuberculosis, 
and for about a year we have carried on a very active isolation 
114- policy in cooperation with the health department. In that year we 
have learned a few things about the advantages and difficulties of 
such a policy. 
Olive View has many patients who are under an order of isolation, 
and some of them have been returned. Our greatest difficulty has 
been with the chronic offenders, the so-called recalcitrant, about 
whom this conference was called. We have said to ourselves on 
several occasions that the problem would be greatly simplified if 
we had somewhere a sort of penal institution where those recalci- 
trants could be placed, they would be unable to leave and could at 
the same time have proper treatment for their tuberculosis. When 
a patient breaks an order of isolation here, the health department 
first tries to find him and return him to the institution from which 
he left. If the patient is unwilling to return, then he is brought 
to court before the justice of the territory in which he resides 
and is probably sentenced. If he is sentenced, he is apt to bo put 
in jail. If he is sent to jail, he is not getting adequate treat- 
ment for his tuberculosis, and I don’t believe any of us whose main 
responsibility is the cure of tuberculosis are pleased about such 
a situation. 
In this county there are a number of patients who have long 
records of going in and out of sanatoria. They arc returned to the 
sanatorium and they go A. ¥. 0. L. They are picked up and sent 
back to another sanatorium where they stay a week or a few months 
and go A. ¥. 0. L. Then they are picked up again and they may go 
15 to jail for awhile. During that time they are not getting any better 
and they are often out of the sanatorium longer than they are in it; 
we know that they are spreading tuberculosis during the time they 
are out, and the order of isolation is not effective with such in- 
dividuals. 
At Olive View and its associated sanatoria, when we adopted the 
policy of universal orders of isolation a year ago, we were somewhat 
dubious about what its effect would be on our patients, and in order 
to insure that there would be as little opposition as possible to the 
program, we insisted that patients coming under an order of isolation 
be given the same privileges in regard to passes and other privi- 
leges that other patients were given, so that they wouldn’t have a 
feeling that they were being discriminated against, and I think as 
a result of that attitude we have had almost no opposition to our 
program among the majority of our patients. 
But we still have the problem of the recalcitrant patient. We 
tell our patients when they threaten to leave that if they do we 
will report them to the health officer by telephone the moment they 
leave, and we feel certain that some action will be taken. This has 
been a deterrent factor in keeping a great many from leaving. But 
the habitual A. W. 0. L.1er just doesn’t pay any attention to such 
talk, so I would like again to stress the suggestion that a penal 
institution of some sort be made a part of our program of isolation 
for recalcitrant natients. 
16 DR. TELFORD: When we began our program in Los Angeles County 
it immediately became apparent that eventually some sort of physical 
setup for the forcible control of a few individuals would become 
necessary. I think that will be an ultimate result of this program 
wherever it is Instituted, Fortunately only a few of the patients 
would have to bo confined in the "barbed wire" enclosure to make a 
program one hundred per cent effective. There is always an occasion- 
al individual who has no sense of responsibility. Many are border- 
line mental cases that cannot bo controlled otherwise. It would 
take only a very few beds, even in this large county. I would say 
a place of six beds would bo sufficient. The mere existence of such 
a place would cure many of our A. W. 0. L. patients who are not 
afraid of jail. 
As far as deputizing the superintendent of hospitals is con- 
cerned, it was considered, and we felt it practicable to put the re- 
sponsibility on the patient. If the order is violated, the patient 
is at fault and is charged with that violation. I feel that the 
institution should not be burdened with the keeping of patients 
under these isolation orders, except in such a place as we have just 
been discussing. But for the vast majority I feel that all that is 
necessary is to issue the order for the patient and if the patient 
leaves, prosecute the patient. 
I think the introduction of the word "quarantine" into this 
procedure is rather unfortunate. Quarantine is applicable to an 
area of danger or applicable to the confinement of persons exposed 
17 to disease during the incubation period, being under observation to 
see whether they develop the disease. Strictly speaking, patients 
are never quarantined* Sven when a patient is within the area of 
quarantine, the patient is isolated and the quarantine is for the 
observation of contacts and to prevent others having access to that 
dangerous area. 
It is an important point, because in the minds of the courts 
and other workers in hospitals and in the minds of patients, quar- 
antine has more stigma attached to it and they feel tha.t inhere arc 
greater restrictions than actually exist, I believe that speaking 
of the restrictions on the patient, it is very much more desirable 
to speak of it as isolation. 
DR. BELT: Dr. Bush, have you any contribution to make? 
DR. CHESLSY BUSH, Medical Director Arroyo del Valle Sanatorium, 
Livermore; Well, tnero seems to oe a hiatus in this program in the 
State of California, and I was interested enough last year to send 
around a questionnaire a.nd found that the isolation oi tuberculosis 
in California, except for a few scattered instances, is carried 
out only in Los Angelos County, I also found, however, uhau SO per 
cent of the health officers were sympathetic with the idea, but 
felt that the legal profession in their vicinity, and probably the 
public as well, were not yet sufficiently sympathetic to be of 
assistance. And the suggestion was given in several instances that 
it was an amazing thing that in Los Angeles Gounuv there nevei nao. 
boon any organized opposition to the program. There never had been 
Ig any largo sized or publicized public trial in relation to it. 
Ac far as Alameda County is concerned, we have all of the prob- 
lems that have been brought out this morning, and there seems to be 
no question in my mind that it would be helpful if we had some more 
power to isolate some of the recalcitrant patients. But it seems 
to me that the question, as far as the rest of the State is concern- 
ed, is not so much a matter of the opinion of the health officer at 
the moment, but rather the opinion of the district attorneys. I 
wonder, Dr. Kupka, whether there has been any organized effort to 
bring the district attorneys together to discuss this problem. 
DR. KUPKA: Mr. Chairman, perhaps Mr. Mattoon can tell us about 
that. 
DR, BELT: Mr. Mattoon, 
MR. EVERETT MATTOON, Assistant Attorney General, Los Angeles: 
I don't know whether this is the stage at which you wish to enter 
upon the discussion of the legal phases. I happen to be in charge 
of the southern California office of the Attorney General1s depart- 
ment of the State, and we have, at the request of Dr. Halverson, 
interested ourselves in this meeting—very gladly. Mr. Martin, the 
deputy in the San Francisco office of the Attorney General has been 
preparing a resume of the legal provisions for the purpose of this 
meeting, and was kind enough to come down here for that purpose, and, 
Dr. Belt, I think if you desire a resume of the legal provisions, 
Mr. Martin would be very glad to present them. 
19 Mr. Martin was formerly a district attorney in one of the 
northern counties of the State where they are not as conscious of 
this problem, or have not been as energetic in its treatment or 
application, and I, having served as County Counsel here for twelve 
years, am of the school in Los Angeles County which developed, with 
Dr. Telford and Dr. Pomeroy, the approach and the technique now 
being applied in this county. Our attitude was one of accepting the 
challenge and leaning toward enforced isolation whenever it became 
necessary, 
DR. BELT: Mr. Martin is the deputy for both the Department of 
Public Health and the State Board of Medical Examiners, so he has 
great familiarity with these medical problems. 
MR. ALLEN MARTIN, Deputy Attorney General, San Francisco: I 
might say preliminarily anything that is stated by me today is the 
expression of the opinion of Allen Martin, the Deputy Attorney 
General, and does not necessarily constitute the expression of the 
opinion of my superior. It is not only a practical rule of our 
office, but also an essential rule that any opinion issued by our 
office must have the endorsement of the chief, So, I can only give 
you the benefit of my limited ability to engage upon the research of 
some of the authority in the light of limitation of time available 
to me. 
I believe it can be said without danger of satisfactory or 
successful opposition that health authorities can take all reasonable 
steps to curb the development and the spread of tuberculosis infec- 
20 tion. It is definitely provided in the Health and Safety Code of 
this State that tuberculosis is a so-called contagious, infectious, 
communicable disease. It is also designated as a reportable disease. 
On the basis of the broad power which has been vested in the vari- 
ous health officers by the Legislature, it is my opinion that not 
only can the health agencies quarantine those infected with tuber- 
culosis, but they can go farther. They can isolate them in places 
where others will not be in danger of Infection. 
It is rather interesting to note that the books which report 
the decisions of our appellate courts and of our supremo courts are 
almost silent on the matter of quarantining and isolating tubercu- 
losis cases. I suppose that results from the fact that the disease 
is slow in its development and just as slow in its retrogression, and 
the period of activation is less well defined than is the period of 
activation of other diseases, such as smallpox and measles. We have 
several cases in the State of California which endorse the isolating 
of other diseases, and, more recently, cases with venereal diseases, 
I think one of the cases with which all health officers are familiar 
is the Johnson case. 
Every case turns on its own facto. No lawyer nor court can tell 
health officers when a. case should bo isolated, or when a case should 
be quarantined. That is a medical matter. That is something that 
must be decided by the health officer on a medical basis. 
There is a provision of the Health and Safety Code that health 
officers have a right to take such steps as are reasonably necessary 
21 to protect the public, in the event there is an existence of a 
disease in an infectious, communicable state, if they have reason 
to believe that such disease exists. Now, when you health officers 
shall have reason to believe that such a disease exists in such 
state, I don’t believe any lawyer can tell you. The Code also pro- 
vides for penalties which will be imposed upon those who violate 
any orders of restriction which have been imposed upon them by the 
health authorities. 
However, the courts have gone to this extent—they have held 
that in the event the action of the health authority is attacked by 
the patient or someone representing the patient, the burden is on 
the health officer to justify his action by showing that there is 
reasonable cause for him to believe that the disease exists or has 
existed. That doesn’t mean that he must prove that the disease in 
fact exists, because there may be reason to believe that the disease 
exists when upon examination you will find that the disease does not 
in fact exist. Whot constitutes reasonable cause to believe is 
another matter which is dependent upon the particular situation. 
It’s rather peculiar to observe in this section of the Health 
and Safety Code which provides that ”any person who, after notice, 
violates, or who, upon the demand of any health officer, refuses or 
neglects to conform to any rule, order, or regulation prescribed by 
the State Department respecting a quarantine or disinfection of 
persons, animals, things, or places, is guilty of a misdemeanor,” 
that it refers to rules with respect to quarantine or disinfection, 
22 and that there is no reference made therein to isolation. I am 
wondering whether, however, the Legislature felt or thought that 
isolation is included in the broad term of "quarantine." I am 
inclined to believe that quarantine is sufficiently broad perhaps 
to include isolation. 
The next section, however, goes farther. It provides that a 
person is guilty of a misdemeanor in this instance: When any person 
is afflicted with any contagious, infectious or communicable disease 
and wilfully exposes himself to the public, and so forth. I think 
that the mechanics are well set up by the provisions of the Health 
and Safety Code with respect to contagious, infectious and communi- 
cable diseases, on the basis of which the health officers are em- 
powered to act. I think there are ample teeth in the appropriate 
sections of the Code to protect health officers and to enable them 
to go ahead, 
I really believe, and I think Mr. Mattoon and our superior 
share that opinion with me, that this is a practical matter. It’s 
a matter which requires education, the dissemination of information 
to the end that g9od will and cooperation on the part of the patient 
and on the part of the public will result. Undoubtedly, as Dr. 
Powell stated, it is necessary at times to restrict patients who 
have been isolated, and I believe that there is ample justification 
to isolate as well as to quarantine, and when he should do it and 
the manner in which he should do it is his problem. 
23 HR. MATTOON; Do you wish to file the memorandum that has been 
p r c par c d on this? 
MR. MARTIN: I have prepared a memorandum. It is silent on 
the matter of isolation, but I think we could file this with the 
reporter. (This memorandum, by its reference here, is made a part 
of this report. See Appendix A.) 
DR, BELT: It's your opinion, then, that the health officer can 
take any steps ho sees fit, even to the use of physical force, to 
make these patients enter a hospital for confinement, and if they 
break those rules to put them in involuntary confinement or jail? 
MR. MARTIN: Of course, he wouldn't have the right to put them 
in jail without an order of the court. He has a right to house them 
in quarters which are provided for the purpose of correcting their 
physical condition as it does exist. In the event they violate such 
orders, ho has the authority to bring the matter through the proper 
channels to the attention of a court of proper jurisdiction, and in 
view of the provisions of the Health and Safety Code, the violator 
can be taken and then can be found guilty. If he is in fact guilty 
of a violation of the section of the Code, in other words, found 
guilty of a misdemeanor, then the court can mete out such penalty 
as is necessary, and I think it's within the power of the court, if 
it desires to impose probationary terms, to suspend sentence and 
direct the confinement of a person in a proper institution. 
DR.MYHNIE GIFFORD, Assistant Health Officer, Kern County: I 
should like to state that we have found what you have said true in 
2K Kern County, Not once have we had any difficulty in getting the 
cooperation of the district attorney. We have made mimeographed 
copies of Section stating the duty of the health officer to 
prevent the spread of certain diseases, including tuberculosis, and 
also the section including the penalties of violation for failure to 
cooperate with the health officer, and wilfully exposing others, and 
in no instance have we had any trouble in securing the cooperation 
of the District Attorney in Korn County, 
For a number of years wo have been requiring all of our open 
cases of tuberculosis to be isolated. In most instances, they have 
needed to be isolated in a hospital. In addition to the sanatorium, 
wc have two xtfards in the Kern General Hospital. 
Also, the director of our tuberculosis sanatorium has taken the 
stand that patients in the sanatorium must conform to certain rules, 
and he will not continue to allow patients to stay who break these 
rules. For instance, smoking is forbidden, and there are certain 
other rules that they must not break. So that if he releases them 
and they are open cases, we have to get them into the tuberculosis 
ward of the Kern General Hospital, and in some Instances we have had 
them arrested. But they are never held in jail. They are brought 
to the psychopathic ward, as a rule, which is a locked ward. And 
they may stay there overnight or possibly over the week end, and then 
wc usually transfer them to one of the tuberculosis wards. 
They sometimes leave without permission, but they are persist- 
cntly brought back. Sometimes they come back before they are 
picked up. 
25 DR. BBLT; That is a very practical review, Dr. Gifford, thank 
you very much. Mr. Mattoon, can you give us the details of any 
practical experience you have had in attempting to enforce the law? 
Has it come under your province to try some of these cases? 
MR. MATTOON: We have had no direct administrative contact with 
this in the Attorney General1s office for the last four years. I 
have merely referred to the development of the trend Los Angeles 
County has taken which differs from that of other counties. This 
is an opinion here dated September S, 1931» which was the first 
assurance given Dr, Pomeroy of legal protection in his desire to 
isolate. This opinion back in 1931 from the County Counsel’s office, 
which is the civil legal office of this county, gave him that 
assurance, and based upon that assurance he proceeded with what has 
developed to be the administrative policy of Los Angeles County. 
In the Attorney General’s office, we have various assignments. 
Mr. Martin is assigned to some of the administrative boards and 
tribunals, of which the State Board of Health is one. 
But the matter of actual enforcement is relatively simple. It’s 
not involved at all. It could be handled by anybody in the local 
district attorney’s office and is purely routine once the courts 
recognize the effectiveness of the law. Although, as Mr. Martin 
said, the term tuberculosis itself has not yet been identified or 
classified with infectious and communicable diseases in the same 
sense that smallpox and diphtheria and measles are, I sometimes 
think that is a good thing. It places it on a little different 
2 6 plane, but it does give rise to an erroneous conception on the part 
of some people as to the extent of isolation and treatment that can 
be applied. I sec no reason why, with the gradual reaching out such 
as this representative group is bound to bring about, a different 
conception in other communities cannot be brought about similar to 
the one found to be highly advantageous and effective in Lon Angeles 
County. 
DR. JOHN C. SHARP, Medics! Director, Monterey County Hospital; 
It seems to me that in this discussion one thing is important and 
that is the definition. What is an open case and what is an in- 
fectious case? What is a positive sputum? I have heard the term 
used this morning of a grossly positive sputum. I think we all know 
what a grossly positive sputum is, but there might be oases where 
sputum is not grossly positive, but which night be equally infectious 
from s public health standpoint. Before we proceed, I think we 
should have an exact definition of what we mean by an infectious 
case of tuberculosis. 
DR. BELT: Thank you very much. I would like to have Dr. 
Telford and Dr. Pottengcr discuss that point. Dr. Telford. 
DR. TELFORD: I think Dr. Pottenger will be able to give you 
the information you wish on that score. When I use the term, Dr. 
Sharp, I have in mind the positive smear. 
DR. POTTEHGrSR; Knowing this question would come up, I looked 
over some of our cases which we have followed for as much as fourteen 
years. I think this is one of the most important questions that we 
27 have to deal with: when is a patient infectious, when is he not, 
and when is he dangerous? (At this time Dr. Pottenger discussed in 
detail the case histories and laboratory studies of two patients 
who were alternately positive and negative over a period of many 
years,) 
We have innumerable examples of this kind. One very important 
thing in the cases we have observed, we haven’t had a single case 
of a contact who has developed open tuberculosis. That is very 
interesting. Further, not one of these patients has later broken 
down. That is another important thing. I think the greatest danger 
is to the patient himself, because he has the infection in his body 
and the spread can readily take place under bad circumstances. Now 
these patients, remember, all live under good circumstances, at a 
different level from many county patients. The latter, as a rule, 
live in overcrowded quarters. Many of them have insufficient food. 
These are the conditions which would make for a ready transmission 
of the disease and also for breakdown. 
According to the Whitney Report brought out; recently by the 
National Tuberculosis Association, two-thirds of those discharged 
patients who had tubercle bacilli in their sputum died within five 
years. Of those who were bacillus free, one-fourth broke down 
within five years. But that is a different point. What we are try- 
ing to discuss here is "When is a patient bacillus free?". It is 
in part academic, and when the sputum is very slightly infected, I 
do not believe that it is particularly a public health question. 
2E5 But when the sputum is grossly positive, it is dangerous. Some 
patients do not expectorate more than 200 bacilli p» day when they 
are positive. With this number it would be almost impossible to 
infect anybody unless the bacilli were put directly into the vistim’s 
tissues. Most of these expectorations take place the first thing in 
the morning, and much of the time the patient does not expectorate 
bacillus-bearing sputum. 
I am very glad to hear the expression by Mr. Martin and Dr. 
Telford that tuberculosis is so different from other diseases. That 
is true. I can see no place for the theory of the high infectious- 
ness. If it were such a dreadfully infectious disease, the whole 
world would have died of it. All the population would have died 
of it before Koch discovered the bacillus. In my own institution, 
which has now run for thirty-eight years, we have not had a single 
infection that we know of among the personnel except one, who lived 
with his wife, who had tuberculosis for eight or ten years before 
he came to the sanatorium. 
Where reasonable care is taken, most of the danger of tubercu- 
losis is removed. There are certain people who will not take proper 
care. Some of these are vicious and don’t care, and I think the 
State Board of Health or the local board of health should have the 
right to handle these people effectively, because society must be 
protected. 
I rather think, too, that as the tuberculosis rate goes down, 
the danger is going to become greater. I think we have evidence that a patient with primary tuberculosis infection has thereby gained 
a protection, since this infection stimulates the patient's immunity. 
Now, as the disease becomes less common as our tuberculosis infec- 
tion rate goes down, we may revert to practically the same condition 
as our aborigines, and we know that tuberculosis in them takes a 
more acute form. We will have to consider more careful public health 
measures as this change takes place. 
DR. BELT: Dr. Pottengcr, in specific reply to Dr. Sharp’s in- 
quiry, what do you consider a grossly positive sputum? 
DR. POTTENG-ER: I would reply that grossly positive should refer 
to sputum in which we find bacilli by direct smear. We have to bear 
in mind that many examinations are done carelessly. Take, for in- 
stance, the collection of sputum. What kind of specimens do you 
take? We take three-day specimens always. The patients guve us 
everything they raise, and after treatment and staining, we search 
it for ten minutes before we declare it negative. We use picric acid 
as a counterstain, which permits a film five times as thick as with 
methylene blue, and consequently aids in finding the organisms. I 
would say that any patient in whose sputum bacilli are found by 
direct smear is undoubtedly dangerous. I won’t say quarantine or 
isolate all of those patients, but I think it would be practical to 
give boards of health the power to do it when the patient is careless 
and won’t take care of himself properly. 
DR. BELT; Would you consider incorporating a definition of 
positive sputum in the body of any new regulations? 
30 DR. POTTENGER: I don't believe so. I think it would be bettor 
to have this understood by health boards without being in the Code. 
DR. POWELL; I would like to ask Dr. Pottenger a question. You 
know the state law about tuberculosis examinations for teachers. 
In our county, the County Public Health Association, and the Tuber- 
culosis Association, too, voluntarily took this upon themselves and 
fluoroscoped all teachers. Wo find a teacher who has what the 
fluoroscopist feels is some questionable thing. We have an X-ray 
and it still shows some question, and then we make sputum tests on 
this patient and they are negative. We don't have a stomach wash. 
This patient has shown a questionable shadow on the X-ray film, and 
still has negative sputum for a period of six specimens. Do you 
think the health officer would be right if he accepted the teacher 
as being free from active tuberculosis? 
DR. POTTENGER: If a smear of that teacher's sputum is nega- 
tive, I think it would be all right for her to teach. 
DR. POTCELL: Then we need not put her out of school? 
DR. POTTENG-ER: I don't think that would be advisable. If we 
could examine all of our people and take X-rays as they are doing 
in the Navy and Army, it would be surprising hoxtf many infected people 
would bo discovered. In many the infection has been there for a 
long period of time. Now, a small infection of this kind will often 
become negative, but occasionally we find a rare bacillus. However, 
we must bear in mind the human as well as the economic side in all 
these cases. 
31 We do not want to stir up the phthisiophobia that we had away 
back in 1900. The worst thing we had to combat then was the fear 
of tuberculosis, and there is a good deal of it yet, and it ought 
not to be. We must remember that we are dealing with human beings, 
and we ought to deal with them in a humanitarian way, as long as 
they will cooperate with us. That is my point of view on the matter. 
There is one other point. If we, in the practice of isolation, use 
harsh measures against tuberculous patients, we are in danger of 
undoing one of the things that we are trying our best to accomplish; 
that is to get everyone to have an X-ray examination. 
DR. CHARLES F. BLANKENSHIP, U. S. Public Health Service, San 
Francisco; Dr. Powell, sin’t it rather dangerous to depend upon a 
sputum test, when the individual is not a patient? If she were a 
patient in your hospital, you would collect the sputum specimens. 
Where she has to collect it herself, and where there is some question 
as to whether she is going to teach school or not, should we not try 
to find some way of diagnosing active tuberculosis, other than a 
specimen which she brings in which may be Cousin Joe’s. I have had 
them do that to me. 
DR. CHARLES L. IANNE, Director of Tuberculosis, Santa Clara 
County; doing back to definition, I think we had better arrive at 
some definition before wo get too far. Now, the County Counsel 
mentioned that tuberculosis is a reportable disease. For instance, 
if you go into a university school where the clinician is not a 
tuberculosis man, he is going to first rule out cancer. He is going to rule out this and he is going to rule out that, and he is going 
to mention a hundred and one things, and if he gets a negative 
sputum, he is then going to fail to report that case. 
Now wo have a case of a food handler, a baker. She says she 
has no sputum, Kow can we prove it? I think those things have to 
be brought out plainly and a minimum made. Perhaps we shouldn’t 
have it in the Code, but we should have a statement made from time 
to time by the State Board, who could, for instance, pick a corn- 
mitt co to decide what is a minimum positive sputum or a maximum— 
whatever is required—and what is a reportable case. It would be 
a good thing to have health officers get together on that point. 
DR. JOHN D. FULLER, County Health Officer, Santa Cruz: This 
whole subject is so controversial I think in a certain sense it 
answers its own questions. It seems to me that the answer lies in 
the very wording of the State law and must lie there. If, in the 
opinion of the health officer, there is reason to believe that 
there is a case of tuberculosis which is inimical to the public 
health, he should take proper action, I think it must continue to 
rest there. There will be differences in technicians and differ- 
ences in techniques and differences in individual patients, and 
their mode of living and their relationship with the public, and 
so on. But I believe each individual case becomes a separate prob 
lorn for the health officer to decide. 
It seems to me that we haven’t stressed the importance of 
contacts. I might cite one instance in which I made a study of 
33  families in which tuberculosis existed, and among the t~{% of 
contacts examined in that total group of families, of the con- 
tacts had active tuberculosis. Our case-finding in tuberculosis 
depends on contact examination. The amount of tuberculosis found 
is going to vary with the number of contacts that we examine care- 
fully and the way wo go about it. 
But I do think health officers must retain jurisdiction. It 
seems to me that the point which was made with regard to quarantine 
vs. isolation is excellent. I do think that isolation of the patient 
is the important thing. It boils down to about two, or perhaps 
three, matters. 
One is the education of the general public, as well as the 
legal profession and the physicians in the community as to what 
constitutes infection and what a case of tuberculosis may do to 
that community. The tuberculosis associations have helped tremen- 
dously in such a campaign of education with the cooperation of the 
health authorities and others. This should be done in every com- 
munity. I believe we are not going to get very far until we do 
have a widespread campaign of education of our legal profession. 
That is particularly true in some of our smaller counties where we 
have part-time district attorneys, where we don’t have full-time 
personnel operating with us, there isn’t the elaborate setup 
of some of the larger counties. As soon as we do educate them, we 
find that they are very cooperative—in fact, sometimes over- 
zealous. I have had that experience in ray own county, where in 1937 I couldn’t get a district attorney or any other person to 
issue a warrant for the arrest of a person with tuberculosis. Now 
they come to me and ask why I haven’t signed one. 
I think that the second important thing is the matter of 
standardization of regulations throughout the State of California 
with regard to release of patients from institutions. Wo have 
numerous instances of persons, non-residents of our county, who 
are hospitalized in other counties while their families remain in 
our county. Wo advise that they be both isolated and treated until 
well, until they are safe to return to our community. They go to 
another county, end for one reason or another they are back in our 
county in a month or so. We have to go through the whole procedure 
again. I* think that before any person is released from any tuber- 
culosis sanatorium there should be a consultation with the health 
officer as to whether, in his opinion, that person constitutes a 
menace to the public health. 
Then I think the third thing perhaps is that the health offi- 
cers might very well be under the guidance of the State Board in 
that instead of saying the health officer may Isolate when, in his 
opinion, there is reason to believe—the health officer shall 
isolate when, in his opinion, a case of tuberculosis is inimical 
to the public health. I think the health officer’s opinion is go- 
ing to have to stand. Someone’s opinion must be final, and the 
health officer has been appointed by the law. It always goes back 
to that matter of the existence of a reasonable doubt. DR. BELT; Dr. Robinson, would you talk to this point? Specifi- 
cally, will you give us some information on tuberculosis findings 
by gastric lavage? 
DR. ROBINSON: Well, before I do that I would like to make a 
plea that we do not attempt to set up standards of communicability 
in the State Code. I say that because it doesn’t seem to me to be 
the main point that we want to accomplish now. We would like to 
see a state-wide policy providing for isolation of recalcitrant 
communicable tuberculous patients, and the standards which will be 
enforced in any one community throughout the State will differ 
according to the consensus of medical opinion and practice in that 
community. 
In southern California we have adopted rather high standards 
as regards communicability for tuberculosis, I would not suggest 
that those be made the standards in the State Code, and I certainly 
wouldn’t like to see any less high standards placed in the State 
Code. So, you can see that if we tried to arrive at a compromise 
and set up specific standards, they would be too high for one com- 
munity and too low for another. Standards of communicability change 
as we learn more about tuberculosis and its spread, and these change 
as doctors and people in the community learn more about it. I 
certainly don’t believe that a community which has not practiced 
isolation at all should immediately adopt very high standards of 
communicability. I think they have to begin rather slowly, and 
so I do believe that we should not make or attempt to set up 
standards here. The standard of communicability adopted at Olive View was 
influenced, in part, by economic considerations. We faced a pecu- 
liar situation where patients who were placed in the sanatorium 
under an order of isolation wore not billed for their care, and 
patients who were placed without an order of isolation were so 
billed. Thus, if a patient came to the institution and the order 
of isolation was later rescinded, the patient would start getting 
bills for his care, and he would get up and leave. So, we had to 
adopt standards of communicability which were somewhat in keeping 
with our standards for discharge of the patient, and I think every 
community will find a similar problem connected with this program* 
We thoroughly believe that a patient with only a few bacilli 
in his sputum is more of a danger to himself, but potentially, at 
least, he is more of a danger to those with whom he comes in con- 
tact than one who has no demonstrable bacilli. We have started a 
follow-up study of the first thousand cases on whom we made gastric 
lavage examinations. We have already found that the percentages of 
readmits is several times as high among those who left with a posi- 
tive lavage examination as among those who left with a negative 
gastric lavage examination. This has some significance. 
Another danger that I would like to mention is that of allowing 
the courts to place their entire emphasis upon whether the sputum 
is positive or negative. We have protected ourselves by saying that 
there must be a negative sputum and a satisfactory X-ray, because 
we know that a patient may have a large cavity and the sputum given may be negative. That patient will go before the court, and if the 
court has no opinion about tuberculosis except sputum, the patient 
says his sputum is negative, and the court will say that patient 
shouldn't be held. But if the court is also educated to the fact 
that the patient1s X-ray is of equal importance to the sputum 
examination, that situation wouldn't exist. We know that the pa- 
tient with tuberculosis bronchitis may have days or or months 
when he expectorates almost no sputum because the bronchial tube 
will be partially or completely blocked. The sputum will be main- 
tained in the cavity and a little later on it will spill and the 
sputum will become very positive. 
DR. BELT: Dr. Russell, a while ago Dr. Powell posed the ques- 
tion of administration of involuntary commitment of persons to 
institutions who have a grossly positive sputum and who will not 
submit to restraint. Particularly, Dr. Powell was interested in 
the mechanism of doing it in rural counties, with very small facil- 
ities for keeping people under involuntary confinement. The doctors 
in your community tell of the smoothness of your administration of 
these different public health activities. I would like to hear how 
you have solved them. 
DR. EDWARD LEE RUSSELL, County Health Officer, Santa Ana: I 
didn't come here to answer questions; I came to ask them. However, 
I will say this, that the problem of isolation of tuberculosis 
patients in our community, Orange County, is not solved yet. We 
have patients in our pavilion who tell us that their method of making sure of a negative stomach wash is to take a large drink of 
water in the morning before the wash is to be done. We know, of 
course, that the patient should not drink water prior to taking the 
wash. I suppose I was as guilty as any of promoting the stomach 
wash in our hospital and using it as an attempt to determine the 
presence or absence of infection in the patient. But we get a con- 
tinuous, consecutive, negative stomach wash, even when we have 
positive sputums from our own laboratory. We likewise have also 
a difference in the reports on the sputums taken to one laboratory 
or to another—the county hospital or ours. We get a much higher 
percentage of positives from our own laboratory. I am simply stat- 
ing the fact without attempting to interpret it or to state why it 
happened that way. 
Another question that I would like to ask. Is the cavity to 
be considered as evidence of infectiousness, regardless of whether 
the sputum is positive or negative? 
Likewise, I would like to ask the question of how one can go 
about getting the cooperation of the district attorney1s office. 
Borne of them agree that enforced isolation should be done—they 
will do their part, but the last case that we took to court the 
district attorney1s deputy appeared with only the carbon copy of 
the complaint in his folder. That is all that he had. The case 
was not prepared, and amazingly enough the attorney tried the 
defendant on something he was not accused of and convicted him, 
simply on the basis of morale, because he felt that those who were on the jury were reasonably honorable citizens and that this fact 
had more implications than simply the technicality of whether the 
defendant was guilty or not guilty. The fact was that the, man lost 
his case in the first ten minutes because he had permitted his wife, 
who was the infectious case, to go out, and under Section 2601 of 
the Health and Safety Code, a person exposing himself or the person 
of another upon a public thoroughfare, knowing of this infection, 
is guilty of a misdemeanor. As for the wife, the patient, who was 
infectious—the case against her was dismissed. They were named 
jointly in the complaint. We have tried a different arrangement, 
and we hope we have solved the problem. We asked the new district 
attorney to assign one man specifically to health department work. 
He readily agreed, and gave us a man of our own choice. To date we 
have been very well satisfied, although we have had no tuberculosis 
cases. 
I would also like to secure suggestions for obtaining isola- 
tion space for the incorrigible patient. We all know that tuber- 
culosis is a long-time illness. Some tuberculosis patients tie up 
the two rooms in our jail for a long time. They must be used by 
the jail for cases of scarlet fever, chickenpox, measles, even 
G-erman measles, which may come into the jail. To put tubercu- 
losis there is hardly the thing to do. I feel very apologetic about 
doing it, but if the patient will not stay in voluntarily under his 
isolation order, those two rooms must be tied up. I think both 
rooms w&re tied up for six and eight consecutive weeks recently 
J+0 with tuberculosis patients, and it so happened we had no ohickenpox 
or other communicable disease in the Jail in that period of time. 
If we had, we would have had to let one of the tuberculous out. 
Also, I would like to know, if I can, what the mechanics are 
for obtaining an executive order from the State Health Officer. 
How can we get that accomplished? Do xve have to take all the re- 
calcitrants to court? It is a tremendously time-consuming thing. 
It seems to me that review by the Chief of our Bureau of Tubercu- 
losis and of the district attorney and the obtaining of any subse- 
quent information that the latter wants might be sufficient 
information for the State Health Officer to Justify an executive 
order of isolation against a given patient. 
Sometimes in our own localities we begin to lose our effective- 
ness. Familiarity breeds contempt. Out people have known us for so 
long that they become immune to what we have to say and to the re- 
strictions that must be placed upon them. So, it is helpful when 
someone from the outside, unknown to the patient, says, "This can't 
go on any longer. You are going to have to stay home.” I wonder 
if there isn't a way of doing this. I wonder why the state author- 
ity isn't applied more, why it can't be used more to help us in 
handling these problems. Certainly, it would be a different 
authority from a different source which is applying the restrictions 
upon the patient, and I believe it would have its effect. 
In our county we have an open case who is not getting any 
treatment. He is a paranoiac. He has had'two insanity hearings, has a long career in crime, does everybody that he can as frequent- 
ly as he can, and loves a fight, particularly if it gives him a 
chance to show off. I believe if we could use authority from some 
other source, he would lose his enthusiasm for a fight, because he 
wouldn't get the front page of the local scandal sheet, I tried 
to get an executive order. I was unsuccessful. Maybe I was wrong, 
maybe I shouldn't have asked for it, but I do feel this method can 
be used more often and more effectively. 
DR. BELT: We will see if we can transfer some of this to Dr. 
Wynns. I should like him to talk to the point of the executive 
order that you were speaking about. 
DR. WYNNS: As far as the executive order is concerned, we 
feel that Section gives the local health officer all the 
authority he needs, provided there is that justification for com- 
pulsory isolation of tuberculosis. He doesn't need the State Health 
Officer adding to that. The section, if it's legal, is already 
there. He has the necessary machinery to act. 
If the custom of asking some outside authority to make an 
investigation were once started, it would mean health officers would 
ask the State to take over the cases that are highly questionable, 
and the State start losing them and it would set up a rather 
bad precedent. The health officer would be winning the easy cases 
and the State Health Department would be losing the difficult ones. 
I think, simply stated, that the health officer has that authority 
under Section without any special directive. I would like to say a word about positive sputum. It1s per- 
fectly rational for us to set up diagnostic criteria as to what 
constitutes a bacteriological positive diphtheria culture, and when 
it is once determined, the health officer is then duty-bound to 
carry out the procedure on that particular case of diphtheria, and 
it would seem that if we set up criteria as to what shall consti- 
tute a positive sputum, then the health officer is going to be 
duty-bound by law to carry out the provisions. Now I don!t think 
that is the intent of this meeting—to quarantine or isolate every- 
one with a sputum positive for tuberculosis. It is only the 
occasional individual that we wish to compel to accept hospital 
care, and in those instances the individual is more likely to be 
a far advanced case with copious amounts of sputum containing large 
numbers of bacilli. 
Another thing that I would like to bring up and ask Dr, 
Telford particularly about is the juvenile cases. Did the cases 
he spoke of all represent adults, or children also? The question 
I had in mind was in the north particularly the custom has been to 
go by way of the juvenile courts and get . children awarded to the 
custody of the courts either because the parents had tuberculosis 
or because the child had, and thus assure care for the children, 
whether or not the adults were given care. There have been some 
adverse rulings on that particular phase of the question in other 
oarts of the State. DR, P0TT3NGER: One point regarding sputum I think should be 
understood. If we could just get the medical profession and tech- 
nicians who handle sputum not to declare a case negative on one 
sputum sample. If you take a twenty-four or forty-eight hour 
sputum instead of a casual specimen, it would be all the difference 
in the world. Then, too, the doctor, when he gets a report from 
the laboratory, always backs down on his diagnosis and accepts the 
laboratory. Wo are too dependent upon laboratories,which is un- 
fortunate. Laboratory facilities ought to be utilized for what 
they are worth, and clinical medicine should be utilized for what 
it can do. After all, I think a. complete clinical conception of a 
case of tuberculosis is best. I never discharge a patient upon a 
sputum examination alone. I discharge a patient on my own clinical 
conception of whether or not he is well, whether he is able to go 
ahead. Much education is yet necessary in this matter. 
DR. 3RLT: Dr. Telford, will you tell us about these juvenile 
oases? I would like to hear you discuss these cases lost in court— 
why wo lost them and dangers confronting the health officers who 
are trying to enforce this law. 
DR. TRLFORD: I have rarely been in juvenile court, I recall 
one case where it was proven that there had been neglect in the 
care of the children. There was no question of enforcing specific 
treatment on the children. It wasn't a matter of whether they had 
tuberculosis or what they had. In that case the court took custody 
of the children, paroled them to me, and I had them placed in the general hospital, where they remained for two or three years. 
Younger children generally are not sources of spread. But when 
wc get into the teen age, this problem of communicability is fre- 
quently present. Then the order of isolation is issued against 
the parent, and if the order is violated, the parent is held re- 
sponsible. 
The case that we lost in court (the jury we felt was prejudiced) 
'was in a rather isolated community where all of the residents were 
familiar with the conditions in the small outlying institution, and 
there was much to oe desired in the conditions tnere. That was one 
only case that we have lost outright. The other difficulties we 
had were in failure to file a complaint because it would not be 
accepted by the justice court for various reasons. One I remember 
particularly was the case of a habitual criminal where one more 
conviction would have been sufficient to convict him for life, so 
the justice felt we weren’t justified in making the complaint. 
DR. RUSSELL; Dr. Wynns answered my question about the use of 
an executive order. In fact, he answered it the way I didn’t want 
him to answer it, because I believe he didn’t recognize the typo of 
case that I am referring to. I am talking about the fellow who 
likes to show off and wants the center of the stage and would take 
any method to got it as long as he doesn’t spend his own money in 
doing it. And I think that there is a place for some procedure 
that siooils the nlans of a man of this kind. I am not asking the State or anyone else to take over my re- 
sponsibility for the control of tuberculosis, but I am asking for 
assistance in that kind of case which comes along rarely, I think 
that even a short review of the information that we have on file 
would make one realize that this is a case that needs special atten- 
tion. We haven’t slept on the job. We really have made a con- 
scientious effort to control a case voluntarily, and we have used 
every method of restriction open to us. Those are successively 
applied and in some cases they are always unsuccessful, and we 
expect them to be. So, I think there is a place there where the 
State or somebody can help. In other words, if we can't do it, then 
who can? Can you? And it seems to me that one of the functions of 
the State Department of Public Health is to step in where the local 
situation is too difficult to be handled locally or where there has 
been political loading or something else that makes it impossible 
for the health officer to do it. To step in in his stead and assist 
him in getting the thing done should be a function of the State Health 
Department. 
DR. WYNIIS: The only thing I can say is that, unfortunately, 
there has been no case that has gone through the higher courts. If 
we had one, just one nice case that had been through, it would be 
different. It might be worth while even to pick up a case and take 
it through somewhere, so we would have something to lean on. We 
haven't that, and everyone is a little leery about what the results 
of that first case would be. 
kb DR. WARREN F. FOX, County Health Officer, Riverside: We health 
officers who have been in public health work for quite a few years 
have encountered different types of legal advice—with all due re- 
spect to the members of the legal profession who are here—and I 
have the utmost respect for their advice. We sometimes are at a 
loss as to how to proceed. 
Now, we have heard some question regarding the legality of the 
State Board of Health1s regulation. But we have also heard the 
lawyers advise us that a health officer cannot be delegated these 
broad powers that certain sections of the State law provide. 
I asked for a decision from my present County Counsel, and I 
just wish I could read it, I am not going to read it—it's too 
long. But I would like to raise one point for the consideration of 
the State Board of Health when this subject comes up. The County 
Counsel in my county does feel that the local health officer has 
the right to quarantine and/or isolate a case of tuberculosis, but 
Section 2571 of the Health and Safety Code, which considers the 
reporting of the various diseases, reads as follows: 
n*tf-5t.ghe diseases enumerated in this section, and 
such others as from time to time may be added by 
the State department, shall be quarantined whenever 
in the opinion of the State department that action 
is necessary for the protection of the public health, 
and shall bo isolated whenever in the opinion of the 
department or health officer, isolation is necessary 
for the protection of the public health.” 
H-7 Again I come back to what I originally said that some attor- 
neys feel that the construction of that section deals with the 
health officer meaning the State health officer, and the depart- 
ment meaning the State department. Therefore, in order to clarify 
the law, why can’t we have, nand shall be quarantined and/or 
isolated whenever in the opinion of the department or the local 
health officer.” Action is necessary in order to clarify that 
Section 2571 hy adding the words ”shall be quarantined or isolated” 
and also the word local health officer. I think that would end some 
of the questions that arise. 
Under the broad powers granted the health officer by Section 
he ”shall take such measures as may be necessary to prevent 
the spread of the disease” and it is the opinion of some that a 
local health officer now has the authority to require physical 
examination of food handlers suspected of being infected with a 
communicable disease. I question whether this was the intent of 
the legislature, and believe that this point should be cleared up. 
I feel that the local health officer or his representative should 
have the authority to require -the physical examination of any food 
handler reasonably suspected of being infected a communicable 
disease or to require the food handler to be examined by a legally 
qualified physician approved by the health officer. All such 
physical examinations would be accompanied by the submission of 
laboratory specimens, (X-ray, sputum, etc.) as required by the local 
health officer. In certain instances it might be necessary to re- 
4-g quire hospitalization in order to obtain authentic specimens. 
One other point, Dr. Belt. I believe that the majority of 
health officers believe in the isolation of cases of tuberculosis. 
Why cannot we have some recommendations from the State Health De- 
partment concerning the wording of the order of isolation? Our 
legal adviser tells us that a quarantine isn’t valid unless a 
placard of a certain designated nature is put on the house. Why 
can’t we have a standard order of isolation, if we are going to 
isolate cases? 
DR. BELT: Mr. Martin, can you help us out on that point? 
MR. MARTIN: There has been a suggestion that this section be 
changed. If that is the opinion of the group, it would be highly 
desirable that you sponsor sufficient legislation. 
DR. BELT: What about the possibility of changing Section 2571 
to put in the word ’’isolation” as well as "quarantine”? 
MR. MARTIN: When I was going over the matter several days ago, 
it struck me that there should be some clarification of that matter. 
DR. BELT: Gould it be done by the Board of Health? 
MR. MARTIN: No, that must be done by legislation. 
DR. BELT: And then there would be no objection to writing in 
local health officer in that same area too? 
MR. MARTIN: That again is a matter of policy. It’s not up to 
us to determine what doctors and health officers want. However, I 
believe the doctor’s point is well taken. 
!+9 DR. BELT: Miss Buben, will you discuss some of the difficul- 
ties which confronted you in confining these people? 
MISS ZDENKA BUBEN, Los Angeles County Health Department; Rep- 
resenting social service within a health department, I should like 
to approach it another way. It seems to me that if we can achieve 
a procedure whereby we have as few barbed wire fences as possible 
and as little mandatory legislation endorsed to the extreme, that 
we will have accomplished something. Dr, Pottenger awhile ago 
mentioned the importance of considering the human being, and I think 
others mentioned the importance of health education. I believe that 
action with a soft pedal is best for an agency to use when it tells 
a patient not only that he has tuberculosis, but that he must be 
isolated under legal orders. 
It is departmental policy to give each of those patients the 
opportunity of an interview with a social case worker. The reason 
is because we believe that if, at the point when the patient is 
faced with this conflict in his usual way of living, we give him 
an opportunity to visualise what this is going to mean to him and 
his family and try to offset some of the hindrances that are in his 
mind, he will be in a much better frame of mind to accept institu- 
tional care or the order of isolation. So our focus in that initial 
interview has been upon the psychological preparation of patients 
for the acceptance of the legal Isolation order, as well as any 
other form of placement which removes him from his home and the 
community. 
50 The medical profession, public health officers and others in 
the medical care field have not focused enough-on that particular 
aspect of service. I say that on the basis of over twenty years1 
experience. The social aspects of this program are exceedingly 
important. You can't expect any of us, when told we have tubercu- 
losis (which alone implies long-time carc) and then on top of that 
to be told we are going to be isolated under legal quarantine or 
legal isolation, to be able to accept the news without some kind of 
psychological block. 
In our department the interview between the medical social 
worker and the patient varies in length from half an hour to as 
long as two hours. The average Interview is about forty-five 
minutes, and I would judge that in more than ninety percent of 
the cases we arc able to get, at least at that point, a good re- 
sponse from the patient. In the small percentage who will not 
accept this, the worker goes back to the doctor and explains the 
patient's point of view, and then the doctor makes the decision as 
to the next step. 
There is a period, of varying duration, during which the patient 
waits for placement, and that gives the worker an opportunity to go 
into the homo, and, if necessary, to work further with that indi- 
vidual. The sort of questions raised in the interview are, "What 
is to become of my children?" Lately we have been hearing, "Do I 
have to pay any income tax if I go to the sanatorium?" There is 
51 always the question of finance, and the patients invariably ask 
what it is going to cost. 
We have been educating them, if you like to call it that, in 
the importance of doing this for the sake of their family and the 
community. We appeal to their sportsmanship to respond on that 
basis. We tell them that when they are able to help they should 
do it, and that if we can help them with any problem that stands in 
the way, that is what we are for. We also toll them that while they 
will not need to pay for the cost of living while they are under 
legal isolation, they will need to pay after their isolation is 
terminated. We prepare them for the whole experience and for what- 
ever may happen to them. 
We also tell them that isolation does not imply that they will 
be treated differently from other patients provided they cooperate 
with the medical authorities, and we also tell them that if they 
find they just must go A. W. 0. L. for some reason or other, will 
they please come and tell us. We get quite a few who come back to 
the agency that placed them under legal Isolation, after they leave 
the sanatorium, to tell why they couldn’t stay there. As Doctor 
Robinson and Dr. Telford and other doctors here have said, there 
must be a close cooperation between the sanatorium and the health 
department. The right hand should know what the left hand is doing 
in tying up this program. 
If I could make one statement of contribution, here it is: 
Let’s not miss the boat in the preparation of the patient psycho- logically for this period of separation from the world, so that as 
few cases as possible will require court action. It’s a reflection 
on us, the doctors, the public health nurses, the social workers, 
all of us down the line, if the patient breaks orders and becomes 
a problem of Isolation. 
DR. BUSH: Right it not be worth while to take a case through 
court in order to clarify the situation? 
DR. BELT: That is a question for Hr. Martin to answer. Do 
you think we should make an example of someone? 
MR. MARTIN; You would have to have someone who is recalci- 
t rant. 
DR. RUSSELL: I've got one. 
DR. BELT; What next? Dr. Russell has one, 
MR. MARTIN: Wo can't suggest any means by which a matter of 
this kind may come to our attention, because it originally will be 
in the hands of the local law enforcement agencies and ultimately 
if it goes up and is appealed it will reach our office. It is a 
matter in which this office could not make any suggestion, because 
it's not within our jurisdiction at this time. 
DR. BELT: That sounds very legal. 
MISS BU32N; I would like to say to Dr. Russell that he would 
lose his case anyway. He said awhile ago the patient was a paranoiac, 
When you have a mental patient, one who wouldn't understand the 
responsibility, I am sure the jury would go against you. 
The other point I would like to make, to go back to my remarks 
53 a minute ago, is that our County Department of Institutions recent- 
ly released some figures comparing the cancellations of placements 
in areas where there was some family planning prior to the patient’s 
accepting the placement, as compared to areas where there was no 
family planning as a preliminary, and it was, I think, 2?S as 
compared with in favor of the area where there was some pre- 
liminary planning. 
DR. BELT: This is a good time to pause for lunch and then 
return to the afternoon session. 
(The meeting adjourned at a. m., end reconvened at 1:15 p. m.) 
DR. BELT: The meeting will come to order. Dr, Kupka, would 
you like to continue the discussion? 
DR. KUPKA: Among the questions brought up this morning is the 
matter of using cavities as a criterion of activity when the sputum 
is negative for short times or for given specimens. I believe that 
the decisions; first, whether the tuberculous is active, and, 
second, whether the patient is a menace, are up to the health officer 
and that an evaluation should be made separately on every case. If 
the health officer wishes to consider the cavity at its full signifi- 
cance and consider negative sputum findings temporarily as less 
important, that is up to him. It’s another aspect regarding which 
shouldn’t set rigid standards. 
Then there is the question of the district attorney's office 
cooperating with the health officer. This has been the most diffi- 
5^ cult point with those health officers who have told me, "Doctor, 
I cannot go ahead with what both you and I agree is the proper thing 
to do because Mr. So-and-so says it can’t be done," or "Mr. 
So-and-so doesn’t want to do it." Well, invited an equal number 
of district attorneys and health officers to this meeting. You see 
how few of the attorneys and how many of the health officers have 
come. Health officers are very much interested in this problem as 
a group; the district attorneys are not so interested. And I be- 
lieve that as individuals, and perhaps as a department, speaking 
for the State Department of Public Health, we may work on the 
problem of interesting and "educating" the district attorneys and 
ether law enforcement officials. 
Another point that was brought up this morning, which as time 
goes on seems to be growing in sifnificance and in necessity: Many 
years have passed since Governor Pardee in 1903 turned down the 
recommendation of a committee on which Dr. Pottenger serving 
to build a State sanatorium. Because California had no adequate 
public sanatoria, it was thought that a State sanatorium was the 
best solution. 
In the intervening forty years sentiment has favored county 
sanatoria, and, by and large, that sentiment is justifiable. It 
has given us 6,000 free beds for tuberculosis, most of them adequate 
by the standards of the Bureau of Tuberculosis. But there are 
certain categories of patients, relatively narrow categories, such 
as the state resident who is a county non-resident, the state non- resident who is awaiting transfer to his state or who, for some 
reason, should not be sent to his state. Then there are counties 
whose population is so small they cannot be expected to build a 
tuberculosis sanatorium or even a tuberculosis wing; for example, 
Mono County or Del Norte County. The state sanatorium could take 
patients like these. Lastly, and most germane to our discussion, 
it could be a place of isolation for incorrigibles, providing means 
of restriction and policing on a state basis. 
Sentiment on this matter is divided. I have spoken to marly 
men around the State who are interested in this matter, and some are 
strongly opnosed to a State institution. I am beginning to feel 
that it may be a good solution to some of these problems. It might 
be worth talking up as a post war project, since there may be funds 
for capital expenditure on State institutions after the war. 
DR. IANNE; Let us approach the isolation problem from the 
viewpoint of a small county. In a little institution like ours in 
Santa Clara County, where we have 100 beds in a clapboard type of 
building, a patient can make himself very obnoxious. If we had a 
patient there even as a probation case, he could make himself 
offensive in many ways, since we have no way of segregation. There- 
fore, we would be very heartily in accord with Dr. Kupka*s idea of 
a state Institution which would also be the place for the reception 
of the recalcitrant patient. 
Then, secondly, we at all times have approximately five to ten 
percent non-resident patients from outside the State, and I think that burden should be lifted from the communities. If we removed 
our ten percent, that would give us the beds for other purposes. 
DR. BELT; Is there any other discussion to the point? 
DR. P0W3LL: If a fellow sticks his chin out, somebody hits 
him. I don’t want to give the impression that in Contra Costa 
County if we find a case of tuberculosis we immediately tell a nurse 
to go to him and say, 11 You have got tuberculosis and what are you 
going to do about it? You have got to go to the sanatorium.” 
I think those communities which are lucky enough to have social 
workers are indeed fortunate, but many of our communities do not 
have medical social workers. But I think the public health nurse, 
too, is an excellent medical social worker. She understands the 
background of these patients and their psychology and all that. And 
I do want to say I also have the cooperation of the legal profession 
in my county. The district attorney and the judges in my county are 
fine. They cooperate with us in every way. We have two 
patients in the county now, out of around 250,000, who are not com- 
plying with our recommendations, which will, of course, rather in- 
dicate that we don't go around with a roll of barbed wire in the 
back of our automobile. 
There are other questions, though, on the legal end of it, that 
should be considered. We have, for instance, the shipyard worker. 
Ke lives in a community that had J>,000 people a year ago and how has 30,000, or in another community that had 25,000 a year ago and now 
has 150,000. How can we control a case of tuberculosis in those 
people? They are living in trailers. They have five or six people 
in the family. There are no facilities for isolation. The man 
says, "I am going to work anyway." I should like to find out, if 
this man won’t stay at home, whether we can keep him from going 
back to work. Can we control him? Should we notify that shipyard 
that this man has tuberculosis? That brings up the question of pro- 
fessional confidence, so must we have his written permission to 
transfer his record from place to place? Could we legally notify 
that shipyard that so-and-so has tuberculosis, in what we consider 
a communicable stage, and would they immediately throw him out? 
Maybe Dr. Telford can answer this. 
DR. TELFORD: They won’t throw him out. They are short of 
help. You can't prohibit a man from building ships, if he has 
tuberculosis. You can prohibit certain occupations. In this county 
we have included barbering and beauty work. But you are shifting 
the responsibility to the employer and he hasn't any basis for ex- 
cluding them either. The solution of such a problem is to isolate 
him and then he cannot leave to go to work, if he is a danger to the 
community, 
DR. FULLER; Apropos of that general point, I would like to 
hear some discussion by other health officers and people here about 
the second paragraph of the suggested new regulations that were read 
this morning. Personally, I feel a little unhappy about putting in 
52 a regulation of the State Board a limitation upon the health officer 
in the control of communicable forms of tuberculosis relative to 
the contact with children or young adults, which I believe is the 
way you stated it, and if the person is engaged in the profession 
of food handling. In other words, it seems to me that it’s still 
a. communicable disease and it still costs just as much money to take 
care of an older person, and what again is your definition of a 
young adult, and how many people in the shipyards are gradually 
becoming older adults? We read in the papers that we are going to 
get oeople in the shipyards and in other industries up to the age 
of sixty, and in my own particular bailiwick I for one would be 
inclined to isolate persons with tuberculosis, regardless of their 
age or occupation. 
DR. BELT: Would you like to have Dr. Kupka read that section? 
(Section 3 of the proposed regulations was read as follows; 
"Persons with a grossly positive sputum shall not 
engage in any occupations involving the handling of 
foods or come in close contact with children or young 
adults. Also, persons suspected of having an open 
case of tuberculosis shall not engage in any of these 
specified occupations until it has been determined 
to the satisfaction of the health officer that the 
suspected case is not a communicable case of tuber- 
culosis. 11) 
DR. WYNNS: This section was introduced at the request of 
several health officers who, in reading the first preliminary regu- 
lations and in commenting upon them, asked to have this phrase 
added; "Persons with grossly positive sputum shall not engage in 
59 any occupations involving the handling of foods or come in close 
contact with children or young adults." 
DR. FULLER: Is that a limiting regulation or simply an ad- 
ditional advisory statement? In other words, does that limit your 
Isolation procedure to that group? 
DR. WYNNS: Along that line, Dr. Fuller, I think that in ordi- 
nary circumstances, if you had an elderly person with tuberculosis 
and there was no one else in the household except his wife, there 
would be no particular reason why you couldn’t put a quarantine 
sign on the house. The only person endangered is wife or 
husband in this particular instance. You are protecting the public. 
The quarantine would do that. The public health is protected, ex- 
cept for that one exception. 
On the other hand, if there were children in that household, 
you don’t want to quarantine that household. You want some other 
lever. You want to be able to drive up an ambulance to the door 
and take that individual out of there, and that is the particular 
implication in that sentence. That was pointed out when we sent 
those early regulations around. It is not a limiting factor, I 
don’t think that it should be interpreted in that way. I think 
it's just an additional lever to use if people in the household are 
being exposed. 
DR. FULLER; I understand that and perhaps my point wasn't 
clear. Perhaps I did not understand, but I gathered that the 
isolation procedure available to the health officer was going to be limited to those engaged in certain occupations and in relation- 
ship to certain age groups, etc., which I thought was unwise. 
DR. WYNNS: There is an angle there all right. 
DR. KUPKA: I would just as soon cut it out entirely and leave 
the matter to the judgment of the health officer. 
DR. FOX; There is a law already to cover that--that no employ- 
er shall permit a person to work with any infectious disease. We 
have regulations that provide that no person to be infected 
with communicable diseases or suspected of being infected with 
communicable diseases, shall engage in any commercial handling of 
food, or be employed on a dairy or on premises handling milk or 
milk products, until the health officer determines him to be free 
of such diseases or incapable of transmitting infection. Section 
t of the Food Sanitation Act covers that also. 
DR. WYNNS: This will be Board of Health regulation. Section 
S of the Food Sanitation Act covers the same problem about anyone 
having an infectious disease. So that statement in Section B could 
be eliminated entirely other than the fact that some felt it might 
add more weight. It !s just perhaps adding a little in one 
way, but it might be a disadvantage in implying a limitation, as 
Dr. Fuller said. 
This matter has come up in other diseases. In the present 
regulations on diphtheria, typhoid and scarlet fever, there is 
specific reference to food handlers and there are other diseases 
in which there are no specific references except as implied in the Health and Safety Code. 
MISS BUBEN: I think what you are after is an over-all state- 
ment, something that covers the whole situation, and then you need 
to add in addition, "except that such and such cases shall always 
be." In other words, if you add it to your general language in A, 
that will take care of it, 
DR. BELT: That is worth following up. Read Section A, please. 
(Section A of the proposed regulations was read as follows; 
"Patients with positive sputums shall be considered 
as fulfilling the requirements of isolation as long 
as they are under adequate medical supervision and 
observe the instructions Issued by the health officer. 
If there are any young children in the household, the 
degree of isolation for the patient shall be such 
that the children are adequately protected and shall 
conform to the requirements of the health officer.") 
DR. BELT: Are there any other suggestions regarding the word- 
ing of this regulation of the health department? 
DR. ROBINSON: I would like to see B taken out entirely and I 
should also like to see Section A modified and the words tubercu- 
losis in a communicable stage" substituted for xeositive sputum, 
because we all know how often it is difficult to establish a posi- 
tive sputum. I would like to see the whole regulation made as 
broad as possible so as to give the individual health officer 
discretion and at the same time back him up with State authority. 
I think that can best be done by eliminating any wording which will 
tend to set up standards. 
6 2 DR. BELT: It seems to me that is true, too. I have been 
listening to all of this discussion with the ears of a urologist. 
I have been thinking of tubercle bacilli in the urine. Now, Dr, 
Fottenger seems to think, and has said in discussion with me 
privately, that he did not believe tubercle bacilli in the urine 
were often a means of distributing tuberculosis. However, I have 
been in the habit of telling patients of mine who have tubercle 
bacilli in their urine to take methylene blue tablets for awhile. 
I nut them on a rather large dose. Then in a little while they 
come to me and say, "Doctor, how long do I have to keep taking those 
blue tablets'?" And I say, "Why, do they bother you?" and they say, 
"No, but everything in my bathroom is blue. The toilet seat is 
blue, and today I see the wainscoting is blue, the bowl I wash in 
is blue." And I say, "Everything that is blue is also covered with 
tubercle bacilli. If there is anybody else in the family, they 
cannot touch those blue things without the hazard of infecting 
themselves." 
As a matter of fact, in one of the very interesting ceremonials 
in medieval times the priest would give a sermon, before which he 
had eaten of a bread which carried a heavy culture of chromogenic 
bacilli, probably 3. Proteus. This, spattered by droplets and later 
transmitted onto the hangings behind his audience, would turn red 
with a heavy growth of the organism. It was a precise but uncon- 
scious demonstration of the effectiveness of the spread of an 
organism by droplet infection. Here we are interested in the pro- 
63 vention of the spread of a disease by just such means. For this 
purpose occasionally enforcement of legal provisions is necessary. 
We have with us the quarantine officer of Los Angeles County. Mr. 
Karvey, I wonder if you would just tell us about some of the 
duties of enforcement? 
HR. C, 0. HARVEY, Quarantine Officer of Los Angeles County: In 
listening to the comments that have been made, I am impressed that 
apparently there is a universal desire for the same thing. During 
ny indoctrination into the health department under Dr. Pomeroy and 
Dr. Telford, apparently I had a very fine course, and my training 
was that we had the laws that were necessary. However, the health 
laws in our State are somewhat complicated. The health officer, 
without question in my mind, has wide authority. In our county we 
have been going a step farther in taking the quarantine law and 
writing our own regulations for the County of Los Angeles. We also 
have a county code, i. e., a health code, for the same purpose of 
bringing that State law down into the county and giving us our 
authority to act. 
When we first started, Mr. Mattoon was the County Counsel and 
Mr. McFadden, the deputy in charge of health work, could not see our 
viewpoint on tuberculosis at all, and I remember that for a period of 
some six months I fought with Mr. McFadden over the question of 
whether tuberculosis was a quarantinable disease, and eventually I 
had a long conversation with him, developing the argument step by 
step, using smallpox and other diseases for comparison, and when we got through he said, "Well, I see your point. There is no question 
but that you have the right and authority." Then we finally got 
the opinion under which we worked. 
The next step was with the district attorney’s office. I found 
that many of the district attorneys and most of the lawyers do not 
know the health laws. They don’t want to know them. For the law- 
yers there is very little advantage in knowing the health laws from 
the financial standpoint. They have to earn a living, and there is 
little profit in connection with that law. Many district attorneys 
do not know the quarantine law, and they try to avoid it because it 
is complicated. 
This morning one health officer related how a deputy in Orange 
County appeared in court without his case prepared. I think that 
is the universal custom. The district attorney in the preliminary 
courts usually appears with the complaint and starts from that 
point. So that in our department we have been forced to brief our 
cases and prepare them for the district attorney’s office. We take 
the essential data with us when we go to court and have the case 
prepared for him, so that he has the necessary ammunition with 
which to present his cases. 
Our actual experience in the courts has been that the people, 
by and large, are in favor of what we are doing. I am reminded of 
one case on jury trial where the jury found the defendant guilty. 
It happened that the foreman of the jury was a former tuberculosis 
patient. She knew all about tuberculosis and was very much insulted by the defendant's attitude, so much so that after the case was over, 
she gave him a lecture from the Jury box. I think you will find 
that in these cases the public is consistently with you; the Judges 
are with you. 
The medical end of it must be well presented. Dr. Telford has 
been very fine in going to court with us to present the medical 
testimony that is necessary to get our cases over to the courts and 
the Juries. They do not know medicine. The burden of proof rests 
with the health officer to decide which case shall be handled and 
the manner in which it shall be handled. Every case must be handled 
on its own merits. There can be no class discrimination or class 
rating. 
When a patient deserts the sanatorium under our order of isola- 
tion, we try, as quickly as possible, to catch up with him. In many 
of those cases we found that some difficulty caused him to leave. 
By and largo, I would say that ninety-five percent of our A.W.O.L.’s 
have mental difficulties or domestic troubles that bring about the 
desertion. About one-half of one percent are recalcitrants with 
whom you can do nothing but lock up. One recalcitrant will wreck 
all the other patients in the sanatorium. 
The Jails are not good places to commit them after they violate, 
Los Angeles County is fortunate to have a large Jail, We have two 
tuberculosis tanks in the Jail where they can take care of the 
patient who leaves for one reason or another. After about thirty 
days in jail, he is asking for a parole and wants to go back to the sanatorium. A few recalcitrants would just as soon stay in jail. 
Then, occasionally, you will have one who will apply for a parole, 
I have one now; we have gone to great lengths with him. He has been 
before the court three times. He violated his pledge for the third 
time. The court had him picked up and sent to jail. Now he is 
asking for a parole to move to Arizona. The parole board asked me 
what 1 thought about it. I refused even to consider a parole for the 
man. He happens to be of independent means and is sufficiently able 
to support himself, but he is an absolute menace to anybody in the 
community, if he is at large. His family has means. That man 
should be forced, or his family should be forced, to pay his expenses 
and piece him in an institution. He is almost a psychopathic case, 
in my opinion. He is still in jail, and the only thing to do with 
him when he comes out of jail will be to take him back to the sana- 
torium for probably two or three days, and when he runs away to have 
him arrested for another six months. 
There was another one who had been in and out of sanatoria in 
this county for some forty years. Fortunately, Long Beach City 
Health authorities and police finally picked him up; he was judged 
insane and sent to Norwalk State Hospital. He had active tubercu- 
losis and should not have been at large at any time. 
There is one other point I should cover; the matter of diag- 
nosis. We use a legal form of order for examination and diagnosis. 
We have asked the courts time and again to have suspects committed to 
the general hospital for examination and diagnosis, and the courts 
67 in this county have bached us, I would say one hundred percent in 
all our operations. But the educational process was slow. We had 
to start, as I said, with our own County Counsel, the lawyers in 
the district attorney1b office. Now we are getting uniform coopera- 
tion. 
DR. BELT: Thank you very much. Hr. Martin, Dr. Kupka brought 
up the possibility of creating a State hospital to which these re- 
calcitrant patients could be referred. The incorrigibles could bo 
sent to that institution. Can you see any legal objection to that 
kind of an arrangement? The man would be taken from his county and 
put in a central place where he not be able to break away and 
where he won’t contaminate others, and where at the same time he can 
be oared for. 
MR. MARTIN: Well, I would say just offhand, Dr, Belt, although 
the powers of the State Department are just as broad as the powers 
of other administrative agencies, the question arises in my mind as 
to whether or not this could be done in the absence of specific 
legislative authority. I think it probably would require such 
specific legislative authority before such an institution could be 
created and the Board empowered to commit cases of the nature mention- 
ed by you to such an institution. That is just an offhand opinion 
of. mine at the present time. As a practical point of view, it would 
be worthy of consideration. 
DR. BUSH: I think Michigan has a system by which a county 
health officer can take his patient before a probate judge to obtain cl commitment similar to an insane case. The patient is then com- 
mitted to an institution. 
MR. MARTIN: So far as commitments of persons because of pecu- 
liar conditions existing, the State of California permits this to 
be done in certain cases; namely, if they have committed crimes. 
On the one hand, if they have committed felonies, they can be com- 
mitted to an institution out of the county. If they are held by a 
court of proper jurisdiction to be habitual intemperates, they can 
be committed to an institution. If they are held to be narcotic 
addicts, they can be committed to an institution, or if they are 
held to be mentally ill, they can be committed. But thus far I 
know of no law which provides for the commitment of a person who is 
suffering from communicable disease. 
DR. BUSK; That was special legislation in Michigan. 
MR. MARTIN: In California it would require special legislation 
in order to permit courts to bring about the commitment of a person 
who is suffering from tuberculosis, probably through no fault of 
his own, to an institution for care, 
DR. S. F. FARNSWORTH, Alameda. County Health Officer, San 
Leandro; That brings up a point that I was wondering about. I may 
bo in error, but there was at least one case that I recall in 
Alameda County in which the court held that a tuberculosis case can- 
not be quarantined axvay from the family. I think that was in 1923 
in the first district court of appeal, the case of Sara Martin, and 
in that decision it was held that the health department had the ri ght to quarantine the individual in his place of residence, but 
that they did not have the right to take him away from his family 
and put him into a separate institution. Now, this question of 
where the individual should be quarantined has arisen in the minds, 
I know, of a lot of the health officers. 
MR. MARTIN: I am not aware of that decision, and if that de- 
cision is the law, it cuts the foundation abruptly out from under 
the attitude that I have expressed and the attitude that others 
have expressed. It1s contrary to the expression that I and my 
colleague, Mr. Mattoon, have made. I venture to say there may have 
been some other element that introduced itself into that matter. As 
I say, I am not aware of that decision. 
DR. WYNNS; That was in a juvenile court—the question of who 
should have legal authority in the case. 
MR. MARTIN; Well, that sheds some light on it. So many times 
there will be other considerations. There is the Stockton case of 
which you are aware and which was called to my attention, which had 
to do with the authority of the juvenile court to exercise juris- 
diction over a child, when, as a matter of fact, the child had com- 
mitted no offense to warrant her being declared a juvenine delinquent. 
That may have been the situation there, and if so, of course, it 
would not have any bearing upon the attitude that we have assumed 
at this time, 
DR. BLANKENSHIP; Was not the petition in the Stockton case for 
the welfare of the child Itself rather than for the public in general on the basis that the home was not a fit place for the child 
to be and that she should be declared a ward of the court and put 
into a tuberculosis sanatorium for her own good, whereas I think the 
interest of most of the health officers in what we were talking 
about was for the protection of the public in general and not pri- 
marily for the person who has tuberculosis. 
MR, MARTIN: That is correct. 
DR. ROY 0. GILBERT, Los Angeles County Health Department: In 
regard to isolation in the home, I believe it1s true that where 
adequate facilities are available in the home no effort is made to 
enforce isolation elsewhere than in the home. But where those con- 
ditions are inadequate and where it does jeopardize public health 
through the various contacts that occur in the home, I don’t believe 
we would ever have any trouble in gaining the support of the court 
in our attitude on just where that person shall be isolated; namely, 
a hospital. 
May I say a word in relation to this proposition in general? 
It has been interesting to watch the way it has unfolded, I think 
Dr. Telford made the point that it’s pretty generally accepted. The 
practice of legal isolation of tuberculosis has been, in general, 
pretty satisfactory in Los Angeles County, He didn’t mention a 
paper published in the American Review of Tuberculosis that he wrote 
back in in collaboration with Dr, Emil Bogen of Olive View 
which sets forth data that I believe substantiates the opinion that 
it has been successful and has a great deal of merit. 
71 There are a number of peasons why it has been relatively suc- 
cessful, at least from the jurisdiction of the Los Angeles County 
Health Department. One of them, probably the Initial one, is the 
fact that Dr. Telford himself has been extremely persistent and 
sold on the idea. He has prosecuted his ideas against great odds 
at times, but he has been persistent throughout. 
Another factor is that the enforcement has been with moderation, 
I think there should be emphasis on the fact that a health depart- 
ment is not just a law enforcing agency in this matter. It actual- 
ly requires a good deal of public health education. There again 
we come to another factor in the success of the plan—the fact that 
the County Health Department organization has gone into action to 
educate the lawyers and the judges—the legal profession in general— 
on the importance of this measure from the public health point of 
view, and, incidentally, in the course of the performance of these 
isolation procedures, the public in general becomes very well 
educated. It is an excellent educational factor. 
The third factor in the success is the one which Miss Buben 
mentioned, and that is adequate preparation of the patient. After 
all, when a diagnosis of tuberculosis is made and Isolation is 
threatened, that is a pretty terrific shock to any patient,- It 
upsets the entire economic and social equilibrium of the individual. 
It does require careful preparation, We have always relied on a. 
trained social service staff to accomplish this. I want to empha- 
size the necessity of trained medical social service workers for 
72 that purpose. I have heard from a number of health officers through- 
out the State a marked antipathy toward medical social service 
workers, but upon further inquiry I find that their unhappy experi- 
ences have usually been due to the fact that they have dealt with 
untrained medical social service workers, particularly during the 
ascendency of the WPA, which provided medical social workers in 
name, but not in quality. Where the parties do not have a medical 
social service, somebody lias to recognize that importance and put 
it into effect, and that is up to the individual health officer. 
Another important factor in the success of this program in Los 
Angeles County has been the work of the quarantine division, which 
has worked with moderation, with intelligence and with the health 
education aspects taking ascendency over the law enforcement 
aspects. I don't think that it's wise to lay down too strict regu- 
lations with regard to the application of isolation. There must be 
a good deal left to the discretion of the health officers in those 
matters. The State Health Department can be of great assistance 
not only in accomplishing standardization of procedure, but also in 
assisting those departments that do not have the facilities to 
perform the proper functions of it in relation to medical social 
service and health education, 
DR. POWELL: There is one thing I think we all are overlooking 
in this health education. We talk about the legal profession and the 
public, but what about the private physicians? Many communities 
certainly are in need of education along this line. I think all 
73 of us ought not to overlook that point. The private physician is 
the best public health representative we can find. He has the con- 
fidence of his people. He tolls them you ought to do this or you 
ought to do that. He is going to help a great deal. I think all of 
us ought to remember that the private physician is a very important 
man to include in our public health education. 
DR. BELT; Mr. Higby, have you any comments? 
MR. W. FORD HIGBY, Executive Secretary, California Tuberculosis 
Association, San Francisco; Mr, Chairman, I have one or two ideas, 
simply as a reporter on what has been going on. It seems to me we 
all are in general agreement about certain things, especially among 
the health officers. Today, because there are so many health 
officers and so many tuberculosis specialists, there has been undue 
emphasis upon the technical side of what is tuberculosis and what 
isn’t tuberculosis, I think you have all come to the agreement that 
the definition should be expressed in broad general terms and should 
bo left in the hands of the individual health officer for exact 
interpretation. 
There are some steps it seems to ms that may be taken; (l), a 
broad, but positive statement by the Board of Health on this matter 
that could be placed in the hands of the health officers; (2), a 
general opinion from the Attorney General’s office on the privileges 
and responsibilities under the law devolving upon district attorneys 
in relation to this matter. Now, if a county health officer had 
those two statements, in the most broad and general terms, then ho could approach his district attorney and his Judges on this subject 
with come backing. That requires a health education Job. I am 
thinking now of getting the machinery started in the voluntary 
associations. Then, if the health officer felt that the tuber- 
culosis association in his county would be of assistance to him in 
bringing information to the district attorneys and the Judges and 
the legal profession, I think we might be able to help. 
Those, as I see it, Mr, Chairman, are the steps that we might 
take. 
DR. BELT; Dr. Kupka, could you bring this discussion to a head 
with specific suggestions for legislation and for the direction of 
the State Board of Health as to what they had best do? 
DR. KUPKA: While Dr. Stone of Madera and Dr. Fox of Riverside 
were directly responsible for this meeting, because of the differ- 
ence of view regarding the interpretation of the law, another and 
•more cogent reason for calling this meeting together was to give 
the Bureau of Tuberculosis the common average of opinion in regard 
to these matters. Those of you who have been here since this morn- 
ing realize that we have reached a common understanding on some of 
the points brought up. 
We can agree, and it has been said several times, that all of 
us want action in this matter. We want the pathway smoothed for the 
authority to allow us to control the incorrigible patient. Second- 
ly, we are sure that the matter should be left to the discretion of 
the health officer of local Jurisdiction in every case and that if 
75 the State enters into it, it should enter to strengthen the health 
officer but not to act as the complainant. Thirdly, we are agreed 
that the present regulations regarding tuberculosis control are too 
diffuse and that the ones we were discussing today will represent 
an Improvement and as such will be presented to the Board for 
approval, giving the health officer something definite to point to 
when he goes into conferences with his district attorney* 
DR. BELT; Thank you, Dr. Kupka. Dr. Pottenger, 
DR. POTTENGER; I have tried to put together the various sug- 
gestions that have been made regarding the new regulations, and I 
believe something like the following will include most of them. 
First, patients with active tuberculosis should be considered as 
fulfilling the requirements of isolation as long as they are under 
adequate medical supervision and observe the instructions issued 
by the health officer. Secondly, persons having tuberculosis in a 
communicable stage who refuse to observe the health officer1s in- 
structions, and thereby expose others needlessly to infection, may 
be placed in quarantine, including the placarding of premises until 
such time as the health officer feels that such quarantine is no 
longer necessary. In the event such quarantine proves Inadequate 
for the protection of members of the household or community, the 
patient may be placed in isolation in quarters designated by the 
health officer until such time as such isolation is no longer 
necessary. 
DR. BUSH; That seems clear and precise. DR. POTTSNG-SR: It gives the health officer all he needs. 
DR. WYNNS: There is only one comment. There were a couple of 
"mays." As I understand it, “mays” are not so good when we go to 
court with them. 
DR. POTTSNG-SH: Would you like to make it “shall"? I don’t 
want to hold the health officer responsible, 
DR. BELT: Hr. Martin has a way of looking at the problem, 
which Dr. Russell presented, as to whether it would be advisable to 
take a case clear through to the superior court for a decision. 
MR. MARTIN: Dr. Belt gave me a memo concerning the proposition 
of making a test case out of Dr. Russell’s particular case, and my 
answer is this: out office must remain non-commital. Although we 
have certain supervisorial powers over the district attorneys through-- 
out the State of California, the matter of prosecuting or not prose- 
cuting any case, whether it has to do with a health violation or any 
other law violation, is a matter of discretion resting with the 
particular district attorney. Thus our office would not like to be- 
come involved unless there were some suggestion emanating from the 
particular jurisdiction in which the case arose. If motivation 
comes from the jurisdiction, then we will counsel with them and give 
them our opinions, but the initiative cannot properly come from our 
office. It must come through regular channels, through the dis- 
trict attorney’r office or the city prosecutor’s office or whatever 
office has jurisdiction over the particular case, 
DR. BELT: Dr. Fuller, have you something further? 
77 DR. FULLER: Yes, I have, Dr. Belt, I don’t know how much 
log!elation might be necessary. I hope none. But I would certainly 
like to see some procedure, even if it’s only a reporting procedure, 
whereby any case, before being released from a tuberculosis sana- 
torium (public or private) will be reported to the health officer 
of proper jurisdiction. So very frequently people are released on 
a medical basis, when the health officer would not approve of the 
return of that person to the environment to which he voluntarily 
returns. 
It might improve the situation by being in touch with the 
patients before they are released, or at least consulting with the 
director of that Institution before their release* I don’t know 
exactly what that would involve, but I think it’s exceedingly im- 
portant , I think wo should have some standardized method of pro- 
cedure regarding release of patients on a medical basis from 
sanatoria in general. When patients are being released on a medical 
basis, they should bo reported so as to bring into the picture the 
public health aspects of the case. In other words, there should 
be official release, or at least some opportunity for the health 
officer to know what the situation is. Do I make my point clear? 
DR. BELT: It’s something like what the home town officers get 
from Sen Quentin Penitentiary when they release the bad boy of the 
neighborhood, I think that would be a very wise thing to do. ‘ 
DR. BUSK: It’s done routinely in our county. It may be made 
a part of the requirements of the Bureau of Tuberculosis for the operation of a public institution, 
DR. BELT: Would it be necessary for the legislators to pass 
law for this? 
MR. MARTIN; No legislation would be necessary. I think a 
ruling of the department would be sufficient to take care of that. 
It can be added to the regulations, 
DR. ROBINSON: Perhaps I might just mention the procedure we 
use here in Los Angeles County. When a patient is recommended by 
the medical staff for discharge, we have a sheet containing a sum- 
mary of the medical information for that patient which is filled 
out by the physician. A copy of the sheet is sent to the local 
health department. That patient is not discharged from the insti- 
tution until the health department has approved the home conditions. 
We always wait for approval from the health department. 
DR. POWELL: I have been in my county for six years and I have 
never had that experience. I would certainly like to have it, I 
have orrticularly in my mind, Dr. Belt, the instance of a tuberculous 
with a highly positive sputum and with two small children in the 
family, with absolutely no opportunity for isolation in the home. 
She was released three different times from hospitals in California 
and sent back to my community. I didn’t know she was at home until 
some good neighbors in the community who were public health minded 
told me about it. 
DR. BELT: The first pair of autopsies I ever saw was upon two 
small children, the little children of a professor at the University 
75 of California* He had come out here at the request of tne University 
from the East and moved his family into what he supposed to he a 
very nice healthy little cottage* In a short time ooth of hio 
children got tuberculous meningitis and died. He later learned that 
the woman who had occupied that cottage before had active tubercu- 
losis, They had moved into the house without knowing anything aoout 
that, so his children, who were little ones in the crawling stage, 
were awaited by that fate, 
DR. TELFORD: We have a system within our registry that keeps 
track of all patients and all institutions, private or public. We 
provide special printed forms for the purpose of roporuing admissions 
and discharges, and we check with the institutions periodically to 
sec if our roster is correct. If we hear of a patient1s being dis- 
charged without being reported to us, we call it to the attention of 
the institution and in that way we obtain thorough cooperation. 
DR. IANNE: We have been doing that in our county voluntarily. 
The sanatoria report to the health department ana ohe noaltn depart- 
ment reports to us, I think that making it a regulation would be 
very good for the doctor in charge of tno insoituulon, He would 
have something with which to hold Lno patient unoil everything is 
ready. 
DR. BUSH: There are several problems to be considered, if I 
rnav speak for a moment, Dr, Belt, Many of the instioutions arc run 
by other organizations than the health department, ihere may oo no 
connection between the institution and the health department. Very often it becomes necessary for the institutional management to dis- 
charge a recalcitrant patient, an alcoholic or something of that 
sort, since the welfare of one hundred or two hundred others may be 
jeopardized, if that patient is not discharged. Who is to make that 
decision as to whether that patient is to be discharged'? That 
frequently comes up with us. The patient possibly has some children 
in the home and that is a bad place for him to be. The health de- 
partment says that patient should be in an institution. The insti- 
tutional management says that patient cannot be kept there because 
he wrecks the institution. Those are real problems and the decision 
has to be made. 
DR. IANNE: That brings up the state institution, 
DR. FARNSWORTH: One question I would like to ask, Dr. Belt. In 
case a tuberculous individual is isolated, who must bear the cost of 
his isolation, and is there any legal provision for determining the 
person who pays the bill—the county, the city or otherwise? 
DR. BELT: Who pays the cost, Dr, Kupka? 
DR. KUPKA: A person under commitment cannot be expected to 
pay the bills. 
DR. TELFORD: The law clearly states that if the health officer 
isolates a wage earner, he is responsible for the support of the 
family. 
DR. BELT: .The health officer is? 
DR* TELFORD: Yes. Very rarely, however, does a tuberculous 
patient constitute the wage earner in the family, because he is too 
gl ill to work, and when he is able to work, he insists on working. We 
are able through the Charities Department to secure subsistence for 
the family. It all comes out of the county pocketbook anyway, so 
that we have not set up the machinery in our department to pay sub- 
sistence for those familido, but it is paid by the county. 
DR. BELT; $50 a month? 
DR. TELFORD: Yes. 
DR. POWELL; There is the problem of the non-resident oases. 
If we were to embark upon a case-finding program in non-resident 
persons, we would find a lot of tuberculosis. Our board of super- 
visors has been very fine. They have taken the point of view I have 
suggested to them that a tuberculous is a public health menace. If 
the patient doesn’t go to a sanatorium, we know, of course, that in 
a year from noxv will probably have txvo or three cases, and by that 
time he is a legal resident and all three of them will go to the 
sanatorium. 
The Federal G-oveminent is doing a great deal for these people 
who are working in war industries. They have furnished them with 
houses. They have put out lots of money. I believe one toxm in our 
county now has 125,000 as compared to 25,000 a year ago; $200,000 
has been spent for landscaping alone. Free crippled children service 
has been furnished to them. Lots of fine things are being done for 
them, but nothing is done for the care of the non-resident tubercu- 
losis cases. It isn’t fair to the local taxpayers, I think a group 
should go after their senators and congressmen and through . someone get a Federal appropriation to care for the non-resident tuberculous. 
If we get a subsidy from the Federal Government for these non- 
resident people, it would help a great deal, 
KISS BUBEN: As far as aid to children is concerned, if a 
father is incapacitated because of tuberculosis, there is a law 
that such a child may have assistance which is financed three x-rays— 
federal, state and county. It may not be enough, but the legisla- 
tion does provide for aid to any children whose father is incapaci- 
tated because of tuberculosis. 
So far as the non-resident is concerned, there is a precedent 
now in the State, in the instance of assistance to crippled children. 
The Federal Government has been financing the care of the child who 
is not a resident of California and the county from the standpoint 
of having lived here three years in the State and one year in the 
county. Until now the Federal Government has accepted that re- 
•sponsibility for that child. 
DR. POWELL: You have got the same program on heart disease. In 
several counties there is a rheumatic fever program. These people 
are cared for completely. 
DR. BELT; I believe, Dr. Blankenship, there was talk of estab- 
lishing by the Federal Government of tuberculosis hospitals in the 
State of California, That was brought under discussion some months 
ago, 
DR. BLANKENSHIP: The Public Health Service is rather limited 
in the number of beneficiaries. They have the Coast Guard, Merchant 
S3 Seamen, the men who are*on Army transports, Federal employees who 
are injured in line of duty and a few others, but the average man on 
the street is not a beneficiary of the Federal Government, If there 
has been any discussion about any Federal hospitals for tuberculosis, 
I haven’t heard of it* The principal objection and the one that 
probably backs everyone off is that if the Federal Government would 
bo given the opportunity, authority, responsibility and the money to 
hospitalize the tuberculous indigents, all that would bo necessary 
for the states that didn’t have sanatoria to do wrould be to move 
their patients across a state line and they would then become Federal 
beneficiaries. Soon after, the Federal hospitals would have all the 
tuberculosis load, certainly in some of the southern states. 
Some years ago a bill was introduced in Congress by Senator 
Robinson from Arkansas. I believe at first it did not have the 
support of the National Tuberculosis Association. That bill pro- 
vided generally for a Federal grant of- aid to States for the con- 
struction and maintenance of tuberculosis sanatoria to bring their 
number of beds up to standard. 
MR. KIG3Y; That wouldn’t apply to California. We have suffi- 
cient beds. 
DR. BLANKENSHIP: That is true, but if Arkansas, Kentucky and 
some of the other states have some place to put these tuberculosis 
cases 
DR. BUSH: They would still come to California. I don’t know 
that it was included in this bill that when patients refuse to re- turn to their state of residence that there would he a shifting or 
exchange of funds between states, reimbursing the state that was 
stuck with the non-resident, 
DR. POWELL; Just try and get it. 
DR. ROBINSON: I would like to suggest to you health officers 
that you read the Lanham Act. It has some pretty broad wording in it, 
\ 
DR. BLANKENSHIP: It says specifically it cannot be used for 
the construction of tuberculosis hospitals, and recently there has 
been a ruling that it can11 be used for their operation, 
DR. ROBINSON: That deflates me, I thought maybe it might be 
used. 
MISS BU3SN; For purposes of the record, I would like to point 
out that there are some of the active tuberculous in the State of 
California who have no place to go, so far as county care is con- 
cerned—the so-called county non-resident. I had one called to my 
attention recently who has been here for fourteen years. He has 
never been outside the State of California during this period. He 
has no county of residence. He is one of the migrants who goes with 
the crops and returns home periodically. So that right within our 
# 
own State we need to fix responsibility for a county non-resident. 
Furthermore, I would like to see an understanding of the sub- 
ject of who is responsible financially on every single case, regard- 
less of residence or anything else, so that we could fix responsi- 
bility for the care of the tuberculosis patient who is a menace to 
the community, whether it’s local or State or Federal or joint 
85 responsibility. There should be some authority within the State 
of California to determine financial responsibility for care of 
those individuals, 
DR. BELT: It seems to me then that it has been brought out 
pretty clearly that the health officer has real and positive powers; 
that his opinions stand paramount above everything else concerning 
the diseased state of the patient under consideration; that smooth- 
ness in handling these afflicted people takes care of the ninety and 
nine; that we must exercise the real teeth that we actually do pos- 
sess for the hundredth, the incorrigible. We must handle him with 
fearlessness and directness and dispatch, and if we get into 
trouble—and after all, it will be good trouble—it will finally be 
taken to the proper courts for a decision; that, furthermore, the 
State Board of Public Health must clarify and change its regulations 
so that they cannot be misinterpreted; that while we may need a 
central state hospital, and while we need definite clarification of 
financial responsibility, there seems to be no need for new legis- 
lation, since the decisions of the courts in the past have been 
largely in our favor. Wo do need, however, the kind of thing which 
the tuberculosis associations can help us with and that is education 
of the public, and particularly education of the legislators, the 
lawyers and the practicing physicians. When that has been accom- 
plished, aroused public and professional opinion will make the 
control of the recalcitrant tuberculous swift and sure. 
The meeting stands adjourned. 
36 APPENDIX A 
AUTHORITY OF HEALTH DEPARTMENT TO QUARANTINE 
PERSONS AFFLICTED WITH TUBERCULOSIS 
By Allen Martin, Deputy Attorney Ceneral 
One of the most important of all health regulations is that 
directed to the exclusion of communicable diseases and the keeping 
of such diseases, when they once gain an entrance, within the small- 
est possible limits and providing for the establishment and enforce- 
ment of regulations by which their general dissemination shall be 
prevented and their continued existence rendered improbable or 
Impossible, Power to make quarantine regulations is one of the 
most frequent powers conferred upon boards of health. The author- 
ity of health officers or boards of health to quarantine for scarlet 
fever, diphtheria, smallpox, measles, and other such common maladies, 
is so well recognized, both as a practical measure and by judicial 
endorsement, that any comment concerning such authority would bo 
superfluous. However, it appears that no definite steps have been 
taken with respect to the quarantine of those infected with tuber- 
culosis. An examination of several of the leading law digests has 
failed to uncover any cases in which definite judicial endorsement 
has been placed upon the power of health officers or boards of 
health to quarantine for such a disease. 
However, it is my opinion that health authorities, at least in 
the State of California, have the power to quarantine in case of an 
la- active case of tuberculosis. It is expressly provided in section 
255S of the Health & Safety Code; 
"Whenever in the judgment of the State department 
it is necessary for the protection or preservation 
of the public health, each health officer shall, 
when directed by the State department, do the 
following: 
(a) Quarantine and disinfect persons, animals, 
houses or rooms, in accordance with general and 
specific instructions of the State department.” 
Health & Safety Code sections 25&1 and 2563 provide the mechan- 
ics for such quarantine. 
Health & Safety Code section provides in part that "each 
health officer. . . knowing or having reason to believe that any 
active case of . . . tuberculosis ... or any other contagious or 
infectious disease exists, or has recently existed, within the 
territory under his jurisdiction, shall take such measures as may 
be necessary to prevent the spread of the disease.” 
Health & Safety Code section 252*4- provides, in part, that the 
State Department of Public Health, upon being informed by a health 
officer of any contagious, infectious or communicable disease may 
take such measures as are necessary to ascertain the nature of the 
disease and prevent its spread. The section further provides that 
the State Department may, if it considers such action proper, take 
possession or control of the body of any living person in order to 
accomplish the purposes authorized by this code section. 
Health and Safety Code section 2571 classifies tuberculosis as 
a "reportable” disease. The last paragraph of section 2571 provides that any of the diseases enumerated in the section and classified 
therein as reportable, and such others as from time to time may be 
added by the State department, shall be quarantined, whenever, in 
the opinion of the State department, that action is necessary for 
the protection of the public health, and shall be isolated whenever, 
in the opinion of the department or health officer, isolation is 
necessary for the protection of public health. 
Health & Safety Code sections 200-209 vest the State Department 
of Public Health with blanket authority to take all reasonable steps 
and measures to protect and preserve the public health. Thus, 
since the legislature has recognized tuberculosis as a contagious, 
infectious and communicable disease, and in one of which sections 
(sec. 2571) specific authority to quarantine is given, it cannot be 
contended successfully that the health departments or health officers 
are without authority to quarantine and isolate for such a disease. 
The courts in this State, as well as in other states, have 
recognized that it is sound public policy for health authorities to 
take reasonable steps to prevent the spread of diseases. 
3-rover v. Zook, gy Pao. 63S 
Adams v. City of Milwaukee, 129 N. W, yig 
In re Johnson, Uo Cal. App. 2^4-2 
In re Culver, 12>7 Cal. *4-37 
In re Arata, 52 Cal. App. 3$0 
In re Travers, 4-S Cal. App. 765. 
3a While the powers of health authorities are very extensive and 
will be upheld whenever possible, and every presumption indulged in 
to sustain the validity of their action, their powers are not abso- 
lute* The power to quarantine must be exercised only when public 
necessity demands it within reasonable and fair apprehension, and 
not on mere suspicion. Whether a quarantine order is justified 
depends upon the facts of each individual case. A condition prece- 
dent to the exercise of the quarantine authority is that the health 
officer shall know or have reason to believe that the disease exists 
or has recently existed. (H. & S. Code sec. In the exercise 
of this unusual power, which infringes upon the right of liberty of 
the individual, personal restraint can only be imposed where, under 
the facts as brought within the knowledge of the health authorities, 
reasonable grounds exist to support the belief that the person is 
afflicted as claimed. Where a person so restrained of his or her 
liberty questions the power of the health authorities to impose 
ouch restraint, the burden is immediately upon the latter to justify 
by showing facts in support of the order. It might be proved, for 
instance, that the Infected person had been exposed to contagious 
or infectious influence; that some person had contracted the disease 
from him or her, as the case might be. Such proof would furnish 
tangible ground for the belief that the person was afflicted as 
claimed. 
In re Arata, 52 Cal. App. y60 
In re Ml1stsad, 44 Cal. App. 239• 
H-a More than mere suspicion that the individual is afflicted is 
necessary to give the officer "reason to believe," 
In re Shepard, 51 Cal. App. k-J 
In re Dayton, 52 Cal. App, 635* 
If reasonable cause to believe that the person involved is 
afflicted with a quarantinable disease, the person may be quaran- 
tined upon a preliminary examination. 
In re Mllstead, kk Cal. App. 239 • 
Under date of March ~J, the Attorney General’s office 
ruled that the Director of the Department of Public Health was 
authorized to request the health officers of a certain locality in 
the State to quarantine an active case of tuberculosis. (Opinion 
NS3330.) 
CONCLUSION 
1. Health authorities are authorized to quarantine for an 
active case of tuberculosis, upon the basis of the provisions of 
the Health and Safety Code, hereinabove referred to, in addition to 
the theme which is present in all court decisions construing these 
and similar health laws. 
2. This authority must be exercised prudently. Reason to be- 
lieve that the disease exists as a prerequisite to the quarantine 
must be present. The burden is on the health officer to show that 
reasonable cause exists. 
5a What constitutes reasonable cause depends upon the peculiar 
facts of each. case. The duration of the quarantine and other con- 
ditions of the same are left to the rule-making discretion of the 
health authorities. 
6o, APPENDIX B 
Section 9^ 
TUBERCULOSIS 
Isolation shall be as defined in Section 37* 
a) Persons having tuberculosis in a communicable stage shall be 
considered as fulfilling the requirements of isolation as 
long as they are under adequate medical supervision and 
observe the instructions issued by the local health officer. 
The isolation shall be adequate for the protection of 
persons residing within the household as well as the public. 
b) Persons having tuberculosis in a communicable stage who 
refuse to observe the Instructions of the local health 
officer and thereby needlessly expose others to infec- 
tion shall be placed in quarantine until such time as 
the local health officer feels that such quarantine is 
no longer necessary for the protection of the public 
and in the event that such quarantine proves inade- 
quate for the protection of members of the household 
or community the patient shall be placed in isolation 
in quarters designated by the local health officer un- 
til such time as such isolation is no longer necessary 
for the protection of the public. 
c) The person officially in charge of a sanatorium or other 
place whore tuberculosis patients are cared for shall be 
responsible for immediately notifying the health officer 
in whose territory a patient resides whenever such patient 
having tuberculosis in a communicable stage leaves the 
institution. 
(From page IS of Regulations of the California State Board of Public 
Health for the Control of Communicable Disease, adopted April 3?19^3) APPENDIX C 
CHAPTER 6. QUARANTINE OF DISEASES 
Article 1. Definitions 
2500. "Health officer," as used in this chapter, includes 
county, town, city, and district health officers, and city and 
district health boards, but does not include advisory health boards. 
Article 2. Functions of State Department 
2521. The State department may establish and maintain places 
of quarantine or Isolation. 
2522. The State department may quarantine, isolate, inspect, 
and disinfect persons, animals, houses, rooms, other property, 
places, cities, or localities, whenever in its judgment such action 
is necessary to protect or preserve the public health, 
2523. The State department may destroy bedding, carpets, house- 
hold goods, furnishings, materials, clothing, or animals, which, in 
its judgment, are an imminent menace to the public health, 
252*4-. Upon being informed by a health officer of any contagious, 
Infectious, or communicable disease the State department may take 
such measures as are necessary to ascertain the nature of the disease 
and prevent its spread. To that end, the State department may, if it 
considers it proper, take possession or control of the body of any 
living person, or the corpse of any deceased person. 
Article 3* Functions of Health Officers 
Each health officer and coroner, knowing or having reason 
to believe that any case of cholera, plague, yellow fever, malaria, 
leprosy, diphtheria, scarlet fever, smallpox, typhus fever, typhoid 
fever, paratyphoid fever, anthrax, glanders, epidemic cerebro-spinal 
meningitis, tuberculosis, pneumonia, dysentery, erysipelas, uncinari- 
asis or hookworm, trachoma, dengue, tetanus, measles, German measles, 
chickenpox, whooping cough, mumps, pellagra, beriberi, Rocky Mountain 
spotted (or tick) fever, syphilis, gonococcus infection, rabies, 
poliomyelitis, or any other contagious or infectious disease exists, 
or has recently existed, within the territory under his jurisdiction, 
shall take such measures as may be necessary to prevent the spread of 
the disease. 
2555. Every health officer shall enforce all orders, rules, and 
regulations concerning quarantine prescribed or directed by the State 
department.  Sach health officer, whenever required by the State de- 
partment, shall establish and maintain places of quarantine or 
isolation that shall be subject to the special directions of the 
State department. 
2557. No quarantine shall be established by a county or city 
against another county or city without the written consent of the 
State department. 
2552• Whenever in the judgment of the State department it is 
necessary for the protection or preservation of the public health, 
each health officer shall, when directed by the State department, 
do the following: 
(a) Quarantine and disinfect persons, animals, houses or rooms, in 
accordance with general and specific instructions of the State de- 
partment . 
(b) Destroy bedding, carpets, household goods, furnishings, 
materials, clothing, or animals, when ordinary means of disinfection 
are considered unsafe, and when the property is, in the judgment of 
the State department, an Imminent menace to the public health. 
When property is destroyed pursuant to this section, the govern- 
ing body of the locality in which the destruction occurs may make 
adequate provision for compensation in proper cases for those injured 
thereby. 
2p59. Upon receiving information of the existence of Asiatic 
cholera, yellow fever, typhus fever, plague, smallpox, scarlet fever, 
diphtheria, or any other contagious, infectious or communicable 
disease that the State department may from time to time declare quar- 
antinable, each health officer shall: 
(a) Quarantine each case. 
(b) Follow local rules and regulations, and all general and 
special rules, regulations, and orders of the State department in 
carrying out the quarantine. 
2560. Each health officer who establishes any quarantine shall 
promptly transmit to the State department a copy of all quarantine 
rules, orders, and regulations, and of all subsequent changes in 
then, adopted by him. 
2561. When all or any part of a building, house, structure, 
tent, or other place is quarantined because of a contagious, in- 
fectious, or communicable disease, the health officer shall fasten 
firmly on its most conspicuous part a yellow placard, upon which 
shall be printed the following words: "Keep out. These premises have been quarantined by order of 
the . Note—Under the provisions of the Health and 
Safety Code of the State of California anyone entering or leaving 
these premises without the permission of the health officer is 
guilty of a misdemeanor.n 
The word "quarantined" shall be printed in plain and legible 
letters at least two and one-half inches in height. 
The placard shall not be removed except by the health officer, 
nor shall it be defaced or obscured. 
2562. When quarantine is established by a health officer, all 
persons shall obey his rules, orders, and regulations, 
2p6p. A person subject to quarantine, residing or in a quar- 
antined building, house, structure, or tent, shall not go beyond the 
lot upon which the building, house, structure, or tent is situated, 
nor put himself in Immediate communication with any person not sub- 
ject to quarantine, other than the health officer and the physician. 
The health officer maintaining the quarantine shall appoint/ or have 
appointed, a suitable person to perform necessary outside services 
for the necessary wants of the persons quarantined. The person 
appointed shall not enter the building, house, structure, or tent, 
nor shall he come in personal contact with any of the persons quar- 
antined. He shall leave at the entrance of the building, house,. 
structure, or tent, or at such other place as may be designated by 
the health officer, all articles that he may bring thereto. He 
shall strictly observe the orders of the health officer. 
No instructor, teacher, pupil, or child affected with 
any contagious, infectious, or communicable disease that is quaran- 
tined, or that is subject to being quarantined or reported, or who 
resides in any house, building, structure, tent, or other place where 
une disease exists or has recently existed, shall be permitted by 
any superintendent, principal, or teacher of any college, seminary, 
or public or private school to attend the college, seminary, or 
school, except by the written permission of the health officer, 
cpon. iMO quarantine shall be raised until every exposed room, 
together with all personal property in the room, has been thoroughly 
or, if necessary, destroyed, by or under the direction 
of the health officer; and until all persons quarantined have taken 
a thorough antiseptic bath and have put on clothing free from con- 
tagion. 
25oo, No milk man shall remove milk bottles or other recem— 
tacles^for milk from any building, house, structure, tent, or other 
pj.ace in which a contagious, infectious, or communicable disease 
exists or has existed, nor from any place within any quarantined district, nor at any time after a quarantine has been removed, with- 
out the written permission of the health officer; and until the milk 
bottles or other receptacles have been disinfected and cleaned to 
the satisfaction of that officer* 
2567. It is unlawful for any milkman, milk dealer, or milk 
distributor in whose house any case of cholera, typhus fever, plague, 
scarlet fever, diphtheria, membranous croup, leprosy, anthrax, 
glanders, cerebro-spinal meningitis, whooping cough, typhoid fever, 
dysentery, trachoma, or tetanus exists, to continue the sale or dis- 
tribution of milk until the health officer has appointed, at the 
expense of the county where the milkman, dealer, or distributor 
lives, a person to superintend his dairy, or other place where or 
from which he sells, delivers, or distributes milk, and all his cows, 
bottles, vessels, and milk utensils. The person appointed shall 
strictly require that any person attending to the cows, dairy, sheds, 
milk cans, bottles, vessels, and milk utensils, shall not have ac- 
cess to, nor have any communication with the persons who reside in, 
the infected house, except with the permission and under the inspec- 
tion of the health officer, 
25o£. In case of a local epidemic of disease, the health 
officer shall report at such times as are requested by the State de- 
partment all facts concerning the disease, and the measures taken to 
abate and prevent its spread. 
2569. Each health officer shall immediately report by tele- 
graph to the State department every discovered or known case of 
plague, Asiatic cholera, yellow fever, or typhus fever. Within 
hours after investigation he shall report the cause, source, and 
extent of contagion and infection, and all acts done and measures 
adopted. Ke shall also make such further reports as the State 
department may require. 
2570‘ Each health officer placing any case under quarantine 
shall, within hours thereafter, report it fully, in writing, to 
the State department. 
2571« The following shall be properly reported in writing to 
the State department by the health officer; 
Chicken pox, erysipelas, pneumonia, epilepsy, uncinariasis, or 
hookworm, epidemic cerebro-spinal meningitis, trachoma, whooping 
cough, mumps, dengue, dysentery, tuberculosis, typhoid fever, tetanus* 
malaria, leprosy, measles, German measles, glanders and anthrax 
affecting human beings, rabies, pellagra, beriberi, syphilis, gono- 
coccus infection, poliomyelitis, and any other disease which appears 
to have become epidemic. 
This list of reportable diseases may be changed at any time by 
the State department. 
11a  t ■h1*- diseases enumerated in tnis section, and such others as from 
time to time may be added by the State department, shall be quaran- 
tined whenever in the opinion of the State department that action is 
necessary for the protection of the public health, and shall be 
isolated whenever in the opinion of the department or health officer 
isolation is necessary for the protection of the public health. 
(Amended by Stats. 1939, Ch. 375.) 
. 2572. Each health officer, other than a county health officer 
in the county shall transmit to the county health officer at least 
weekly in writing a report showing the number and character of in- 
tectious, contagious, or communicable diseases reported, and 
location, 
'-573• All physicians, nurses, clergymen, attendants, owners, 
proprietors, managers, employees, and persons living, or visiting any 
sick person, in any hotel, lodging house, house, building, office, 
structure, or ouner place where a,ny person is ill of any infectious 
contagious, or communicable disease, shall promptly report that fact 
,° health officer, together with the name of the person, if known 
tne place where he is confined, and the nature of the disease if 
known. ’ 
Unless otherwise directed by the State department, 
Socpons 2559, 25ol to 2563, Inclusive, 2365 to 2567/ inclusive, and 
ObJ to 2571, inclusive, of this chapter shall be strictly observed 
in all cases of quarantine. 
Article Violations 
c_6oo. Any person who, after notice, violates, or who, uoon the 
demand of any health ofiicer, refuses or neglects to conform to any 
rule, order, or regulation prescribed by the State department re- 
specting a quarantine or disinfection of persons, animals, things 
or places, is guilty of a misdemeanor. 
2o01. Except in the case of the removal of an afflicted person 
in manner tne least, dangerous to the public health, any person 
afilicted with any contagious, infectious, or communicable disease 
wuo wilfully exposes himself; and any person who wilfully exposes 
another person afflicted with such disease in any public place or 
thoroughfare is guilty of a misdemeanor. 
2o02 Any person who violates any section in Article 3 of this 
chapter, witn the exception of 25b5, is guilty of a misdemeanor 
punishable by a fine of not less than twenty-five dollars (|25),nor 
more than five hundred dollars ($500), or by imprisonment for a term 
of not more than 90 days, or by both. He is guilty of a separate 
offense for each day that the violation continues. 
12a