Among the influences favoring the spread of smallpox in this section may be mentioned the mild type of the disease that made people unafraid of it, and therefore averse to observe the proper precautions to prevent its spread.

Fully 90 per cent of the people in the territory included in this survey were unprotected by recent vaccination. Approximately 75 per cent at least had never been vaccinated.

In rural communities it is a difficult matter to enforce strict quarantine, especially against a disease of which the people are not afraid. Many instances were reported of cases in the eruptive stage breaking quarantine. The indictment of 14 persons for violation of quarantine ordinances by the Butler County grand jury will doubtless put an end to this practice. In spite of the penalty attached for each offense, under the Kentucky statutes, it is believed many cases of smallpox had been concealed from the health authorities.

A complete report of Dr. Clark's investigation was published in the Public Health Reports for February 21, 1913.

SUSPECTED TYPHUS FEVER AT PETERSBURG, Va.

At the request of the State commissioner of health of Virginia, Passed Asst. Surg. J. Goldberger was detailed on July 6, 1912, to Petersburg, Va., in order to examine a suspected case of typhus. While the clinical picture presented by the patient was that of typhus fever and negative Widal and fecal cultures seemed to exclude typhoid fever, yet no final opinion could be formed as to the nature of the disease, as two guinea pigs inoculated with blood from the patient died prematurely. A diagnosis of probable typhus was therefore made, and a course of treatment was outlined on this basis. It was recommended that the patient's hair should be treated with a parasiticide, his clothing boiled, and that in other respects he should be treated as if suffering with typhus.

LABORATORY INVESTIGATIONS OF TYPHUS FEVER.

The studies of typhus fever referred to on page 23 of the last annual report have been continued in the Hygienic Laboratory, particular attention being paid to the question of natural immunity to the disease. It was found that approximately 20 per cent of monkeys resist the primary injection of virulent material. This immunity of monkeys to the disease has without doubt played an important part in the reports of certain observers as to the filterability of the virus and perhaps also the seat of the virus in the blood.

The typhus-fever virus originally obtained from a case of so-called Brill's disease in Mount Sinai Hospital on September 20, 1911, is still maintained in the laboratory by passage from guinea pig to guinea pig. It has now been almost two years since this was begun. In spite of this long-continued passage from animal to animal there does not seem to have been any change in the virulence of the infection.

ALLEGED TUBERCULOSIS CURES.

Announcements in the lay press during the year served to attract considerable attention to a number of remedies advocated for the cure of tuberculosis. With a view to safeguarding the interests of the public and securing the enforcement of the law of July 1, 1902, for the control of the sale of biological products in interstate traffic, action was taken by the bureau in several instances.

The Friedmann treatment. During the latter part of the fiscal year a board of service officers, consisting of Surg. J. F. Anderson and Passed Asst. Surg. Stimson, was instructed to investigate a treatment for tuberculosis prepared and advocated by Dr. Friedrich Franz Friedmann, of Berlin, Germany. These studies have been conducted in part in New York City by the observation in certain hospitals located there of patients treated by Dr. Friedmann and in Washington by laboratory studies of certain materials given the board by Dr. Friedmann for investigation. A preliminary report has been made to the bureau by this board. While the studies of the board have not yet been completed, the preliminary report shows that the extravagant claims made for the treatment by its sponsors have not been confirmed by the board. The observation of patients in the New York hospitals is being continued and the studies of the cultures and pathogenic properties of the organism used in the preparation of the vaccine are now being continued in the Hygienic Laboratory.

The preliminary report referred to was published in the Public Health Reports of May 16, 1913.

The Duket treatment.-In accordance with repeated requests for an investigation of a remedy originated by Dr. Peter P. Duket, of Chicago, Ill., Surg. J. O. Cobb was instructed to make preliminary inquiries in regard to the character of this treatment and the advisability of undertaking the investigation requested. A report was made by him on May 16, advising, for various reasons, against the proposed investigation, and the bureau declined to take any further action in regard to the matter.

The Von Ruck treatment.-In accordance with a resolution of the United States Senate, the laboratory was instructed about the close of the fiscal year to investigate the claims made by Dr. Karl von Ruck and Dr. Sylvio von Ruck for a method of immunization against tuberculosis prepared by these men. Studies of this treatment have not yet been commenced, but it is purposed to begin them at a very early date.

STUDIES ON TUBERCULOSIS.

The universal prevalence of tuberculosis and the numerous claims made for different methods of treatment render necessary systematic studies of the disease in the field and in the laboratories which will throw light on its relation to interstate traffic.

The question of the relationship of the various acid-fast bacteria to the tubercle bacillus is of great importance, especially in view of the fact that some workers have claimed the production of resistance to tuberculosis infection by animals as a result of the treatment with such acid-fast bacteria.

The question of the change of biologic characteristics of the tubercle bacillus by passage through the cold-blooded animal is also one that should receive attention.

INVESTIGATIONS OF CONTAGIOUS AND INFECTIOUS DISEASES AMONG THE INDIANS.

In the act approved August 24, 1912, making appropriations for the current and contingent expenses of the Office of Indian Affairs, for fulfilling treaty stipulations with various Indian tribes, and for other purposes, for the fiscal year ending June 30, 1913, there was included the following provision:

Provided: That the sum of $10,000, or so much thereof as may be necessary, is hereby appropriated, out of any money in the Treasury not otherwise appropriated, to enable the Public Health and Marine-Hospital Service to make a thorough examination as to the prevalence of tuberculosis, trachoma, smallpox, and other contagious and infectious diseases among the Indians of the United States, full report to be made to Congress not later than February 1, 1913, with such recommendations as may be deemed advisable.

In accordance with the directions contained in this law steps were taken to make the necessary investigations. They consisted in examinations of available records at Indian agencies and boarding schools as to the past prevalence of contagious and infectious diseases, consideration of available records of State boards of health, examinations of Indians on reservations and in boarding schools, inspection of insanitary conditions having a bearing on the propagation of communicable diseases and house to house inspections upon as many reservations as possible.

The field investigations were begun September 28, 1912, and terminated December 30, 1912, 14 officers being assigned to the work. Reservation and nonreservation boarding schools in 25 States were visited, and a total of 39,231 Indians examined, representing approximately one-eighth of the entire Indian population of the continental United States.

The examinations consisted in complete inspections for the detection of trachoma, supplemented by physical examinations for tuberculosis whenever indicated by the general appearance or the family history. In addition, the tuberculin (Von Pirquet) test was applied to 1,225 Indian children to ascertain the extent of tribal exposure, and a sufficient number of arms were examined to determine the thoroughness with which vaccination had been performed.

Attention was also paid to the sanitary conditions in schools and on reservations, with special relation to housing conditions, food supply, and social and personal habits tending to favor the spread of disease among the Indian population. As a result of the examinations it became evident that trachoma and tuberculosis are veritable scourges of the Indian race.

Trachoma.-Out of 39,231 Indians examined at all the reservations and nonreservation boarding schools visited, 8,940 individuals, or 22.7 per cent of the entire number, were found to have trachoma.

The incidence of trachoma was found to vary greatly in the different sections of the country and even in different parts of the same reservation. The highest percentage of incidence was found in Oklahoma, where 68.6 per cent of those examined were found to be trachomatous. In New York, on the other hand, only 2, or 0.2 per

cent, out of 943 Indians had the disease, and these two contracted the infection at a nonreservation boarding school.

Trachoma was found to be generally prevalent in the schools to a greater degree than in the reservations from which the pupils are drawn, and in nonreservation boarding schools it was found that groups of pupils, from areas where trachoma is absent or but slightly prevalent, presented a high percentage of infection. The inference was reasonable that these pupils contracted the disease at such nonreservation boarding schools.

No reliable data could be obtained by which the origin and duration of the disease among the Indians could be determined. On the whole, it appears that trachoma has been prevalent among Indians in widely scattered sections for many years, but the source of the infection among them must, in all probability, remain a mystery.

Tuberculosis. Although no accurate data could be obtained relative to the length of time tuberculosis has existed among the Indians, it was found that the disease is widespread among them.

Considerable variation was noted in the case incidence of the discase, the percentage of tuberculous Indians varying in the several States and on the different reservations in the same State. The more primitive the Indian, generally speaking, the higher was the percentage of tuberculosis.

On the whole, it may be said that the prevalence of tuberculosis among the Indians is very greatly in excess of that among the white race, depending on locality, and the survey, as conducted, has revealed a situation so serious as to require the prosecution of vigorous measures for its relief.

Smallpox.-Only 6 Indians of the 39,231 inspected were found suffering from smallpox at the time of the examination. Minor outbreaks have been noted from time to time on reservations in various parts of the country, but the prevailing type of this disease has been mild and but few deaths have resulted.

It was estimated that in Arizona at the time of the investigation there were 23,000 Indians who had not been vaccinated. Apart from this large body of unprotected Indians, the rest of the Indian population may be said to be vaccinated with a fair degree of thoroughness.

Typhoid fever and other diseases. No case of typhoid fever was met with on reservations or in schools among the Indians inspected, and such records as were available at schools and agencies showed the disease to be very uncommon among them.

It may be expected, however, when the Indian is brought into closer contact with white populations that typhoid fever will become increasingly prevalent in the Indian race. There was no evidence that other infectious and contagious diseases are more prevalent among Indians than among the white population.

On the whole, the sanitary conditions on reservations were found unsatisfactory. The primitive Indians themselves were found to be careless and dirty in their personal habits and generally ignorant of the first principles of hygiene. Their personal and social habits favor the spread of disease, as they are careless about spitting and the disposition of human and household waste. Their fondness for visiting, together with dances and social gatherings, which are

attended by the sick and the well, afford opportunity to spread any communicable disease which is present.

The high prevalence of trachoma and tuberculosis among the Indians is of importance, not only with respect to the Indian but also to other races. Many counties on Indian reservations are being opened to white settlement, and the Indian is in a gradual process of assimilation with the rest of the population. The future development of transportation also will tend to bring the Indian into closer contact with other inhabitants. The control of communicable diseases among Indians and the prevention of their spread to other races are, therefore, indicated.

On completion of the field investigations, all the data collected by the several officers were collated by the bureau and embodied in a report which was submitted to Congress January 23, 1913. This report was published as Senate Document 1038 (62d Cong., 3d sess.) and contained not only the data mentioned, but recommendations dealing with conditions found, which, in many instances, were a menace to the welfare of the Indian and to the health of the country generally.

INVESTIGATIONS OF TRACHOMA IN MINNESOTA.

In the annual report for 1912, page 24, reference was made to a preliminary survey of conditions in Minnesota to determine the prevalence of trachoma among the Indians on the White Earth and Leech Lake Indian Reservations. As a part of the investigations of contagious and infectious diseases among the Indians in the United States, a second survey was made by Surg. T. Clark in October and November, 1912. The results of these studies were received and embodied in a report, which was sent to Congress and published as Senate Document No. 1038.

The previous surveys having related largely to the Indian population in Minnesota, a third survey was begun by Dr. Clark in accordance with orders of February 19, 1913. This last survey consisted of an examination of school children in public and parochial schools and various places within the State, pupils of the various State normal schools, students of the State agricultural school at Minneapolis, and inmates of the various penal and reformatory institutions and schools for the deaf, blind, and feeble-minded.

The work was carried on in cooperation with the State Board of Health of Minnesota, and as a preliminary measure the secretary of that board addressed letters to the boards of education of the various towns to which visits were to be made. Permission for such examinations was promptly granted, the various boards of education, with one exception, being alive to the desirability and importance of these surveys.

The examinations were confined to no one particular class of the population, but embraced all classes at widely separated points. They consisted of an inspection of the conjunctiva of each individual after everting the eyelids so as to allow of proper scrutiny. In this manner Dr. Clark within the past 12 months examined within the State of Minnesota 52,847 persons of all classes, including Indians, and found 610 cases of active trachoma, i. e., 1.14 per cent of the total number examined. In the white population 77 cases were found