was considerable apprehension among the white population in the adjacent towns. In part, as the result of the natural stoical and taciturn disposition of the Indian, many mild cases of smallpox had occurred before the presence of the disease was discovered. Many of the Indians were employed as laborers upon farms and in the nearby villages. A few who had been exposed and were unvaccinated, as already mentioned, had left the reservation prior to the investigation.

As a majority of the Indians who were ill or whom it was necessary to quarantine as contacts were made indigent thereby, it became necessary to provide immediately for care and maintenance, as well as to provide guards to prevent unvaccinated persons leaving the reservation.

Poor law officials of towns in which Indian reservations are located are empowered by law to defray expenses incidental to epidemics of communicable disease, the law further providing that the State Commissioner of Health may reimburse them for such expenditure. A joint meeting of the various town boards with the state health officials was called to consider "ways and means." In view of the extent of area of the reservation and the wild character of the country thereabouts involving the necessity for a large number of guards, and of the number of exposed individuals and the likelihood of many becoming indigent when incomes from daily labor were temporarily discontinued, it was obvious that the local expense of controlling the outbreak and caring for the Indians would be large. On this account and because of an unfortunate experience which one of the boards had had before the enactment of the law authorizing reimbursement by the State Commissioner of Health, the local officials were reluctant to assume responsibility. This they finally agreed to do, however, and they have since been reimbursed. This incident is related as pointing to the need for more definite and workable laws than now exist in regard to control of outbreaks of communicable disease upon reservations. It may be noted in passing that the expenditure for which local officials have been reimbursed in this single outbreak have amounted to approximately seven thousand dollars.

Here, for the first time, was demonstrated the value of the

state constabulary as an agency for the protection of life and health. When it was found practically impossible to secure an adequate number of men who could be depended upon to perform fearless and efficient service as guards, six troopers were assigned by the superintendent of State Police to this duty and their services proved highly effective.

Through the cooperation of the State Department of Education, vaccination centers were established at the reservation schools and approximately 1,500 of the 1,600 residents of the reservation, most of whom were unvaccinated, were vaccinated. Throughout the epidemic the Indians generally, and particularly the council of the Seneca Nation, cooperated cordially in its control.

While the outbreak was in progress, vaccination was performed very generally in the surrounding towns and villages.

The 348 cases of smallpox which occurred during 1917 in the State outside of New York city were distributed by race as follows:

The following table presents the vaccination history for the 348 cases reported outside of New York city.

RECORD OF VACCINATION IN REPORTED CASES OF SMALLPOX 1917, NEW YORK STATE, OUTSIDE OF NEW YORK CITY

During the year, 14,386 vaccinations were reported. It is believed that many vaccinations have been performed reports of which have not been made to this Department as required by

section 311 of the Public Health Law. Many reports received do not indicate whether or not vaccination was successful. A special effort is being made to enforce this section of the law and to encourage physicians performing vaccinations to ascertain whether or not such vaccinations have been successful before making reports. The following item which appeared in the January, 1918, number of the HEALTH NEWS is of passing interest:

AN AMBULATORY SMALLPOX CASE

The following incident strikingly illustrates the possibility of mistaken diagnosis in smallpox, the serious results which may follow failure to report so-called "minor" communicable diseases, and the difficulty of preventing the spread of smallpox in the absence of general vaccination.

A traveling salesman, calling upon physicians and coming in contact daily with a large number of people, became ill on January 2, while stopping at a hotel in Jamestown, N. Y. From the third to the fifth day of the month he was attended by a physician who treated him for "grippe.” On the morning of January 6, he felt better and continued his travels, stopping at hotels in Olean, Bradford and Salamanca within the next few days. On January 9, while at Portville, he noticed an eruption and is said to have casually consulted a physician, who advised him that his eruption resembled chickenpox but allowed him to continue his travels, and apparently did not report the case. On January 10, at Cuba, it is stated that he again called the attention of a physician to his eruption. The physician suspected smallpox and later called the attention of a sanitary supervisor to the case, but permitted the man to leave, and apparently did not report the case to the local health officer. The sanitary supervisor started an investigation which resulted in the man being later located at Olean. Just prior to the arrival of the information from the sanitary supervisor, two Olean physicians had made a diagnosis of smallpox. Later this diagnosis was confirmed by the sanitary supervisor and by several other local physicians. It was found that the man had never 'been vaccinated.

The incident should serve to impress upon physicians the importance of regarding all cases of "grippe" and chickenpox as suspicious at a time when smallpox is prevalent, especially if associated with severe backache and headache. It indicates clearly that failure to comply with regulations of the sanitary code relative to reporting communicable diseases may lead to serious complications. Incidentally, no better argument is needed to convince laymen of the decided advantage of being protected against smallpox by vaccination.

Typhoid fever

During the year, 4,293 cases of typhoid fever were reported, 1,442 of these from New York city, 2,851 from the rest of the state. There were 591 deaths from the same cause, 229 occurring in New York city (see special report, page 184).

Among the various upstate counties, by far the highest case rate prevailed in Albany county, which had a case rate of 223 per 100,000, the next highest being Greene county with 130 per 100,000, and the lowest being Wyoming county with 6, and Nassau with 11. The excessive rate in Albany county was largely due to a prolonged outbreak which occurred at Watervliet, a city of approximately 14,000 population.

Inasmuch as this was the most important, and incidentally the most troublesome, typhoid outbreak which occurred during the year, the complete report of the investigation of Dr. Edward S. Godfrey, Jr., epidemiologist, is here presented:

TYPHOID FEVER IN WATERVLIET

The city of Watervliet, Albany county, having a stationary population of almost exactly 15,000, has suffered from an excessive typhoid rate for many years past and has gone through three epidemics in the past five years. About the 15th of September, 1917, attention was called to the fact that 16 cases had been reported since the 1st day of the month; 13 additional cases were reported on the 17th through the Watervliet and Troy Health Departments.

A preliminary investigation by Dr. Duryee, the sanitary supervisor of the district, showed that a very large proportion of the cases were located in a district bounded by the Arsenal wall, north to Fourteenth street and from Broadway west to Fourth avenue. Dr. Duryee found that a very large percentage of the cases did not drink city water but used water from one or all of three wells located at Second avenue and Thirteenth street, Third avenue and Thirteenth street and Third avenue and Fourteenth street, respectively. The members of these families, however, as a rule did use city water for domestic purposes.

In times past the general water supply of the city has been held accountable for the high typhoid rate and it was assumed prior to Dr. Duryee's investigation that this was the case in the present instance. The Engineering Division accordingly began an investigation of the general water supply simultaneously with Dr. Duryee's investigation of the eases, leading to the discovery of certain facts which will be noted later. Inasmuch as an under