examination of individuals suspected to be tuberculous. Two officers, however, employed the tuberculin (Von Pirquet) test on 1,225 children.

By reason of these limitations placed upon the examination it is believed that the prevalence of tuberculosis reported by the officers engaged in these studies is lower than that actually existing among the Indians visited. The large number of school children it was necessary to inspect for the incidence of trachoma likewise reduced the amount of tuberculosis reported for the reason that the regulations of the Indian Office, excluding tuberculous children from school, are generally observed. This resulted in finding an artificially reduced prevalence of tuberculosis in a proportionately large group of those examined. It was, nevertheless, found that tuberculosis is widely spread among the Indians.

Considerable variation was noted in the case incidence of the disease, 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. The rate was relatively low among the prosperous Southern Utes at Navajo Springs, Colo., and extremely high among the Paiutes of Nevada, the rate of incidence reaching 32.67 per cent among the Paiutes of the Pyramid Lake Reservation. The observed incidence was also high on some of the Oregon reservations-24.56 per cent on the Siletz Reservation, 20.27 per cent at Klamath Lake, 20.66 per cent on the Umatilla Reservation, and 22.75 per cent at the Warm Spring Reservation. The lowest incidence for a State was observed in New York with a case rate of 1.27 per cent. These Indians are in an advanced condition, are self-supporting, and their mode of life does not differ materially from that of the white rural dweller.

In the Northwestern and Northern States the incidence of tuberculosis varied from 15 per cent for the Sac and Fox Indians of Iowa and 12.14 per cent for the Montana Indians to 2.33 per cent for those of Michigan, while in the Southwest a considerable variation for the different tribes was noted, the Jicarilla Apaches of New Mexico and the Walapais of Arizona giving high percentages of infection, 9.45 and 14.96, respectively. The lowest percentages in these States were reported among the Navajo and Zuñi Tribes in New Mexico, who are prosperous and well fed.

The Von Pirquet test, referred to above, was applied to 1,225 school children in New Mexico. With reference to white children, McNeil reports (Edin. Med. Jour., April, 1912) positive reactions to this test among 531 white children to range from 14.1 per cent for children under 1 year to 55 per cent in girls from 11 to 14 years of age and 60.5 per cent in a group of boys of the same age.

Smith, who applied this test to the Indian children of New Mexico, found a considerably higher percentage of positive reactions than those above referred to, in one instance 95.5 per cent of the children over 11 years giving the reaction. This was among the Jicarilla Apaches who gave the highest incidence of clinical tuberculosis in any tribe he examined. On the other hand, in the case of the Taos Indians, among whom 4 deaths only had been recorded from tuberculosis, the percentage of children giving a positive reaction to the Von Pirquet test was but 1.42. No case of clinical tuberculosis was

found among these Indians, and 2 of the cases referred to contracted the disease at a nonreservation boarding school.

On the whole it may be said that the prevalence of tuberculosis among 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.

PREVALENCE OF SMALLPOX AMONG INDIANS.

Only 6 Indians of the 39,231 inspected were found suffering from smallpox at the time of the examination. The records examined at the various reservations furnished data which were generally unsatisfactory as to the past prevalence of smallpox. The last severe epidemic among the Indians took place among the Zuñis of New Mexico in 1899 when 555 deaths occurred, and, according to trustworthy information, 900 freshly pock-marked Indians were counted after the epidemic. Since then 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.

Thoroughness of vaccination among Indians.-It is estimated that in Arizona there are 23,000 Indians who have 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. A lack of thoroughness in the vaccination of those of the school age was observed among Indians in certain sections and, unless steps are taken to correct this deficiency, there is danger of the growth of an unvaccinated generation.

On the whole it may be said that smallpox has not prevailed to any extent among Indians of recent years, and that vaccination is probably as thorough among the Indians as among whites in the average rural community.

As the incidence of smallpox should be nil in a well-vaccinated community, the occurrence of occasional cases of smallpox among the Indians is evidence that vaccination among them has not as yet been practiced with sufficient thoroughness. As obedience to sanitary laws is as much the duty of Indians as of others, superintendents and agency physicians should be held strictly accountable for the control of smallpox in the Indian population.

PREVALENCE OF OTHER INFECTIOUS AND CONTAGIOUS DISEASES AMONG THE INDIANS.

Typhoid fever. 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. This is surprising in view of the existence among Indians of conditions apparently favorable to its spread, but its rarity may be partly accounted for (1) on the ground that the disease has not as yet been extensively introduced among them; (2) that the the Indian's water supply is comparatively safe as, in most instances, he lives at a distance from his sources of drinking water and owing to the low annual rainfall on many Indian reserva

tions and the impermeability of the subsoil, the chances of pollution of sources of water supply through seepage or surface washings are reduced; (3) the Indian is a nonmilk drinker, hence an important agency for the spread of typhoid fever in white communities becomes nonoperative in his case.

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.

Measles is common among Indians and outbreaks in the Southwest have been attended with a considerable mortality. In the Northwest, while outbreaks are frequent, the type of the disease has seemed milder.

Scarlet fever is rare and but one case was encountered during the investigation. The disease is infrequently reported in agency morbidity records.

Diphtheria, according to agency physicians, is rare among the Indians. The Mescalero Apaches seem to have presented the highest incidence, 19 cases having been noted in the two years ending June 30, 1912.

Whooping cough is common among the Indians, and in infants is attended with the usual high mortality.

Chicken-pox and mumps are frequently met with in Indian populations, but are unattended with mortality.

Epidemic cerebrospinal meningitis is rare. During the epidemic of this disease in Oklahoma in 1911 and 1912, out of 902 cases, 17 or 18 were in Indians. Five cases and 2 deaths occurred at the Cheyenne and Arapaho School at Lawton.

Infantile paralysis. The occurrence of cases of infantile paralysis was reported on the Flathead and Blackfeet Reservations in Montana in 1911.

Malaria was reported to be prevalent among the Indians in the southern and eastern parts of Oklahoma. The Indians of this section suffer in about the same ratio as do the whites.

Venereal diseases. Contrary to the general impression, venereal diseases seem uncommon among reservation Indians. Syphilis seems more infrequent than gonorrhea, but there was no evidence found of extensive prevalence of either disease.

Contagious skin diseases. Of the contagious skin diseases, impetigo contagiosa and scabies are the most common among Indians.

Hookworm infection was reported among the Cherokees of North Carolina. In 1911, 41 per cent of the children examined in the Cherokee boarding school were found to be infected with the disease.

Rocky Mountain spotted fever. One case of this disease was reported on the Wind River Reservation in Wyoming. Cases are reported annually among the white residents in this section. The disease here is mild.

INSANITARY CONDITIONS FAVORING THE SPREAD OF CONTAGIOUS AND INFECTIOUS DISEASES AMONG THE INDIANS.

The sanitary conditions on reservations were found on the whole unsatisfactory. The Indians' houses are small, usually overcrowded and leave much to be desired from the standpoint of cleanliness. 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 of 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.

Owing to their improvidence and racial indolence and poverty, their food supply on the whole is scanty and inferior, thus lowering vital resistance and increasing the predisposition to disease.

Flies are also numerous on reservations on account of breeding places created by accumulations of filth of various kinds and may play a part in the dissemination of tuberculosis and trachoma among the Indians.

Schools. The schools, generally speaking, were overcrowded or, owing to disproportion in the sexes present, schools with an enrollment below the rated capacity might have more pupils of one sex present than the accommodations warranted. In many instances overcrowding in the dormitories existed.

The regulations of the Office of Indian Affairs, calling for separate towels for each pupil were generally complied with, but in most instances, the manner of disposition of the towels was faulty, as when not in use, they were hung up in such manner as to permit the transfer of infection from one towel to another.

Trachomatous pupils in most schools were allowed to mingle freely with healthy pupils in the classrooms, dormitories, and at play. The washing and toilet facilities were, in many instances, inadequate, of obsolete pattern, and frequently in a state of disrepair. The water supply in some schools was inadequate or was rendered defective through faults in the plumbing. The schools were also generally found imperfectly screened against flies with the exception of dining rooms and kitchens. The medical and sanitary supervision also left something to be desired.

THE BEARING OF THE PREVALENCE OF CONTAGIOUS AND INFECTIOUS DISEASES AMONG THE INDIANS ON THE HEALTH OF OTHER RACES.

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 is, therefore, indicated as a public-health measure.

MEDICAL BRANCH OF THE OFFICE OF INDIAN AFFAIRS.

It was found that the curative efforts of the physicians of the Office of Indian Affairs were largely nullified by the conditions under which work is attempted and by the indifference and ignorance of the primitive Indian. The important problem is not so much the medical treatment of the Indian for disease as the improvement of insanitary conditions causing such diseases.

Under existing regulations agency physicians are subordinate to agency superintendents in medical and sanitary matters, and such superintendents are not in many instances sufficiently impressed with the importance of health problems. The status of the agency physicians was found to be unsatisfactory from the standpoint of inadequate compensation, lack of organization, and the esprit de corps necessary in any great coordinated work.

The reports of sickness and deaths are the foundation of publichealth work. Records of these were indefinite and fragmentary on most reservations, and due care was not exercised in all instances in their compilation and preservation.

CONCLUSIONS.

I. Trachoma is exceedingly prevalent among the Indians and this prevalence was found (a) highest in Indian boarding schools, (b) less in Indian day schools, and (c) least among reservation Indians above and below school age.

II. Tuberculosis is very prevalent among Indians. Although the conditions of the investigation did not permit the detection of all the cases which might have been found with more extended opportunities, there is good ground for belief that the incidence of tuberculosis among the Indians is greatly in excess of that estimated for the white population, and the undertaking of immediate means of relief are indicated.

III. Smallpox is little prevalent among Indians at the present time. Evidence was found that the Indian population is vaccinated with approximately as great a degree of thoroughness as the rural white population.

IV. Typhoid fever, contrary to expectation, is less prevalent among the Indians than among the whites. There was no evidence that other infectious and contagious diseases are more prevalent among Indians than among the white population.

V. The conviction can not be escaped that Indian boarding schools have been an important agency in the spread of trachoma.

VI. The sanitary conditions on reservations are, on the whole, bad, and require improvement in housing conditions and habits of living. VII. The primitive Indian requires instruction in personal hygiene and habits of living, especially in stationary dwellings, and practical education in such matters must be made the basis of future advancement.

VIII. The social habits of Indians (visiting, dances, etc.) may serve to spread any communicable disease present among them.

IX. The presence of numerous flies on reservations is believed to be a factor in the spread of tuberculosis and trachoma.

X. The sanitary conditions in most Indian schools are unsatisfactory because of one or more of the following conditions: Overcrowding, inadequate equipment, imperfect sanitary supervision, and lack of observance of necessary sanitary precautions.

XI. There is danger of the spread of tuberculosis and trachoma from the Indian to other races by reason of the increasing intercourse taking place between them.