tuberculin test is found associated with a like high death rate from tuberculosis. Therefore the result of this test in a given population under known conditions not only enables us to calculate the probable death rate from tuberculosis, but also serves as an index of the actual prevalence of this disease.

North Carolina.-Fricks examined 317 Cherokees in North Carolina and found 6 cases of tuberculosis, 4 pulmonary and 2 glandular, a percentage of 1.89. He says: "The Cherokees, numbering 2,115 with 41 per cent full bloods and 59 per cent mixed, are citizens of North Carolina. They live just as the poorer white mountaineers of that section."

North and South Dakota.-North and South Dakota are treated as a unit in the consideration of the prevalence of tuberculosis among the Indian population because of their contiguity, and also because two officers, Schereschewsky and Preble, collected data independently

in these two States.

In all, 9,568 Indians were examined in these two States and 361 cases of tuberculosis found.

Tuberculosis incidence was considered by each of the two officers from the standpoint of

(1) Tuberculosis in reservation Indians exclusive of schools. Of these, 5,813 were examined, and 296 cases of tuberculosis found, a percentage of 5.09. Of these there were 162 pulmonary, 108 glandular, 19 osseous, and 7 cases of all other forms of tuberculosis.

(2) Tuberculosis in Indian boarding schools. There were examined 3,103 Indian boarding-school children in these two States and 52 cases of tuberculosis found among them, namely, 18 pulmonary, 32 glandular, 5 osscous, and 1 of other forms, a percentage of 1.67.

(3) Tuberculosis in Indian day schools. Schereschewsky examined 652 children in Indian day schools of the two Dakotas and found 9 cases of tuberculosis, 4 pulmonary and 5 glandular, a percentage of 1.38.

Schereschewsky properly observes—

Cases of tuberculosis found among the reservation Indians examined exclusive of those in attendance at schools give us a much better idea of the incidence of tuberculosis among the Indians of the Northwest than the tables relating to its prevalence in schools. In school children we are dealing with a class in which the incidence of tuberculosis is artificially diminished by the exclusion from their number of those suffering from the disease. Among reservation Indians such is not the case.

He found the highest percentage, 5.89, of tuberculosis among the Indians of North Dakota, on the Fort Berthold Reservation, and the lowest at the Turtle Mountain Reservation, where only 0.92 per cent of the Indians examined were found to be tuberculous. A compilation of agency mortality records by Schereschewsky shows that tuberculosis causes approximately 22.32 per cent of all the deaths in the reservations visited by him. This, he says, is twice the percentage, 11, found in the registration area of the United States. "The tubercular death rate is 6.99 per thousand, or 4.37 times the white death rate (1.63) per thousand." 1

Oregon.-Billings inspected 316 Indian children in the Salem nonreservation boarding school and found 11 cases of pulmonary tuberculosis, 29 glandular, and 3 osseous, a total of 23, or 13.6 per cent.

Mortality Statistics, Bureau of Census Bul. 109.

Among 788 reservation Indians examined were found 61 pulmonary, 59 glandular, 8 osseous, and 3 of other forms of tuberculosis, a total of 131, or 16.62 per cent.

The highest percentage, 24.56, of this disease was found in the various tribes of the Siletz Reservation. Percentages for other reservations are: Klamath Lake, 20.27; Umatilla, 20.66; and Warm Spring,

23.75.

Pennsylvania.-Among the 552 students of the Carlisle Indian Boarding School, Carlisle, Pa., who were inspected for tuberculosis, 26 cases of this disease were discovered, or 4.7 per cent. Of these cases of the disease 8 were pulmonary, 17 glandular, and 1 osseous. The Carlisle school receives pupils from nearly every tribe in the United States. In view of the great prevalence of tuberculosis among some of these tribes, a certain number of cases of tuberculosis may be expected to develop in this student body in the course of each scholastic year.

At Carlisle are found facilities for caring for a small number of tuberculous students, who are in the early stages of this disease. Attached to the school hospital are sleeping porches wherein students infected with tuberculosis sleep in the open air.

An agreement has also been entered into by the school authorities with the State of Pennsylvania whereby certain of these Indian students in the more advanced stages of tuberculosis are taken into the State Tuberculosis Sanatorium at Mount Alto, Pa.

Utah.-Among the Uintah and Ouray Indians of Utah, 182 were inspected and 8 cases of tuberculosis found, 4 pulmonary, 3 glandular, and 1 osseous, a percentage of 4.39.

Virginia. Cumming inspected 43 Indian students at the Hampton Normal Institute, Hampton, Va., and found 3 cases of tuberculosis, 2 pulmonary and 1 osscous, a percentage of 6.97.

Washington.-Lloyd inspected 1,347 Indians, including school children, in Washington, and found 73 cases of tuberculosis, namely, 48 pulmonary, 21 glandular, and 4 osseous, a percentage of 5.41 for the State.

The large number of school children inspected and included in the total number used for the calculation of the percentage of prevalence of tuberculosis in this State, reduces the tuberculosis rate by reason of the exclusion of known tuberculous pupils from Indian schools. It is therefore believed that the prevalence of tuberculosis among these Indians is much greater than shown by the figures presented herewith.

Among the Dwamish and allied tribes, exclusive of the Cushman and Tulalip Schools, Lloyd found the following percentages of tuberculosis according to reservations: Lummi, 11.95; Suquamish, 13.51; Swinomish, 10.20. On the Colville and Spokane Reservations the percentage of tuberculosis was found by him to be 8.26. Washington may therefore be classed with California, Oregon, and Nevada as one of the States in which the greatest prevalence of tuberculosis was found in the course of this investigation.

Lloyd considers tuberculosis a serious problem among the Indians. of Washington. Specific mention is also made of overcrowding in poorly ventilated houses as the principal factor in producing this heavy tuberculosis infection.

Wisconsin. An inspection for tuberculosis was made of the Indians in all boarding schools and reservations in Wisconsin. A total of 1,703 reservation Indians, exclusive of school children, was inspected and 52 cases of tuberculosis were found, a percentage of 3.05 for the State. The greatest relative number of tuberculosis cases was found among the Indians of the Lac Du Flambeau Reservation, with a percentage of 6.48. The majority of these Indians dwell in very insanitary homes and their customs and habits favor the spread of this disease among them.

The following percentages of tuberculosis were found among the Chippewas of Wisconsin: Lac Courte Oreille, 3.72 per cent; La Pointe, 4.73 per cent; Red Cliff, 2.89 per cent.

Among the Monominees and Oneidas the percentage of tuberculosis among those examined was found to be 1.35 and 2.76, respectively. The sanitary condition of the majority of the homes visited among these Indians was good. The Oneidas cultivated a considerable part of their lands and are self-supporting.

Among the 1,296 children examined in the Indian boarding schools of Wisconsin were found 37 cases of tuberculosis, of which number 24 were pulmonary, 9 glandular, 3 osseous, and 1 cutaneous, or 2.98 per cent.

At the Lutheran mission, Stockbridge Reservation, 8.88 per cent of tuberculosis was found. In the Government school at Keshena, Menominee Reservation, the percentage was 7.69. This percentage includes the children of this school transferred to the agency hospital at that place.

The presence of tuberculosis in these boarding schools, however, is adventitious and due to reluctance on the part of the school authorities to return children, in the early stage of this disease, to insanitary homes and to a poor food supply.

The tuberculosis case incidence among the Indians of Wisconsin, inclusive of school children, according to data collected in this investigation, is 29.6 per 1,000.

Wyoming.-Among the Arapahos and Shoshones of the Shoshone Reservation in Wyoming, 392 Indians were examined and 13 cases, or 3.31 per cent, of tuberculosis was found.

CONSIDERATION OF RECORDED DEATHS FROM TUBERCULOSIS.

During the inspection complete data were not found at all the agencies by officers engaged in the work. On request, therefore, the Office of Indian Affairs furnished a compilation from their records of the birth rate, death rate, and number of deaths reported as due to tuberculosis among the Indian population of the United States during the fiscal year 1912. From these data was compiled the following table. It is proper to add that, in view of the known difficulties on many of the reservations in obtaining accurate information as to the causes of deaths among Indians, some of these figures must be in the nature of estimates. It is likely that many deaths among Indians are considered by them to be due to tuberculosis, and so reported to the agency, when no physician has been called, that were not caused by this disease at all.

Table VI.—Indian birth rate, death rate, and death rate due to tuberculosis, 1912. [From a compilation by the Office of Indian Affairs.]

It will be observed on comparing this table with the case incidence of tuberculosis found, by the officers engaged in this investigation, among these Indians examined, such incidence is correspondingly high on one or more reservations in the majority of the States in which the tuberculosis death rate is high.

Mention has been made in another part of this report of the inability of the medical officers engaged in this investigation to make repeated examinations of tuberculous suspects by reason of the short time allowed for the completion of the survey. The detection of tuberculosis may not be easy in its earliest stages even with the aid of all modern appliances in use for that purpose, and then only after repeated examinations of the suspected subject. The medical officers were restricted to the making of a physical examination of each suspect, and to but one examination. For these reasons it is believed the percentages of tuberculosis incidence found during this investigation are lower than a more detailed and prolonged inspection would reveal, and may be considered in the nature of a preliminary sanitary survey. However, this survey as conducted has revealed so great a prevalence of tubercular infection among the Indians. inspected as to warrant the immediate adoption of measures for the relief of this situation in the Indian population of our country.

PREVALENCE OF SMALLPOX AMONG THE INDIANS.

Inasmuch as smallpox is highly contagious, it occurs usually in the form of explosive outbreaks. It could not be expected, therefore, that many cases would be encountered in widely scattered sections of the country within the limited time devoted to these inspec

tions of Indian reservations and boarding schools. For the purpose of this report, therefore, it became necessary to depend for evidence of the prevalence of the disease on: First, actual cases encountered; second, reports of cases; third, pock-marked Indians; fourth, the completeness of vaccination as determined by examinations of a large number of vaccination scars.

SMALLPOX CASES INSPECTED.

A total of 6 Indians was seen who were suffering from smallpox. One of these cases was seen by Clark at the Red Lake Reservation, Minn., in the person of a woman who had been vaccinated many years ago. The disease was of a mild character, and the source of the infection could not be traced. The remaining 5 cases were seen by Lloyd on the Yakima Reservation in Washington.

REPORTS OF CASES AND OUTBREAKS OF SMALLPOX.

Such records as were examined at the various reservations furnished unsatisfactory data generally regarding the past prevalence of smallpox, nor were the records of States inquired into more satisfactory. Information of outbreaks in the past was obtained by the officers, however, on a number of reservations.

Arizona.-As a result of inquiry and examination of records, Fricks states that there has been no smallpox reported on any of the reservations in Arizona since 1909, when there was an epidemic of 60 cases with no deaths at Fort Mojave Boarding School. Severe and extensive epidemics were reported previous to 10 years ago.

California, Nevada, and Oregon.-Judging from the places inspected in these three States, Billings states that smallpox may now be considered a disease of no more frequency or of no greater severity among Indians than it is among people of any other race. He found a history of one case occurring five years ago (diagnosed by an Indian) on the Western Shoshone Reservation, Nev., and of 5 occurring 9 and 10 years ago. Some of the reservations had been 20 years without a case. In respect to the past prevalence of the disease, Billings states as follows:

The only history of this disease is almost entirely hearsay as the epidemics which have occurred were before the advent of many white men and long before any attempt at keeping records was made. Chief Charley Shoplish, an Indian 95 years of age, told me of the great epidemic among the Walla Wallas in 1868 in which he said over 1,500 died and the tribe was nearly annihilated. The fact that it is very unusual to see a full-blood Walla Walla now seems to give some weight to this statement.

Colorado and New Mexico.-In Colorado, Smith states there were 23 cases and 1 death in 1911 among the Southern Ute Indians of Ignacio, but that the Southern Utes of Navajo Springs have been free from the disease. The superintendent at the reservation was also quoted as saying that to his personal knowledge no case of smallpox had occurred among these Indians for at least 6 years.

Vital statistics were available at the agency of the Mescalero Apache Indians for a little over 10 years, but no cases of smallpox were recorded during this time. Neither were any cases reported or recorded among the Jicarilla Apaches for 14 years.