death rate for whites from 1.644 to 1.552, but the death rate for the colored people increased from 4.926 to 4.943. The incidence of the disease on the colored race, as compared with the incidence on the white race, was relatively higher than at any other time during the past ten years; figures for comparison with years antedating that period are not available for convenient reference.

Pneumonia.-There was a slight diminution in the number of deaths from pneumonia. The general death rate from this disease dropped from 1.752 to 1.641; that for the whites from 1.065 to 0.994, and that for the colored from 3.372 to 3.176. The ratio between the death rate for whites and that for colored people bears a remarkable similarity to the corresponding ratio between the death rates from pulmonary tuberculosis.

Diarrheal diseases of children under 2 years old. There was a material decrease in the number of deaths in this class among white children and a material increase in the number among colored. The death rate among white children fell from 0.642 to 0.554; that for colored children rose from 1.903 to 2.206. The net result was an increase in the death rate for all classes from 1.018 to 1.043.

Grippe.-Grippe, in a fatal form, prevailed less extensively during 1905 than during the preceding year. The death rate fell from 0.347 to 0.325, owing to diminished prevalence among both races.

This disease seems, however, to have obtained a firm foothold on the community, the number of fatal cases reported during the past five years having been 448 while during the preceding five-year period only 181 deaths were attributed to it.

Steam railroad accidents.-More deaths occurred during 1905 from steam railroad accidents than at any other time during the past decade. Thirty-five fatal accidents were reported, the nearest approach to this number having occurred in 1904, when 31 deaths occurred. Omitting these two years the highest number of deaths reported during any one year was 22 in 1900.

Street railroad accidents.-There was a large increase during 1905 in fatal street railroad accidents. Fourteen deaths due to this cause were reported. The next highest number, 9, was reported in 1902, and the average per annum for the decade was but 7.2.

Typhoid fever, diphtheria, and scarlet fever.-A detailed statement relative to the prevalence of these diseases appears on pages 56, 57, and 58, in connection with the report on the operation of the contagious disease service.

MORTALITY OF WHITE PEOPLE AND OF COLORED PEOPLE COMPARED.

The extent to which certain diseases operate to bring about the difference between the death rate for whites and that for colored is shown in the following statement. Those disorders whose point of attack is the respiratory system, those which act through the digestive organs, and those incident to childbirth and infancy operate with peculiar effect on colored people.

Relative incidence of certain specified diseases on the white and on the colored race during the calendar year 1905.

That the ravages wrought in 1905 in the colored race by diseases operating through the respiratory and digestive systems, and by diseases incident to childbirth and infancy, were not peculiar to that year is shown by the statement below.

Ratios between the death rates for white and for colored, from certain diseases, during the four years ended December 31, 1905.

[The death rate for white: the death rate for colored :: 1: X. The figures in this table represent X.]

Ratios between the death rates for white and for colored, etc.—Continued.

For the prime cause or causes of the high mortality among the colored residents of the District, we have examined, without result, sex and age distribution and place of residence; and in connection with the examination of the subject from the standpoint of age distribution attention has been called to the fact that the nature of the work in which the larger part of our colored citizens are engaged offers no sufficient explanation of the high death rate among them. The study of the nature of the diseases, in which there is the greatest disproportion between the white and the colored death rates, yields, it seems to me, better results. These diseases alone do not account for the excessive colored mortality, but the same causes that operate to produce them operate to produce bodily conditions in which other diseases are more apt to develop and more apt to prove fatal when they have developed, and they may be even more directly responsible for such other diseases in certain cases.

Diseases of the respiratory tract, even those that are due in part to infection by specific bacteria, are more or less dependent upon defective heating, ventilating, and lighting of the dwelling and upon dampness of floors and walls, due either to the defective planning or construction of the building or to failure on the part of the occupant to utilize to the best advantage those facilities for heating, lighting, and ventilating and for keeping the building dry that have been provided, or to any or all of these causes. Diseases of the digestive organs are due largely to improper food or feeding; to the eating of food that is beyond the capacity of the digestive system to digest; food not rightly cooked or that has been imperfectly protected from infection after having been cooked; food that is tainted, or food in excessive amounts. And the diseases incident to childbirth and infancy that figure in the foregoing tables-puerperal, peritonitis, septicemia, eclampsia, and congenital debility, marasmus, and convulsions of children--prove fatal to a considerable extent because of the absence of proper medical care. Not that the physician in attendance is at fault, but that, either in the hope of avoiding burdensome expense or because of the failure to appreciate the gravity of the situation, the physician is too often called in too late. And, too often, when called in he is unable to obtain for the case the care that it requires, because those responsible for the patient are without the means necessary to enable him to do so.

Interesting data confirmatory of the views heretofore expressed relative to the absence of proper medical advice and treatment as a factor in the causation of the high death rate among our colored people

appear in the table printed on page 307, showing the extent to which certain communicable diseases prevail in this jurisdiction. From this table it appears that typhoid fever, diphtheria, and scarlet fever are less prevalent among colored people than among whites, but that when they do occur they are much more apt to prove fatal. These figures may represent either a peculiar form of susceptibility to these diseases on the part of the colored race or the effect of improper treatment in bringing about fatal results in mild cases in which recovery should properly occur or a failure to report the milder cases. It is hardly conceivable that the colored race should be possessed of a peculiar susceptibility to the diseases named so that when attacked by them the results should be unusually severe and yet possess a certain immunity to the attack in the first instance. And if the apparently limited prevalence of these diseases, which goes along with the unusually large percentage of deaths, is due either to the aggravation of mild cases by improper medical advice or treatment, or to the failure of the family of the patient or of the medical attendent to recognize and to report mild cases, then the theory heretofore advanced, that the colored race suffers from lack of proper medical advice and treatment, is with respect at least to these diseases confirmed. And there is no reason for believing that what is true with respect to these diseases is not equally true with respect to all others.

The high death rate among colored people in this District is in my judgment due to bad housing (incident to a certain extent to defective location and construction of houses but probably to an even greater extent to bad housekeeping), to bad clothing, to bad feeding, and to the absence of needed medical advice and treatment at the proper time. And all of these are due to poverty and ignorance. Whether an equally large aggregation of persons of Caucasian extraction, whose average and extremes of poverty and ignorance were like those of the colored people living in this District would or would not show an equally large death rate, it is impossible to tell; there are, so far as I am informed, no available figures bearing on this point. But it must be borne in mind that defects of housing and of clothing, which are largely responsible for the diseases of the respiratory system which bear so heavily on the colored race, are incident to civilization, and that while the white race has possibly become inured to such conditions by reason of the long years during which it has been subjected to them, the colored race has had no such immunizing experience. It is from an ethnological standpoint in the position of a race just entering into what is termed civilized life, and it is a matter of common belief that under such conditions death levys a heavy tribute for the advance of the race.

The hypothesis that attributes the high death rate among our colored population to conditions arising out of ignorance and poverty is strongly supported by the marked fall that the death rate shows during the past thirty years, a period of such wonderful advance by the colored race in knowledge and in property interests. There have been fluctuations in the colored death rate, of course, just as there have been in the white death rate, but the fall has been too steadily downward to be the result of any suddenly operating cause. And the improvement in the colored death rate has been so much greater than the improvement in the mortality of the whites as to indicate that there were causes operating to improve the former that were not

affecting the latter, or that the causes that were operating on both were operating in favor of the colored race much more strongly than in the favor of the whites. The white death rate, which for the fiscal year 1875-76 was 19.54, in 1905 was 15.16, a fall of 4.38 points, while the colored death rate during the same period fell from 40.78 to 28.81, a fall of 11.97. Time does not permit a detailed study such as must be made before it would be possible to point out the particular diseases in which the improvement has occurred and the extent to which it has occurred in each, but available figures afford a most inviting field for study along these lines.

No figures are available from which to base any statement as to the extent to which sickness prevails among the colored people as compared with its prevalence among whites. But if the death rate is unduly high it is reasonable to suppose that the prevalence of sickness and of impaired vitality and energy short of definite illness is excessive too. And these conditions breed the very causes out of which they themselves arise, poverty and ignorance.

For the excessive death rate among our colored people there is no sovereign remedy. The Government has already done much tending to reduce it. Other things must be done and are now under consideration, as the establishment of public baths, the reclamation of the Anacostia flats, and the extension of public playgrounds, and of other movements already inaugurated. One thing else has not yet been taken up in the serious way in which the importance of the matter deserves, and that is the establishment of day nurseries. Further than this there is, it seems to me, nothing that the Government can do directly to diminish the prevalence of physical impairment, of sickness, of disease, and of death among them. Everything further depends upon the initiative of the individual, and the most that can be done is to place the individual in a position where he can and will take that initiative. And this can be effected only through education. Not necessarily or even chiefly school education, but necessarily and chiefly education in the art of good living; in the art of keeping the home, however poor it may be, clean, and of making the best use of such facilities as it affords for lighting, heating, and ventilation; in the art of keeping the person and the clothing clean and of rightly preparing and using foods; and in the art of recognizing at an early stage evidences of disease, of appreciating their significance, and of instituting proper measures for their mitigation and cure, calling on the physician for advice and assistance when necessary.

Such instruction can not be given in school or from books but must be given at first hand in the home. Compulsory process by the health department can accomplish something, but the best and most lasting results can and will be obtained, not by the man or the woman who goes into the home primarily as a representative of the Government, armed with compulsory process, but by the man or the woman who enters the home as a friend not only to advise, but to show how things must be done. The most that law can do toward this end is to provide methods whereby danger spots can be located, and this personal instruction be directed first to the places where the greatest need exists. Private organizations have already entered upon just such educational work as has been outlined, but they must receive much greater financial support than they have heretofore received or other agencies must enter the field if even reasonably rapid progress is to be made.