DIET.

While naturally robust, owing to his indifferent nature, his improvidence, and his aversion to agricultural pursuits, the Indian, as a race, is rather under than over nourished. His dietary regimen is marked by periods of repletion when he is in funds and of abstinence when the larder is low. He takes but little advantage of present plenty to provide for future want, and, owing to his hospitable nature, his provisions, while they last, are freely at the disposal of his friends.

Much of the food eaten by the Indian is of poor quality and poorly prepared. They are meat eaters by preference, and meat is eaten whenever it can be obtained. Owing to their poverty and their habit of killing and eating their cattle instead of breeding them, they are often obliged to go for long periods without meat, subsisting for the most part on coffee, baking-powder biscuit or fried bread, and whatever else they may be able to obtain.

It is probable that the inferior diet of the Indian plays some part in the prevalence of disease among them by lowering his vital resistance.

Use of alcoholic beverages. The craving of the Indian for alcoholic stimulants is well known to have a pernicious effect upon the race. The use of alcohol diminishes the resistance to disease, augments carelessness and indolence, and causes the Indian to expend money which had far better be used for nutritious food.

SCHOOLS.

There are certain conditions observed in the Indian schools which have a bearing more or less direct on the propagation and spread of contagious and infectious diseases among the Indians.

Conditions inherent in institutional life. In any boarding school, Indian or otherwise, it is obvious that plentiful opportunity exists, by reason of intimate personal contact, for the propagation of contagious and infectious diseases. It is evident in Indian schools, dealing as they do with a population primarily affected with an undue prevalence of tuberculosis and trachoma, that, unless the greatest vigilence be exercised, many instances of the transfer of infection from one inmate to another are bound to occur. It has already been pointed out, in the case of nonreservation boarding schools, that they may be the means of implanting trachoma in areas where, at present, it does not exist, or at most is but slightly prevalent.

Fricks states, with reference to an Arizona boarding school, that, according to the agency superintendent, of all the pupils, 249 in number, leaving the agency boarding school within the past 10 years, 33.74 per cent are now dead from tuberculosis, and further, owing to the incomplete record of deaths between 1904 and 1910, that the percentage found is probably much lower than it actually is. It is probable in this instance, however, aside from the acquisition by the children of tuberculosis from other inmates in infected dormitories, classrooms, and the like, that the change from the nomadic life of their tribe to that of the school was too great. Smith points out that the regular hours of work and study, the irksomeness of the labor required from school children, while light, is nevertheless

a greater tax upon the physical capacity of the Indian child than the hardship of the indolent camp life to which he is inured.

Overcrowding and ventilation. The majority of Indian boarding schools seem crowded beyond their capacity, or, owing to disproproportionate numbers of the sexes, while the total enrollment may be below the rated capacity of the school, the dormitories for one sex may be overflowing while ample room may exist for the other. The regulations of the Indian Office allow a minimum of 500 cubic feet of air space per pupil in the dormitories. This air space is sufficient in the presence of adequate ventilation. Most of the dormitories are supplied with enough window space to afford proper ventilation if the windows are kept open. It is obviously impracticable, however, in severe winter weather adequately to ventilate some of these dormitories during the night by natural means, with the present air space allowed. At all events, chronic nasopharyngitis and enlarged tonsils and adenoids are too frequently observed among the pupils in Indian boarding schools and serve as mute evidence of an inadequate or incorrectly moistened air supply.

Washing facilities. With a view of limiting the spread of trachoma among the pupils of Indian boarding schools, the regulations of the Indian Office provide for running water for washing and separate towels for the pupils. It was found, however, that while separate towels are provided the washing arrangements are on the whole inadequate or defective, and the advantage of providing separate towels was in most instances nullified by the manner of their disposition when not in use.

The towels are generally hung up by loops at their corners upon rows of nails, marked with the pupil's number or name. These nails are so closely spaced that the towels overlap each other, and thus provide opportunity for the transference of infection from one towel to another. In some of the schools, however, the "Pullman" system of separate towels is used.

In most of the schools facilities for washing in running water are provided. The arrangements to this end, however, may be criticized from the standpoint of inadequacy and also because the faucets are of the usual pattern instead of the pedal variety. Ordinary bar soap is provided instead of liquid soap or soap powder in sanitary containers. In other schools set bowls, or even the ordinary hand basin, are still in use, the bowls and washbasins being inadequate for the number of pupils and, in the case of washbasins, being kept nested when not in use.

Tubs, instead of shower bath, are still in use in most schools for bathing purposes. It is plain that the tub used in common by large numbers of individuals, and difficult to cleanse owing to the hardness of the water at many Indian reservations, may be a factor in the spread of infectious and contagious diseases.

Toilet facilities. The plumbing fixtures in many of the Indian schools are of obsolete pattern, located in damp and dark basements and often in a state of disrepair. At some of the schools the ordinary outdoor insanitary privy is still in evidence and serves as the breeding place of numerous flies in the summer.

Water supply. The water supply at some of the schools is inadequate, and instances have been noted where a supply primarily suffi

cient was rendered either unsightly or insufficient through defects in well casings, leaks in supply pipes, etc.

The importance of an adequate water supply for washing and laundry purposes, the maintenance of water-closets and urinals in a sanitary condition by proper flushing and for fire protection can not be overestimated.

The common drinking cup. The common drinking cup is too frequently seen in Indian schools. Sanitary bubble fountains, however, are being gradually introduced.

Flies. The Indian boarding schools are inadequately protected against flies. The dining rooms and kitchens are usually screened but not the dormitories and class rooms. Allusion has already been made to the fly as a factor in the spread of disease.

Sanitary supervision. The sanitary supervision of pupils in many Indian schools leaves much to be desired. Pupils suffering from trachoma are allowed freely to mingle with the others in the class rooms, at play, and in the dormitories in most of the schools visited. Tuberculous pupils in most instances are sent home when detected, but the frequency with which such conditions are early discovered depends more or less upon the character of medical supervision exercised.

Where the superintendents of schools are physicians, such supervision is more complete. On the other hand, when no medical supervision is provided, or the medical attendant is a contract or an agency physician, there is room for much improvement. The contract physician is usually too busy with his private practice to pay much attention to the school, and the calls on the agency physician, which frequently take him to distant parts of the reservation, prevent his devoting sufficient time to the pupils.

Gymnasium playrooms. In the colder climates some provision for indoor physical exercise is necessary to the maintenance of health in the Indian boarding schools. Gymnasiums and well-lighted and ventilated playrooms are therefore necessities to this end. In the majority of Indian schools no gymnasiums are provided, and the playrooms are too apt to be situated in comparatively dark and poorly ventilated basements.

From the foregoing it is evident that sanitary conditions among the Indians are generally unsatisfactory and that the schools which are one of the most important agencies existing for the advancement. of the Indians are also capable of improvement from a sanitary standpoint. It is necessary to state, however, that there were evidences of recent systematic efforts to improve these conditions. The extent of improvements are, of course, largely dependent on available funds.

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

The presence of considerable numbers of Indians on reservations in many States, the gradual opening up of portions of these reservations to white settlers, and the consequent increase of communication between the two races, renders pertinent in this report some consideration of the bearing of the prevalence of contagious and infectious diseases among Indians on the health of other races.

In a previous official report Clark referred to the prevalence of trachoma and tuberculosis among the Indians of Minnesota and the possibility of the spread of these diseases to the surrounding white population. In an examination of 1,428 public school children in counties adjacent to Indian reservations, he found but 3 cases of trachoma and these among 77 Indian children of mixed parentage who were enrolled in these schools.

With the allotment of lands and further opening of reservations to white settlers, increased opportunity will be afforded for a more intimate commingling of the races. In the course of time, counties will be organized within many of those reservations and public schools established for the use of children of the two races. The intimate contact during school life will thus afford a greater opportunity for the spread of disease from one to the other than is now the case.

A considerable number of Indian children now attend the public schools of Michigan and Wisconsin. The prevalence of trachoma and tuberculosis among the Indians of these two States may be a source of infection to the school population, and furnishes a problem worthy of careful consideration by the proper authorities.

The introduction of railways is bringing the Indian into closer contact with the white population and opens a channel through which communicable diseases may be spread by them. It is well known that Indians are fond of travel and make long journeys to visit allied or kindred tribes, and diseases among them may easily be spread to others in the course of such journeys.

Fricks reports the closure of the public schools of Bisbie, Ariz., during the past year because of an outbreak of trachoma, and that the disease is common, according to report, among Mexican school children in and around Phoenix. In one school he examined 30 pupils and found 3 cases of trachoma, one in an American child and two in Mexican children, a brother and sister. He considers the Walapais of Arizona a menace to the public health because they dwell in insanitary hovels at various points along the Santa Fe Railroad. Among these Indians he found a tuberculosis case incidence of 76.9 per 1,000 in those examined.

Schereschewsky cites the Turtle Mountain Reservation, N. Dak., as "a striking instance of the way in which a destructive disease (trachoma) now more or less closely confined to a resricted area, is about to be implanted in another section of the country. This reservation is situated in the northern part of North Dakota. Its area is small, approximately 30 square miles *. Only a portion

of this small reservation consists of arable land, so it is manifestly impossible to allot land to these Indians on their own reservation. As a result, they are being allotted land out of the public lands in Montana, and thus are in the process of being dispersed from their original reservation."

It has previously been stated that only two cases of trachoma were found among the 943 Indians examined in New York, and that these two cases had probably contracted their infection at a nonreservation boarding school in another State. The Indians of New York have manifestly had the greatest opportunity of any Indians in the United States for association with persons of foreign birth, and Leake states that numbers of them have been employed on construction works in association with immigrants from southern Europe. It would appear

from this that, in view of present precautions, the danger now is not so much the transmission of contagious and infectious diseases from immigrants to inhabitants of the United States, but from Indians to immigrants settling on lands in the West. There is evidence for instance that, since the inauguration of measures in 1897 by the Government to exclude trachoma from among arriving immigrants, the disease has decreased in some eastern cities. In isolated interior localities, on the other hand, the disease has now been shown to be endemic for years and increasing.

The control of communicable diseases among Indians and the prevention of their spread to other races is, therefore, indicated as a public health measure.

THE MEDICAL BRANCH OF THE OFFICE OF INDIAN AFFAIRS.

The prevalence of contagious and infectious diseases among the Indian population may in some degree be influenced by the measures taken to cure cases of those diseases, but in far greater degree by the observance of hygienic habits by the Indians themselves. During this investigation opportunity was afforded for observations of conditions militating against the successful treatment of diseased individuals themselves and also of conditions preventing the improvement of sanitation among the Indians.

The relief of suffering and the cure of disease are necessary, and provisions made to this end are commendable, but under present conditions their application is discouraging and does not approach the problems of sanitation among the Indians. The curative effects aimed at, at the present time, by the physicians of the Office of Indian Affairs are largely nullified by the conditions under which the work is attempted and by the indifference of the primitive Indian and his ignorance of the first principles of hygienic living.

It was the common observation that many of the medical officers of the Office of Indian Affairs were working hard, but a great deal of this really hard work is wasted. In the following graphic manner Dr. Lloyd refers to conditions by asking a question and answering it: What is the matter? Let us visit an average doctor on an average reservation. We enter his office, which is reasonably well provided with drugs but not much else. Five minutes later Billy Blackhawk comes after the doctor and we consent to go with him. After a drive of 14 miles over bad roads, through rain and sleet we arrive, the doctor carrying his old-fashioned pill bags or medicine case containing a hatful of promiscuous drugs. We enter the house; in one room about 12 feet square live from 5 to 10 people; they sleep on dirty blankets or a pile of dirty rags strewed around on the floor, which is covered with grease and filth. They have a small stove in the center of the house, with a very little fire, because fuel is scarce and hard to get, or, if it is easy to get, as it frequently is, it is easier to keep the doors and windows closed than to chop wood. At any rate, all the doors and windows are closed to keep out the cold. It is now night, and from the dying embers in the stove and a well-smoked lantern there are emitted rays of light approximating in number half a candlepower. Dark as it is and cold, every time you move you can hear the flies buzzing as they are driven from their sleeping places. Indeed, some of them have not yet gone to bed and can be dimly seen crawling around over the nostrils and lips of the little sufferer whom the doctor has come to see. Let us look at the child. He is 5 years old, has had whooping cough for the past three weeks, and now has pneumonia. The poor little fellow is so dirty the doctor hates to touch him. On the same pile of rags is stretched his sister, 12 years old, in the last stages of consumption. If by some miracle the child should survive its present ailments, it would certainly die later of tuberculosis. Now, what can a doctor, though armed with all the drugs in the pharmacopoeia,