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D EPA R TM E N T OF CO M M E R C E A N D L A B O R
.B U R E A U
OF
LABOR
CH A S. P. N EILL, Comm issioner
CARE OF
TUBERCULOUS WAGE EARNERS
IN GERMANY
BU LLETIN O F T H E U N ITED
STA TE S BU REAU O F L A B O R
WHOLE NUMBER 101
*56
WORKMEN’S INSURANCE AND COMPENSATION SERIES
No. 1
JULY 1, 1912
W ASH IN G TO N
GOVERN M EN T P R IN T IN G O FFICE
1912
CO N TEN TS.
Page.
Introduction and summary....................................................................................... 5-11
Mortality from tuberculosis in the German Empire............................................... 11-15
Comparative mortality from tuberculosis in Germany and in the United States. 15-18
Estimated economic loss from tuberculosis to wage earners in the United States. 18,19
Estimated economic value of sanatorium treatment in Germany........................ 20-22
Legal provision for treatment and care by invalidity insurance institutions..........22,23
Number of German wage earners receiving sanatorium treatment in 1910......... 23,24
Cost of sanatorium treatment of German wage earners in 1910............................24-26
Restoration of earning capacity of wage earners resulting from sanatorium
treatment...................................................................................................................26-32
Comparative results of institutional and noninstitutional treatment................... 32,33
Comparative results of hospital and sanatorium treatment................................... 33,34
Organization and activities of the German Central Committee for the prevention
of tuberculosis......................................................................................................... 34-38
Dispensaries and information bureaus............................................................. 35,36
Treatment and care of tuberculous children...................................................
36
Present status of agencies for prevention and cure of tuberculosis............... 36,37
Conclusions in regard to work of German Central Committee...................... 37,38
Treatment of tuberculous wage earners in public institutions, 1896 to 1901........... 38-58
How cost of treatment is provided for..............................................................
39
Age, sex, and conjugal condition of patients under treatment..................... 40,41
Proportion of indoor and outdoor workers.......................................................
41
Dust and fumes as a predisposing cause of tuberculosis.................................41,42
Unfavorable occupational conditions............................................................... 42,43
Social condition..................................................................................................
43
Patients with a fam ily history of tuberculosis.................................................43,44
Predisposing or complicating causes in tuberculosis...................................... 44,45
Previous sanatorium treatment.........................................................................
45
Previous duration of disease.............................................................................. 45,46
Relation of treatment to stage of disease..........................................................46,47
Condition of patients on admission...................................................................47,48
Relation of treatment to gain in bodily weight...............................................48,49
Changes in condition during treatment...........................................................
49
Cough and expectoration on admission and discharge...................................
50
Tuberculous bacilli in the sputum on admission and discharge.................. 50-52
Duration of treatment........................................................................................ 52,53
Medical result of treatment............................................................................... 53,54
Economic results of treatment.......................................................................... 54,55
Importance of treatment in the incipient stage of the disease...................... 55,56
German sanatorium experience, 1896 to 1901.................................................. 56-58
Treatment and care of tuberculous wage earners by German invalidity insur
ance institutions, 1897 to 1909.............................................................................. 58-98
Number of patients treated, by sex................................................................. 60,61
Expenditures on account of treatment and care, 1897 to 1909...................... 61-63
Increase in expenditures on account of treatment and care.......................... 63,64
Comparison of contributions and expenditures for treatment.......................
64
Expenditures during 1909................................................................................. 64,65
Proportion of insured population treated and cared for during 1909...........
65
3
4
CONTENTS.
Treatment and care of tuberculous wage earners b y German invalidity insur- Pag©*
ance institutions, 1897 to 1909—Concluded.
Proportion of patients treated, by selected States.......................................... 65,66
Notification of army recruits who were rejected on account of tuberculosis.
66
Financial aid given by invalidity insurance institutions in the campaign
against tuberculosis.........................................................................................
67
Family support of tuberculous wage earners in public sanatoria................ 68,69
Methods of treatment and care..........................................................................69-75
Per capita cost of treatment and care...............................................................75,76
Financial statistics of sanatoria owned by German invalidity insurance
institutions....................................................................................................... 76,77
Loans provided for the erection of public sanatoria....................................... 77,78
Suitable employment of tuberculous patients................................................
78
Average cost and duration of treatment........................................................... 78-80
Effect of premature discontinuance of treatment...........................................
81
Statistics of readmissions for treatment............................................................ 81-83
Classification of tuberculosis according to Turban stage of disease.................83,84
Statistics of admission and discharge according to Turban stage of disease. 84-87
Postdischarge results of sanatorium treatment...................................................87-94
Financial statistics of successful and unsuccessful sanatorium treatment.. 94-96
General conclusions as to the value of institutional treatment for tuberculosis. 96-98
Administrative control of tuberculosis, with special reference to tuberculosis
dispensaries, information bureaus, and housing reform......................................98-116
Limitations of sanatorium treatment................................................................ 98,99
German tuberculosis dispensaries and information bureaus........................ 99,100
Organization and scope of the tuberculosis dispensary............................... 100,101
Tuberculosis dispensaries in Germany in 1911............................................ 101,102
Tuberculosis dispensaries in Berlin............................................................... 102-104
Tuberculosis dispensaries in Hamburg......................................................... 105,106
Tuberculosis dispensary in Leipzig.............................................................. 106,107
Tuberculosis dispensary in Munich.............................................................. 107-109
Tuberculosis dispensaries in Silesia..................................................................
109
Tuberculosis dispensary in Augsburg...................*....................................... 109,110
Tuberculosis dispensaries in Westphalia...................................................... 110, 111
Agricultural colony for tuberculous wage earners....................................... I l l, 112
Control of tuberculosis through housing reform........................................... 112-114
Building loans by invalidity insurance institutions................................... 114-116
Town planning and sanitary progress in Germany..........................................
116
Experience data of representative invalidity insurance institutions in the treat
ment and care of tuberculous wage earners in 1910........................................ 117-161
Berlin................................................................................................................ 117-125
Westphalia....................................................................................................... 125-130
Rhenish Prussia............................................................................................... 130-136
Wurttemberg.................................................................................................... 136-143
Baden............................................................................................................... 143-149
The Hanse Towns............................................................................................ 149-161
Appendix I .—Treatment of tuberculous wage earners in public institutions,
1902 to 1904................................................................................ 162-164
. Appendix II.—Memorandum on tuberculosis, compiled by German Imperial
Board of Health at Berlin....................................................... 165-169
Appendix III.—Definition of German terms relating to treatment and care of
tuberculous wage earners.....................................................169,170
Appendix IV .—Legal provisions regarding treatment of actual or prospec
tive invalids........................................................................... 171-173
Appendix V.*—B ibliography................................................................................173-179
B U L L E T IN O F T H E
U N IT E D
STA TE S
w hole n o . 101.
BU REAU
O F
W A SH IN G T O N .
LA B O R .
july i , 1 9 1 2 .
CARE O F TUBERCULOSIS W A G E EARNERS IN G E R M A N Y .
BY FREDERICK L. HOFFMAN.
INTRODUCTION AND SUMMARY.
Under the German compulsory invalidity insurance law which
went into effect on January 1, 1900, provision was made that—
I f an insured person is so ill that incapacity to earn a livelihood
is to be apprehended as a consequence o f the illness, which would
constitute a claim to a pension in accordance with the laws o f the
Empire, the insurance institution is entitled to cause him to undergo
a cure to the extent it may think desirable in order to avert this
loss. The insurance institution can effect the cure by placing the
sick person in a hospital or in an establishment for convalescents.
I f the sick person is married, i f he has a household o f his own, or
if he is a member o f the household o f his people, his consent to
this step is required.
Since tuberculosis o f the lungs is responsible fo r 15 per cent o f
the disability annuities granted to males and fo r 9.5 per cent o f those
granted to females, extended provision has been made on the basis
o f the foregoing provision for the systematic treatment and care o f
tuberculous wage earners throughout the German Empire. The
importance o f tuberculosis as a cause o f invalidity or wage-earning
disability is better emphasized by the statement that o f the annuities
granted during 1896 to 1899 the proportion paid to males at ages
20 to 24 on account o f tuberculosis o f the lungs was 54.9 per cent;
at ages 25 to 29, 50.9 per cent; at ages 30 to 34, 43.9 per cent; and
at ages 35 to 39, 36.7 per cent. The proportions fo r females were, at
ages 20 to 24, 42.6 per cent; at ages 25 to 29, 34.3 per cent; at ages
30 to 34, 25.8 per cent; and at ages 35 to 39, 20.3 per cent.
F or the systematic treatment and care o f tuberculous wage earners
a chain o f special sanatoria was gradually established by the in
validity insurance institutions. Commencing with 1 in 1895, the
number o f sanatoria by 1902 had increased to 15, and by 1909 to 37.
In addition thereto, a number o f public sanatoria were established by
provincial, communal, and other authorities, largely out o f funds
provided at low rates o f interest by the invalidity insurance institu
5
6
BULLETIN OP THE BUREAU OP LABOR.
tions. In 1911 there were 99 o f these public sanatoria fo r the treat
ment o f tuberculous wage earners in the German Empire.
Commencing with 3,334 tuberculous wage earners provided with
systematic institutional treatment in public sanatoria in 1897, the
number had increased to 16,489 in 1902 and to 42,232 In 1909. Dur
ing the period 1897 to 1909, in the aggregate, 272,480 tuberculous
wage earners were treated and cared for, and o f this number 194,787
were males and 77,693 were females.
Commencing with an annual expenditure on account o f tuber
culous wage earners in 1897 o f 1,024,507 marks ($243,833), the
amount had increased to 5,858,615 marks ($1,394,350) in 1902 and
to 16,303,618 marks ($3,880,261) in 1909. During the period 1897
to 1909 the total amount disbursed on account o f institutional treat
ment and care fo r tuberculous wage earners on the part o f in
validity insurance institutions was 99,673,648 marks ($23,722,328).
The average cost o f treatment on account o f tuberculosis in sanatoria
owned and maintained by invalidity insurance institutions was 4.60
marks ($1.09) per patient per day. The maximum cost was 8.96
marks ($2.13) and the minimum cost 2.97 marks (71 cents).
The 37 sanatoria owned and operated by invalidity insurance in
stitutions in 1909 provided 3,134 beds for males and 1,289 beds for
females. The cost o f the ground occupied was 2,256,438 marks
($537,032); the cost o f buildings, 38,238,124 marks ($9,100,674);
and the cost o f installation, 4,349,854 marks ($1,035,265). The
annual cost o f maintenance during 1909 was 7,820,388 marks
($1,861,252). The number o f male patients treated was 16,593, and
o f female patients, 6,141.
U p to December 31, 1909, the invalidity insurance institutions
had loaned 13,062,625 marks ($3,108,905) for the building o f sana
toria maintained by provincial, communal, or other authorities.
O f this sum, 1,252,607 marks ($298,120) had been repaid, leaving
a net outstanding obligation o f 11,810,017 marks ($2,810,784).
The average cost o f treatment per patient per annum in all insti
tutions was 386.05 marks ($91.88). The cost fo r male patients was
404.22 marks ($96.21) and for female patients 344.97 marks ($82.10).
The average cost per patient per day was 5.41 marks ($1.29), or 5.77
marks ($1.33) for males and 4.29 marks ($1.02) for females.
The average duration o f treatment was 73 days, having been 70
days for males and 80 days fo r females.
The economic results o f institutional treatment and care on ac
count o f tuberculosis o f the lungs are determined by means o f special
inquiry for a period o f five years subsequent to the patient’s dis
charge. B y economic results is meant the restored wage-earning
capacity to the extent, at least, o f 33.3 per cent o f the patient’s wage
earning ability previous to the disease. Selecting, for illustration,
the
male patients discharged during 1905 with their wage-earning
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
7
capacity fully restored within the meaning o f the insurance laws,
the proportion retaining their earning capacity to the end o f 1905
was 76 per cent; to the end o f 1906, 63 per cent; to the end o f 1907,
54 per cent; to the end o f 1908, 48 per cent; and to the end o f 1909,
44 per cent. The corresponding economic results fo r women patients
were somewhat better, having been respectively, 78 per cent for
the first year, 67 per cent for the second, 60 per cent fo r the third,
55 per cent fo r the fourth, and 52 per cent fo r the fifth year.
The tendency is distinctly toward an improvement in the economic
results as is made evident by the fact that while o f the male patients
treated in 1897 only 68 per cent were discharged with their earning
capacity restored, the corresponding proportion for 1909 was 83
per cent. F or female patients the results were exactly the same.
On account o f 24,337 male patients successfully treated from an
economic point o f view, 10,456,400 marks ($2,488,623) was expended
during the year 1909, or an average expenditure o f 429.65 marks
($102.26). On account o f 4,940 male patients unsuccessfully treated
from an economic point o f view during 1909, the sum o f 1,378,094
marks ($327,986) was expended, or an average expenditure o f 278.97
marks ($66.40). On account o f 10,794 female patients treated suc
cessfully from an economic point o f view during 1909 the sum o f
3,911,657 marks ($930,974) was expended, or an average expenditure
o f 362.39 marks ($86.25). On account o f 2,161 female patients un
successfully treated from an economic point o f view the sum o f
557,467 marks ($219,912) was expended, or an average expenditure
o f 257.97 marks ($61.40).
The economic and medical results o f treatment are naturally more
or less determined by the condition o f the disease on admission. O f
the 24,766 male patients admitted fo r treatment during 1909, the
number in the first Turban stage o f the disease1 was 12,015, or 49
per cent; in the second stage, 9,161, or 37 per cent; and in the third
stage, 3,590, or 14 per cent. O f the 20,567 male patients successfully
treated and discharged with their earning capacity restored to them,
11,111 were in the first Turban stage o f the disease, or 92 per cent
o f all admitted in that stage o f the disease; the number in the second
Turban stage o f the disease on discharge was 7,777, or 85 per cent o f
those admitted in that stage; the *number discharged in the third
Turban stage was 1,679, or 47 per cent o f those in the third Turban
stage o f the disease when admitted.
O f the 10,379 female patients admitted, 5,826, or 56 per cent, were
in the first Turban stage o f the disease; 3,399, or 33 per cent, were in
the second stage; and 1,154, or 11 per cent, were in the third. O f
those successfully treated, on discharge, 5,507 were in the first
Turban stage o f the disease, or 95 per cent o f those admitted in that
1 For explanation of the term “ Turban stage,” see page 83.
8
BULLETIN OF TH E BUREAU OF LABOR.
stage. O f those discharged, 2,670 were in the second Turban stage
o f the disease, or 79 per cent o f those admitted in that stage o f the
disease. O f those discharged, 385 were in the third Turban stage, or
33 per cent o f those admitted in that stage o f the disease.
The economic and medical results are affected by the inclusion
o f patients who were less than 14 days under treatment* I f these
are deducted, the proportion o f male patients treated successfully
from an economic point o f view was increased from 83 to 86 per
cent; and the same results were secured in the case o f females.
O f every 1,000 male patients discharged, 5 required readmission
fo r treatment during the first year o f admission, 59 after one year
o f admission, 68 after two years, 45 after three years, and 33 after
four years. O f every 1,000 female patients, 3 required readmission
during the first year, 51 during the second, 48 during the third, 34
during the fourth, and 23 during the fifth year.
In addition to a large expenditure fo r institutional treatment and
care o f tuberculous wage earners through invalidity insurance insti
tutions, considerable sums are paid out in support o f the general anti
tuberculosis movement, which within recent years has made material
progress throughout the German Empire. In 1909, 288,365 marks
($68,631) was disbursed fo r various purposes, chiefly in support o f
tuberculosis dispensaries and inform ation bureaus. The correspond
ing expenditure during 1908 was 248,805 marks ($59,216). In 1910
the sum o f 480,964 marks ($114,469) was expended for aid and sup
port o f the general antituberculosis movement, and o f this sum
297,941 marks ($70,910) was in the nature o f subventions to tuber
culosis dispensaries and inform ation bureaus.
There were in 1911 some 99 public sanatoria in the German
Empire, and o f this number, in 1910, 381 were owned and main
tained by invalidity insurance institutions. There were in addi
tion 34 private sanatoria, some o f which provided fo r wage earners
at reduced rates. F or tuberculous children 22 institutions were
in operation in 1911, and in addition thereto for children likely
to become tuberculous or scrofulous, or otherwise in need o f insti
tutional care as a safeguard against tuberculosis, 86 institutions were
in operation, providing treatment free or at very reasonable rates;
the number o f sanatoria fo r school children only was 7, and the
number o f forest day and night camps was 98. The number o f
open-air or forest schools in 1911 was 15, and two agricultural colo
nies had been established, one in the Province o f Brandenburg and
one in the Grand Duchy o f Oldenburg. F or far-advanced cases 96
homes for incurables were in operation, or in the form o f isolation
divisions o f hospitals established and maintained fo r general pur
poses. F or the benefit o f discharged patients in need o f supple
1Statistik der Heilbehandlung, 1905-1910, p. 69.
CARE OP TUBEBCULOTJS WAGE EARNERS IN GERMANY*
9
mentary treatment and care 17 convalescing homes were in opera
tion, and for the study o f incipient cases to determine the stage o f
the disease, or the actual existence o f tuberculosis, there were 33 obser
vation stations, chiefly in connection with sanatoria or general hos
pitals. There were also 19 polyclinics for the tuberculous, conform ing
probably to the tuberculosis clinic as clearly differentiated from the
tuberculosis dispensary. The number o f tuberculosis dispensaries
and inform ation bureaus was 528, and in addition thereto 537 dispen
saries were maintained in the Grand Duchy o f Baden. A large
number o f tuberculosis associations are in active operation, provid
ing the means for a systematic warfare against the disease through
out the entire German Empire, the work being directed through, and
if necessary sustained by the financial assistance o f the German Cen
tral Committee, which is under the protection o f Her Im perial
M ajesty the German Empress, and the presiding honorary officer o f
which is the imperial chancellor.1
The German Central Committee had on January 1, 1910, funds
o f 370,349.55 marks ($88,143.19), receiving in membership fees
39,877 marks ($9,490.73); in gifts, 15,000 marks ($3,570); in interest,
16,245.28 marks ($3,866.40); and by way o f imperial subsidy, 60,000
marks ($14,280). It expended during the year, in the form o f finan
cial aid to the establishment o f sanatoria and other tuberculosis
institutions, the sum o f 177,300 marks ($42,197.40). F or tuberculosis
museums, 33,316.68 marks ($7,929.37); fo r the special campaign
against lupus, 30,000 marks ($7,140); and for all other purposes the
sum o f 59,880.10 marks ($14,251.46), including 29,081.76 marks
($6,921.46) for administration.23
It is evident from the foregoing that the antituberculosis move
ment throughout the German Empire is thoroughly organized and
sustained by ample funds. The results o f systematic treatment and
institutional care have been quite satisfactory and, as far as
known, sufficient to reimburse the insurance institutions by the release
o f funds that would otherwise have been required for the payment
o f disability annuities.
Largely as the result o f the general movement against tubercu
losis and the provision for institutional and dispensary care, the
general tuberculosis death rate o f German cities has progressively
declined. From an average o f 23.08 per 10,000 during 1895-1899
the rate fo r the German Empire as a whole has declined to 21.16
during 1900-1904 and 18.45 during 1905-1909. The m ortality from
tuberculosis o f the lungs in German cities has declined from an aver
age rate o f 34.6 per 10,000 o f population during 1889-1884, to 27.4
1Beilage zum GescMftsbericht, 1911. Published by the German Central Committee,
Berlin, 1912.
3 Annual Report of the German Central Committee for 1911.
10
BULLETIN OF THE BUREAU OF LABOR.
during 1890-1894, to 21.0 during 1900-1904, and finally to 17.9 during
1905-1909. The tuberculosis death rate o f Berlin has decreased from
34.7 per 10,000 in 1880 to 17.9 in 1909; o f Bremen, from 39.7 to 15.1;
o f Cassel, from 32.4 to 12.2; o f Chemnitz, from 27.7 to 12.6; o f
Cologne, from 41.4 to 15.6; o f Dresden, from 36.9 to 17.7; o f Essen,
from 40.9 to 10; o f Frankfort, from 37.7 to 15.8; o f Hanover, from
42.4 to 11.5; o f Leipzig, from 35.5 to 16.3; o f Munich, from 40.5 to
22.9; o f Strassburg, from 33.5 to 19; and finally, o f Stuttgart, from
23 to 16.8.
These results are unquestionably, in a large measure, due to the in
telligent and well-sustained effort which has been made throughout
the German Empire to reduce the mortality and m orbidity, as well as
the economic consequences o f the form erly excessive death rate from
tuberculosis. The movement has been nation-wide and has enlisted
the hearty cooperation o f employers and employees, the public at
large, and the numerous governmental authorities—from the Empire
itself to the royal, provincial, municipal, and communal governing
bodies. A large number o f public associations have been established
and are being maintained by private subscription, which in the aggre
gate must amount to a very considerable sum.
W ithin recent years vast sums o f money have been provided for
building purposes by invalidity insurance institutions, as well as
through provincial and communal authorities. U p to December 31,
1910, 320,000,000 marks ($76,160,000) had been furnished in the
form o f loans for building purposes through invalidity insur
ance institutions, and the tendency is decidedly toward a gradual
reconstruction o f the housing accommodation o f the wage-earning
population. This effort is under strict governmental supervision
as a first requisite for the safeguarding o f the public interests
against speculation and misdirected effort contrary to the common
good. Extensive inquiries have fully established the direct relation
between insanitary housing accommodation and the excessive mor
tality from tuberculosis and possibly from nontubercular lung dis
eases. The problem o f housing reform is, therefore, one o f material
importance to the invalidity insurance institutions, and this explains
the considerable extent to which these institutions have financially
sustained the nation-wide effort to improve the living conditions o f
wage earners and their families.
What has been done in all o f these directions has naturally reacted
most favorably to the advantage o f the German people as a whole.
The activity o f invalidity insurance institutions in the field o f social
betterment is obviously conditioned by the vital interests which these
institutions have, perhaps not so much in a low death rate as in
a low m orbidity rate. Every case o f tuberculosis involves a material
risk to these institutions, which comprehend in their membership
practically
the entire wage-earning population. The position o f life
OAEE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
11
insurance companies in this respect, however, is a very different one,
and it should be thoroughly understood that not a single German life
insurance company—all assertions to the contrary notwithstanding—
has seen its way clear to undertake the treatment and care o f its
tuberculous policy holders in the manner which has been found pos
sible and expedient fo r members o f invalidity insurance institutions
maintained in compliance with law by the compulsory contributions
o f employers and employees, plus a subsidy from the imperial Gov
ernment. In other words, the payment o f death claims by life insur
ance companies involves totally different considerations from the
payment o f disability annuities by the invalidity insurance institu
tions maintained in conform ity to the principle o f social insurance,
which in effect is no more and no less than a method o f special but
direct taxation.
The marvelous results achieved in the German Em pire through
the intelligent coordination o f public and private agencies enlisted
in the effort to reduce the m ortality from tuberculosis to a minimum
entitles the German experiment, as the first and most successful o f
its kind, to the admiration o f the entire civilized world. Whether
what has been done has paid fo r itself in a strict financial sense is
wholly secondary to the social results which have been achieved, and
which have unquestionably conferred an infinite amount o f good upon
the German people engaged in German industry in successful compe
tition with the economically more advantageously situated wage
earners o f many other lands. From the social, economic, and med
ical points o f view the treatment and care o f tuberculous wage
earners in Germany is a subject well deserving o f intelligent and
sympathetic study as a distinct contribution to the civilization o f
the present time.
MORTALITY FROM TUBERCULOSIS IN THE GERMAN EMPIRE.
The present discussion is largely lim ited to what has been done in
this direction during the period 1897 to 1909, but some consideration
has been given to earlier years. The modern movement may be said
to rest in part upon the statistical analysis o f the m ortality o f the
German Em pire fo r 1893, when out o f 268,500 deaths o f persons aged
15 to 60 years, 88,654, or 33 per cent, were caused by tuberculosis o f
the lungs. But in some Provinces o f the German Empire the propor
tion was as high as 43 per cent, while in others it was as low as 22
per cent. In 1899 it was ascertained by means o f a special statistical
inquiry that there were then 226,000 tuberculous patients in hospitals
and other institutions o f the German Empire, or 42.2 per 10,000 o f
population. Between 1892 and 1900, in 10 o f the principal cities o f
the Empire, 1,066,722 persons died from tuberculosis o f the lungs,
or 24.2 per 10,000 o f population. In that portion o f the Kingdom
12
BULLETIN OF THE BUREAU OF LABOR.
of Bavaria which lies on the left side of the Rhine, the rate was as
high as 32.9 per 10,000 of population, while in East Prussia, which is
almost entirely agricultural, the rate was only 14.6. For a full under
standing, therefore, of the underlying reasons for the extensive and
costly campaign against tuberculosis in Germany it is necessary to
consider briefly the mortality data for a period of years.
The statistics for the German Empire extend only over the period
1892 to 1909, including in the last-named year 24 States with a popu
lation of nearly 63,000,000, or 98.3 per cent of the total. In this area
the average death rate from tuberculosis of the lungs was 21.2 per
10,000 of population during the period 1895 to 1899, diminishing to
19.2 during 1900 to 1904, and still further to 16.0 during 1905 and 1909.
There was an increase, however, in the mortality from other forms of
tuberculosis from 1.9 per 10,000 during 1895 to 1899 to 2.5 during
1905 to 1909. Combining all forms of tuberculosis, the death rate
declined progressively from an average of 23.1 .during 1895 to 1899
to 18.5 during 1905 to 1909. The mortality from nontubercular
lung diseases declined from 26.4 during the first five years under
observation to 24.8 during the last five years. The evidence, there
fore, is quite conclusive that the decrease in the mortality from tuber
culosis of the lungs was not the result of possible changes in methods
of medical diagnosis, nor was it due to an increase in the mortality
from other forms of tuberculosis or from nontubercular diseases of
the lungs. The details of the mortality from tuberculosis in the
German Empire are given in the following table:
MORTALITY FROM TUBERCULOSIS OF THE LUNGS AND FROM OTHER LUNG DISEASES
IN THE GERMAN EMPIRE, 1892 TO 1909.
Year.
1892.............
1893.............
1894.............
1895.............
1896.............
1897.............
1898.............
1899.............
1900.............
1901.............
1902.............
1903.............
1904.............
1905.............
1906.............
1907.............
1908.............
1909.............
1895 to 1899..
1900 to 1904..
1905 to 1909..
Num
ber of
States
in regis
tration
area.
9
10
11
13
18
20
20
20
20
21
21
23
23
23
24
24
24
24
Deaths from
tuberculosis of
the lungs.
Popula
tion.
Number.
41,475,116
47,625,932
48,684,503
49,752,057
50,331,987
51,528,038
52,084,384
53,510,403
54,662,484
55.061.664
55.061.664
57,619,810
58,433,571
59,768,198
59,912,782
61,260,509
62,111,705
62,954,673
257,206,869
280,839,193
306,007,867
97,599
115,641
115,034
113,786
109,659
110,225
103,425
107,633
111,804
106,941
105,376
107,299
106,709
106,552
93,152
97,555
95,402
90,962
544,728
538,129
488,623
Deaths from
other forms of
tuberculosis.
Deaths from
all forms of
tuberculosis.
Deaths from
other lung
diseases.
Rate
Rate
Rate
Rate
per Number. per Number. per Number. per
10,000.
10,000.
10,000.
10,000.
23.53
24 28
23.63
22.87
21.79
21.39
19.86
20.11
20.45
19.42
19.14
18.62
18.26
17.83
16.38
15.92
15.36
14.45
21. IS
19.16
15.97
7,051
8,434
8,870
9,373
9,452
10,099
10,136
9,786
10,244
10,655
10,940
12,140
12,237
15,440
15,280
15,135
15,200
14,948
48,846
56,216
76,003
1.70
1.77
1.82
1.88
1.88
1.96
1.95
1.83
1.87
1.94
1.99
2.11
2.09
2.58
2.55
2.47
2.45
2.37
1.90
2.00
2.48
104,650
124,075
123,904
123,159
119,111
120,324
113,561
117,419
122,048
117,596
116,316
119,439
118,946
121,992
113,432
112,690
110,602
105,910
593,574
594,345
564,626
25.23
26.05
25.45
24.75
23.67
23.35
21.80
21.94
22.33
21.36
21.12
20.73
20.36
20.41
18.93
18.40
17.81
16.82
23.08
21.16
18.45
150,241
156,831
135,332
127,824
131,930
134,403
132,133
151,661
162,413
144,561
151,622
153,948
149,199
156,120
142,933
154,019
153,526
150,627
677,951
761,743
757,225
36.22
32.93
27.80
25.69
26.21
26.08
25.37
28.34
29.71
26.25
27.54
26.72
25.53
26.12
23.86
25.14
24.72
23.93
26.36
27.12
24.75
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
13
The statistics for Prussia extend over a muchlonger period, includ
ing the years 1875 to 1909, but unfortunately the mortality from the
different forms of tuberculosis was not separately returned previous
to 1892. Considering, therefore, only the mortality from all forms
of tuberculosis, it is shown by the official returns that the death rate
from this group of causes has progressively decreased from 31.8 per
10,000 during 1875 to 1879 to 25.5 during 1890 to 1894, and finally
to 16.9 during 1905 to 1909. The mortality from other lung diseases
in Prussia, which had been increasing up to 1893, decreased pro
gressively from an average of 28.6 per 10,000 during 1890 to 1894 to
24.6 during 1905 to 1909. The details of the mortality from tubercu
losis by single years for the Kingdom of Prussia are given in the
table which follows:
MORTALITY FROM TUBERCULOSIS OF THE LUNGS AND FROM OTHER LUNG
DISEASES, PRUSSIA, 1875 TO 1909.
Deaths from
tuberculosis of
the lungs.
Year.
Deaths from all
forms of
tuberculosis.
Deaths from other
Population.
Number.
1875 .......
1876 .......
1877 .......
1878 .......
1879 .......
1880 .......
1881..........
1882..........
1883 .......
1884 .......
1885 .......
1886 .......
1887 .......
1888 .......
1889 .......
1890 .......
1891 .......
1892 .......
1893 .......
1894 .......
1895 .......
1896 .......
1897 .......
1898 .......
1899 .......
1900 .......
1901 .......
1902 .......
1903 .......
1904 .......
1905 ........
1906 ........
1907 ........
1908 .......
ions
1875toi879
1880 to 1884,
1885 to 1889,
1890 to 1894.
1895 to 1899,
1900 to 1904,
1905 to 1909,1
Deaths from
other forms of
tuberculosis.
25,742,404
126,049,745
126,357,086
126,664,427
126,971,768
27,279,111
127,486,983
127,694,855
127,902,727
128.110.599
28,318,470
128.646.249
128,974,028
129,301,807
129,629,586
29,957,367
130,336,918
130,716,469
131,096,020
131,475,571
31,855,123
132.378.600
132,902,077
133,425,554
-33,949,031
34,472,509
135,036,672
135,600,835
136,164,998
136,729,161
37,293,324
137,857,487
138,421,650
138,985,813
139,549,976
131,785,430
138,474,275
144,870,140
153,582,345
164,510,385
178,004,175
192.108.250
Rate
Rate
• Rate
Rate
per Number. per Number. per Number. per
10,000.
10,000.
10,000.
10,000.
72,645
73,428
71,133
70,109
66,583
66,400
61,595
64,333
66,349
63,065
62,224
64,310
63,777
63,767
57,878
58,308
56,371
53,934
23.65
23.61
22.60
22.01
20.56
20.18
18.43
18.95
19.25
18.00
17.48
17.78
17.36
17.10
15.29
15.18
14.46
13.64
3,516
3.549
3,523
3,643
3,790
3,980
3,965
4,075
4,253
4,380
4,502
5,739
5.549
6,556
6,581
6,746
6,949
6,937
1.14
1.14
1.12
1.14
1.17
1.21
1.19
1.20
1.23
1.25
1.26
1.59
1.51
1.76
1.74
1.75
1.78
1.75
329,020
319,725
290,258
20.00
17.96
15.11
19,453
24,423
33,769
i.i8
1.37
1.76
1 Estimated.
82,122
79,770
83,769
86,294
87,294
84,895
84,363
85,359
88,837
87,756
88,056
88,283
84,124
84,109
82,529
84,086
80,151
76,161
76,977
74,656
73,752
70,373
70,380
65,560
68,408
70,602
67,445
66,726
70,049
69,326
70,323
64,459
65,054
63,320
60,871
419,249
431,210
427,101
392,031
348,473
344,148
324,027
31.90
30.62
31.78
32.36
32.36
31.12
30.69
30.82
31.84
31.22
31.09
30.82
29.03
28.70
27.85
28.07
26.42
24.79
24.75
23.72
23.15
21.73
21.39
19.61
20.15
20.48
19.25
18.74
19.37
18.87
18.86
17.03
16.93
16.24
15.39
31.81
31.14
29.41
25.46
21.18
19.33
16.86
42,065
41,221
42,595
42,991
44,736
49,182
55,602
54,973
61,387
58,525
62,745
64,455
63,584
63,238
63,708
85,693
78,542
94,627
97,921
82,000
80,881
83,716
84,308
81,516
95,972
104,157
90,702
96,275
96,235
95,112
96,170
89,090
97,068
96,513
94,258
213,608
279,669
317,730
438,783
426,393
482,481
473,099
16.34
15.82
16.16
16.12
16.59
18.01
20.23
19.85
22.00
20.82
22.16
22.50
21.95
21.58
21.50
28.60
25.89
30.81
31.49
26.05
25.39
25.86
25.62
24.39
28.27
30.21
25.89
27.04
26.61
25.90
25.79
23.53
25.26
24.76
23.83
16.21
20.20
21.93
28.57
25.92
27.11
24.63
14
BULLETIN OF TH E BUREAU OF LABOR,
A most useful contribution to the study of the mortality from
tuberculosis in Prussia according to sex and age was made for the
year 1905.1 According to this analysis the proportionate mortality,
by divisional periods of life, attains its maximum at ages 20 to
25 years, when of the mortality from all causes 45.7 per cent are
deaths from tuberculosis. For males the proportion at this age was
44.1 per cent and for females 47.6 per cent. It requires no further
analysis to emphasize the economic importance of tuberculosis pre
vention to a State in which practically the whole wage-earning popu
lation is insured against the risk of permanent or partial disability
resulting from disease. The details of the mortality from all forms
of tuberculosis in Prussia according to age and sex during 1905 and
also during 1910 are given in the table which follows:
MORTALITY FROM TUBERCULOSIS, PRUSSIA, ACCORDING TO SEX AND AGE, 1906 AND
1910.
[From Das Gesundheitswesen des Preussischen Staats, for 1905, p. 259, and for 1910,
p. 198. Published by Richard Schoetz, Berlin, 1907 and 1912.]
1905.
Deaths from tubercu
losis.
Proportionate mortal
ity by divisional
periods of life.
Mortality rate (per
10,000) from tubercu
losis according to age.
Age at death.
FeFe
Fe
Total. Males. males.
Total. Males. males.
Total. Males. males.
1,532
996
568
730
1,234
1,845
3,139
3,561
3,816
5,721
3,826
3,141
2,624
867
94
3
1.37
4.55
7.02
8.01
11.94
25.04
40.37
45.74
42.79
33.84
23.22
15.04
7.77
2.26
.47
1.95
1.35
4.64
6.85
7.43
10.86
17.75
34.85
44.10
41.41
33.35
23.71
16.48
8.69
2.49
.55
1.05
1.40
4.47
7.18
8.61
12.98
31.43
46.60
47.59
44.12
34.35
22.52
13.20
6.84
2.07
.41
4.55
31.42
21.71
11.52
7.27
5.24
7.03
17.16
22.11
24.96
23.84
25.33
29.75
33.17
22.32
10.09
5.15
23.81
22.71
11.43
6.81
4.70
4.63
15.54
22.94
23.65
24.04
30.91
38.98
40.94
25.86
12.03
3.62
28.96
20.70
11.62
7.73
5.79
9.45
18.81
21.30
26.27
23.63
20.01
21.63
26.71
19.55
8.66
7.17
Total........................... 70,323 36,626 33,697
9.68
9.66
9.70
19.13
20.21
18.08
998
701
425
615
1,111
1,455
2,848
3,371
3,345
5,572
3,433
2,560
2,103
770
82
1.18
4.38
7.24
8.68
12.52
24.14
39.35
44.20
41.89
32.91
21.73
12.87
6.18
1.85
.40
.36
1.19
4.62
7.50
8.23
11.14
18.33
33.14
41.69
39.98
32.24
22.31
14.30
6.76
1.92
.44
.50
1.17
4.13
6.95
9.17
13.91
29.65
46.51
47. uO
43.73
33.57
20.94
11.06
5.61
1.80
.36
20.92
15.09
9.38
5.98
4.33
5.46
13.44
20.56
19.32
20.43
20.33
23.47
23.66
17.24
7.75
23.10
16.15
10.03
5.79
3.83
4.02
12.05
20.51
18.10
19.80
24.40
30.84
28.54
18.59
8.80
18.68
14.00
8.72
6.17
4.82
6.92
14.86
20.61
20.53
21.05
16.42
16.89
19.67
16.20
7.01
Total........................... 60,479 31,099 29,389
9.48
9.42
9.54
15.29
15.92
14.68
0 to 1 year.......................... 3,366
lt o 2 years........................ 2,093
2 to 3 years........................ 1,129
3 to 5 years........................ 1,379
5 to 10 years........................ 2,240
10 to 16 years........................ 2,757
16 to 20 years........................ 5,788
20 to 25 years........................ 7,306
25 to 30 years........................ 7,258
30 to 40 years........................ 11,476
40 to 60 years........................ 9,473
60 to 60 years........................ 8,126
60 to 70 years........................ 5,974
70 to 80 years........................ 1,764
190
80 years and over..................
5
Unknown.............................
1,833
1,097
661
649
1,006
912
2,649
3,745
3,442
5,756
5,647
4,985
3,350
897
96
2
1910.
0 to 1 year........................... 2,267
1 to 2 years.......................... 1,526
2 to 3 years..........................
920
3 to 5 years.......................... 1,199
5 to 10 years........................ 2,001
10 to 15 years........................ 2,307
15 to 20 years......................... 5,188
20 to 25 yea rs..,................... 6,702
25 to 30 years......................... 6,289
30 to 40 years......................... 10,814
40 to 50 years......................... 8,327
50 to 60 years......................... 6,732
60 to 70 years......................... 4,597
70 to 80 years......................... 1,454
80 years and over..................
155
1
Unknown.............................
1,269
825
495
584
890
852
2,340
3,331
2,944
5,242
4,894
4,172
2,494
684
73
1
1 The information for 1910 also is given in the table shown on this page.
brings out the considerable decline in the death rate at every period of life.
The table
CASE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
15
Since the mortality from tuberculosis of the lungs is largely an
urban disease, although there are important exceptions to this rule,
it has seemed advisable to include in this discussion a table of the
combined mortality from the disease in large German cities for the
period 1880 to 1909. The table will afford a meansof convenient com
parison with the corresponding mortality of American cities, which
will subsequently be referred to. The average death rate from tuber
culosis of the lungs in the principal German cities decreased from34.6
per 10,000 during the five years ending with 1884 to 17.9 per 10,000
during the five years ending with 1909. The maximum rate during
the period prevailed during 1883 and 1884, when it attained to*35.2
per 10,000. The minimum rate prevailed during 1909, when it was
only 16.6 per 10,000 of population. The details, by single years, are
given in the table which follows.
Most of the data used in this table have been derived from volume
33, Part I, of Statistique Demographique des Grandes Villes du
Monde, published by the Bureau of Municipal Statistics of Amster
dam, Holland.
MORTALITY FROM TUBERCULOSIS OF THE LUNGS, LARGE GERMAN CITIES,
1880 TO 1909.
COMPARATIVE MORTALITY FROM TUBERCULOSIS IN GERMANY AND
IN THE UNITED STATES.
When the foregoing data relating to the mortality from tubercu
losis of the lungs in the German Empire are compared with the
corresponding data for the registration area of the United States,
it is shown that while during the earlier years the mortality was
much higher in Germany, the rate has fallen more rapidly, particu
larly during recent years, until the position of the German Empire
is nowmore favorable than the corresponding position of the United
States. A comparison, for illustration, shows that the rate for
German cities in 1880 to 1884 was 34.6 per 10,000, and the corre
16
BU LLETIN OF TH E BUREAU OF LABOR.
sponding rate for American cities was 32.1. During the five years
ended with 1909 the rate for German cities was only 17.9 per 10,000,
against a rate of 18.5 for American cities. While, therefore, during
the first five years the mortality from tuberculosis of the lungs in
German cities was 2.5 per 10,000 in excess of the corresponding mor
tality in American cities, it is shown that during the last five years
under review the mortality from tuberculosis of the lungs in Ameri
can cities was 0.6 per 10,000 in excess of the corresponding mortality
in German cities. The positions, therefore, have been reversed, and
as will subsequently be shown, there are strong reasons for believing
that*the German advance in this direction has been largely because
of the systematic and effective treatment and care of tuberculous
wage earners in special institutions or sanatoria established for the
purpose, and many collateral institutions and efforts contributory
thereto. The details regarding the mortality from tuberculosis of
the lungs in the registration area of the United States and American
cities are given in the two tables which follow:
MORTALITY FROM TUBERCULOSIS OF THE LUNGS IN THE REGISTRATION AREA
OF THE UNITED STATES, 1900 TO 1909.
Pulmonary tuberculosis.
Females.
Males.
Deaths.
Years and
periods.
Population.
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
...
...
...
...
...
...
...
...
...
...
15,758,235
16,089,548
16,461,407
16,834,902
17,210,033
17,586,800
21,382,973
21,782,186
23,545,009
25,588,273
Deaths.
Deaths.
Num
ber.
Rate Population.
per
10,000.
Num
ber.
Rate Population.
per
10,000.
Num
ber.
29,372
29,569
28,250
29,061
31,833
31,047
36,032
37,191
38,055
39,456
18.64
18.38
17.16
17.26
18.50
17.65
16.85
17.07
16.16
15.42
26,132
25,166
23,829
24,849
26,930
25,723
29,309
29,183
29,321
30,584
17.40
16.41
15.19
15.48
16.42
15.35
14.38
14.06
13.07
12.54
55,504
54,735
52,079
53,910
58,763
56,770
65,341
66,374
67,376
70,040
T otal... 192,239,366 329,866 17.16
1900 to 1904... 82,354,125
1905 to 1909... 109,885,241
Total.
148,085 17.98
181,781 16.54
15,019,568
15,335,351
15,689,779
16,045,766
16,403,313
16,762,419
20,380,647
20,761,146
22,441,336
24,388,823
183,228,148 271,026 14.79
78,493,777
104,734,371
30,777,803
31,424,899
32,151,186
32,880,668
33,613,346
34,349,219
41,763,620
42,543,332
45,986,345
49,977,096
Rate
per
10,000.
18.03
17.42
16.20
16.40
17.48
16.53
15.65
15.60
14.65
14.01
375,467,514 600,892
16.00
126,906 16.17 160,847,902 274,991
144,120 13.76 214,619,612 325,901
17.10
15.19
Tuberculosis other than 'pulmonary.
15,758,235
16,089,548
16,461,407
16,834,902
17,210,033
17,586,800
21,382,973
21,782,186
23,545,009
25,588,273
3,558
3,745
3,714
4,075
4,313
4,523
5,427
5,599
5,926
6,281
Total... 192,239,366
1900 to 1904... 82,354,125
1905 to 1909... 109,885,241
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
...
...
...
...
...
...
...
...
...
...
2.26
2.33
2.26
2.42
2.51
2.57
2.54
2.57
2.52
2.45
15,019,568
15,335,351
15,689,779
16,045,766
16,403,313
16,762,419
20,380,647
20,761,146
22,441,336
24,388,823
3,034
3,287
3,290
3,655
3,845
4,185
4,880
4,786
5,107
5,514
47,161
2.45
183,228,148
19,405
27,756
2.36
2.53
78,493,777
104,734,371
2.02
2.14
2.10
2.28
2.34
2.50
2.39
2.31
2.28
2.26
30,777,803
31,424,899
32,151,186
32,880,668
33,613,346
34,349,219
41,763,620
42,543,332
45,986,345
49,977,096
6,592
7,032
7,004
7,730
8,158
8,708
10,307
10,385
11,033
11,795
2.14
2.24
2.18
2.35
2.43
2.54
2.47
2.44
2.40
2.36
41,583
2.27 375,467,514
88,744
2.36
17,111
24,472
2.18 160,847,902
2.34 214,619,612
36,516
52,228
2.27
2.43
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
17
MORTALITY FROM TUBERCULOSIS OF THE LUNGS IN THE REGISTRATION AREA
OF THE UNITED STATES, 1900 TO 1909—Concluded.
A ll forms o f tuberculosis.
Females.
Males.
Deaths.
Years and
periods.
Total.
Deaths.
Deaths.
Population.
Num Rato
per
ber. 10,000.
Num
ber.
Rate Population.
per
10,000.
Num
ber.
Rate
per
10,000.
32,930
33,314
31,964
33,136
36,146
35,570
41,459
42,790
43,981
45,737
20.90
20.71
19.42
19.68
21.00
20.23
19.39
19.64
18.68
17.87
29,166
28,453
27,119
28,504
30,775
29,908
34,189
33,969
34,428
36,098
19.42
18.55
17.28
17.76
18.76
17.84
16.78
16.36
15.34
14.80
62,096
61,767
59,083
61,640
66,921
65,478
75,648
76,759
78,409
81,835
20.18
19.66
18.38
18.75
19.91
19.06
18.11
18.04
17.05
16.37
T otal... 192,239,366 377,027
19.61
Population.
...
...
...
...
...
...
...
...
...
...
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
15,758,235
16,089,548
16,461,407
16,834,902
17,210,033
17,586,800
21,382,973
21,782,186
23,545,009
25,588,273
1900 to 1904... 82,354,125 167,490 20.34
1905 to 1909... 109,885,241 209,537 19.07
15,019,568
15,335,351
15,689,779
16,045,766
16,403,313
16,762,419
20,380,647
20,761,146
22,441,336
24,388,823
183,228,148 312,609 17.06
78,493,777
104,734,371
30,777,803
31,424,899
32,151,186
32,880,668
33,613,346
34,349,219
41,763,620
42,543,332
45,986,345
49,977,096
375,467,514 689,636
18.37
144,017 18.35 160,847,902 311,507
168,592 16.10 214,619,612 378,129
19.37
17.62
MORTALITY IN AMERICAN CITIES FROM TUBERCULOSIS OF THE LUNGS, 1870 TO 1909.
Year.
1870.
1871.
1872.
1873
1874,
1875
1876
1877
1878.
1879
1880
1881,
1882
1883
1884
1885
1886
1887
1888
1889
1890
1891
1892
1893
Num
ber
Popula
tion.
Deaths.
3,064,248
3,152,034
3,671,562
4,241,333
4,057,378
4,670,708
4,830,045
5,254,820
5,530,567
6,064,577
6,721,841
7,011,801
7,191,252
7,505,986
7,736,682
7,979,952
8,298,185
8,305,090
8,905,415
9,441,109
9,878,969
10,722,433
11,022,883
10,877,321
10,224
10,257
12,270
13,635
12,394
14,625
15,486
15,973
17,244
18,416
21,047
23,502
23,431
24,028
23,995
23,906
24,522
23,720
24,120
24,061
26,280
26,691
27,059
25,987
of
cities.
Rate
per
Year.
10,000.
33.37
32.54
33.42
32.15
30.55
31.31
32.06
30.40
31.18
30.37
31.31
33.52
32.58
32.01
31.01
29.96
29.55
28.56
27.08
25.49
26.60
24.89
24.55
23.89
1894.
1895.
1896.
1897.
1898.
.
1900
1901
.
1902
..
1903
.
1904
..
1905
..
1906
..
1907
..
1908
..
1909
..
1870 to 1874..
1875 to 1879..
1880 to 1884..
1885 to 1889..
1890 to 1894..
1895 to 1899.,
1900 to 1904.,
1905 to 1909.,
Num
ber
of
cities.
Popula
tion.
11,188,919
11,451,786
11,870,008
12,181,994
12,436,938
13,208,505
13,129,350
14,252,940
14,500,917
14,962,711
15,325,964
15,586,747
16,170,144
16,636,665
17,064,491
17,492,509
18.186.555
26,350,717
36,167,562
42,929,751
53,690,525
61,149,231
72,171,882
82.950.556
Rate
Deaths. per
10,000.
25,303
25,928
25,768
25,253
25,554
27,358
26,080
28,758
27,459
29,220
31,790
30,349
30,719
31,514
30,753
30,091
58,780
81,744
116,003
120,329
131,320
129,861
143,307
153,426
22.61
22.64
21.71
20.73
20.55
20.71
19.86
20.18
18.94
19.53
20.74
19.47
19.00
18.94
18.02
17.20
32.32
31.02
32.07
28.03
24.46
21.24
19.86
18.50
For the purpose of convenient comparison the essential facts are
summarized for large German and American cities in the table
below, in which is given the total number of deaths fromtuberculosis
of the lungs and the rate per 10,000 of population, by quinquennial
periods since 1880. It may be stated that the population of large
German cities increased from 3,516,914 in 1880 to 9,487,821 in 1909,
while the population for large American cities increased from
6,721,841 in 1880 to 17,492,509 in 1909. The number of large German
49397°—12---2
18
BULLETIN OF THE BUREAU OF LABOR.
cities considered in the investigation of 1909 was 26, and the number
of American cities was 63. It is a matter of regret that complete
returns for German cities for a longer period of years are not avail
able, but the comparison which follows will serve the present purpose
to emphasize the decline in the death rate from tuberculosis of the
lungs which has taken place in the case of the large cities of both
countries during the last 30 years.
SUMMARY OF MORTALITY FROM TUBERCULOSIS OF THE LUNGS IN LARGE
GERMAN AND AMERICAN CITIES, BY PERIODS, 1880 TO 1909.
German cities.
Number of
from
Aggregate deaths
population. tubercu
losis of
the lungs.
Periods.
1880 to 1884.....................................
1885 to 1889....................................
1890 to 1894.....................................
1895 to 1899.....................................
1900 to 1904.....................................
1905 to 1909....................................
18,423,010
21,920,532
30,661,604
34,905,723
40,606,352
46,342,006
63,709
70,833
84,087
79,909
85,195
82,961
American cities.
Number of Rate
Rate
per
from per
Aggregate deaths
tubercu 10,000
10,000 population.
of pop
losis of of pop
ulation.
the lungs. ulation.
34.6
32.3
27.4
22.9
21.0
17.9
36,167,562
42,929,751
53,690,525
61,149,231
72,171,882
82,950,556
116,003
120,329
131,320
129,861
143,307
153,426
32.1
28.0
24.5
21.2
19.9
18.5
ESTIMATED ECONOMIC LOSS FROM TUBERCULOSIS TO WAGE
EARNERS IN THE UNITED STATES.
The importance to the United States of the subject of tuberculosis
prevention and cure is best emphasized in the statement that during
1910 there occurred in the registration area 86,309 deaths from
tuberculosis, of which 73,214, or 84.8 per cent, were deaths from
tuberculosis of the lungs. Since the registration area of the United
States comprehends 58.3 per cent of the total population, the number
of deaths from tuberculosis, for the country as a whole, may be con
servatively estimated at 150,000, and the number of deaths from
tuberculosis of the lungs at 125,000. Assuming, further* that there
are at least five living cases of tuberculosis to every death from
tuberculosis occurring during theyear, thenumber of casesof tubercu
losis in the United States is approximately 750,000. Estimating the
number of wage earners in the United States of ages 15 to 64 years,
inclusive, for the year 1912 at 27,313,160 males and 6,081,223 females,
the proportion of such wage earners to the total population is 28.7
per cent for males and 6.4 per cent for females, respectively. Since
according to the census mortality data of 19001 the mortality rate
from tuberculosis of the lungs among wage earners was 2.37 per
1,000 for males and 1.73 per 1,000 for females, the probable num
ber of deaths from tuberculosis of the lungs among wage earners
in 1912 may be conservatively estimated at 75,250, or, respectively,
xNo later data are at present available.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
19
64,730 males and 10,520 females. The deaths occur chiefly at the pro
ductive period of life when its conservation, from an economic
point of view, should be a matter of most serious concern to the
Nation and the several States. Assuming that there are only 5
cases of tuberculosis of the lungs to every death from the dis
ease, there would be approximately 376,250 cases or patients in the
different stages of the disease, fromthe incipient to the far advanced.
There are, however, sound reasons for believing that the actual
number of cases is much larger, and that a ratio of 10 cases to every
death is, perhaps, not an exaggeration. If that ratio is accepted, the
number of cases of tuberculosis of the lungs among the wage earners
of the United States, ages 15 to 64 years, inclusive, during 1912 would
be 752,500. These estimates take no account of the mortality or
morbidity from other forms of tuberculosis, which may safely be
estimated at not much less than 5 per cent additional.1
For the German Empire it has been estimated that the number of
cases is not less than 1,000,000, and some authorities have placed the
number as high as 1,300,000. This estimate, however, is for the entire
population, while the preceding estimate for the United States has
reference only to the wage-earning element. In this connection it
may also be stated that the average age at death from tuberculosis
of the lungs in the United States during 1910 was 39.4 years for males
and 36 years for females,2 and since at this age the average expecta
tions of life are approximately 27.8 and 31.8 years, respectively, the
potential loss in years of life on the basis of the estimated number of
75,250 deaths of wage earners was 2,135,400 years. The economic
value of a wage earner’s life may be conservatively estimated at $100
per annum as the net gain or contribution toward the national wealth
resulting from products of industrial and other economic activities.
When this estimate is applied to the number of years of curtailed ex
pectation as previously given, the potential economic loss as the re
sult of tuberculosis of the lungs in the United States is $213,540,000.
While this loss is not an actual one in the sense of wealth destruction,
it is a real loss in the sense of curtailed wealth production, which
would unquestionably accrue from a larger population engaged in
gainful occupations, but which is prematurely destroyed in conse
quence of the common prevalence of a strictly preventable disease.
1 See in this connection report of the commission to investigate and report upon a
system of caring for tuberculous patients by State and local authorities made to the
Massachusetts Legislature under date of Nov. 1, 1910. (Senate No. 318, Boston, 1910.)
2 According to an official statement by the Division of Vital Statistics of the United
States Census Office for 1910 the average age at death was 39.4 years for males and 36
years for females and 38 years for both sexes combined.
20
BULLETIN OF THE BUREAU OF LABOR.
ESTIMATED ECONOMIC VALUE OF SANATORIUM TREATMENT IN
GERMANY.
An official German estimate of the economic value of sanatorium
treatment is contained in a report of the imperial board of health on
the statistical experience of public sanatoria for tuberculous patients,
published in 1904.1 In that report it is argued that if of the 90,800
deaths from tuberculosis of the lungs at ages 15 to 60 years occurring
annually inthe German Empire only about one-seventh or one-eighth,
that is, approximately 12,000, could have received systematic and
effective treatment in sanatoria established for that purpose, and if
only about three-fourths of these, or 9,000, could have returned to
their former occupations or industrial activity with a reasonable
degree of their full earning capacity restored, and, that further, if
they could have maintainedthis gain for only three years, and assum
ing finally that the average earnings of wage earners of both sexes
are approximately 500 marks ($ 1 1 9 ), there would have been a gain
of 3 X 5 0 0 X ^ ,0 0 0 , or 13,500,000 marks ($ 3 ,2 1 3 ,0 0 0 ). This gain would
have to be offset by the net expenses of about 40 0 marks ($ 9 5 ) for
each of the 12,000 patients, without reference to interest on the in
vestment in institutions, or approximately 5,000,000 marks ($ 1 ,1 9 0 ,0 0 0 ), or, including interest, estimated at 1,000,000 marks ($ 2 3 8 ,0 0 0 )
more, there would remain as the result of sanatorium treatment a
net oreconomicgainto the German Nation of 7,500,000 marks ($ 1 ,7 8 5 ,0 0 0 ). This estimate does not take into account all the collateral
gains to the patient, his family, and the State resulting from restored
earning capacity and prolonged longevity. Granting that this esti
mate is partly a matter of conjecture, it is entitled to thoughtful
consideration, since it was prepared as early as 1896 by an expert
thoroughly familiar with the facts and was published with the sanc
tion of the imperial health office. More recent estimates of the eco
nomic value of sanatoriumtreatment will subsequently be referred to,
for as the entire system of treatment and care of tuberculous work
men in special sanatoria, maintained at the cost of invalidity insur
ance institutions, rests upon an economic principle, the pecuniary
considerations of gain and loss have not been lost sight of in the
discussions and debates which have been had upon the merits of the
question from a public point of view.
In 1907 an address on the past results of sanatorium treatment was
read before the German National Association for the Prevention of
Tuberculosis, in which address the economic aspects of the disease
were discussed at considerable length.2 The term “ restored earning
1 Deutsche H eilstaetten ftir Lungenkranke. G eschichtliche und statistische M itteilungen. I. B erichterstatter: Dr. Hamel, H ilfsarbeiter im K aiserlicken Gesundheitsamte.
M lt 12 Tafeln. Berlin, Verlag von Julius Springer, 1904, p. 40.
2 Die bisherigen Leistungen der H eilstaetten, yon Bielefeldt, May, 1907.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
21
capacity,” in an economic and legal sense, according to the practice of
German invalidity insurance institutions, it was stated, requires that
the patient must be able to earn at least one-third of his previous
normal wages. The term “ disability ” is one which does not permit
of exact definition, either in German or American law, but it is evi
dent that the meaning is more broad in German experience than
would be the case in English or American insurance practice. If,
therefore, the definition by this authority, which apparently is in
accordance with section 4 of paragraph 5 of the German invalidity
insurance law, applies to the economic results achieved by German
sanatoria for the treatment of tuberculosis of the lungs, it should be
understood throughout this discussion that, unless otherwise stated,
the term “ restored earning capacity” is subject to the limitation as
herein explained.
According to this authority, in 1905 the average amount of a dis
ability annuity was about 160 marks ($38.08) per annum. This
would in five years amount to 800 iparks ($190.40), and to this
period of time most of the investigations of post-discharge results
of sanatorium treatment have been limited.1 In 1905 the aver
age cost per case of treatment and care on account of tuberculosis of
the lungs was 363 marks ($86.39). Assuming that the economic
results of the treatment can be maintained on an average for at least
five years after discharge, there would accrue a net gain to the insti
tution of 437 marks ($104.01) in each case; that is, by deducting the
cost of treatment, 363 marks ($86.39), from the amount which would
be required as a disability annuity for five years of 800 marks
($190.40). Making allowance for the differential duration of sus
tained earning capacity, it is shown that if this duration were for
only four years there would be a net gain to the institution of 277
marks ($65.93); and if for three years, of 117 marks ($27.85). In
the case, however, of patients retaining their earning capacity for
only twoyears the loss would be 43 marks ($10.23). Without enlarg
ing upon the details of the calculations by which the economic gain
and loss was determined it may be stated that it is estimated that for
every 100 patients of the year 1901 discharged as successfully treated
therewas a net saving in disabilityannuitiesof 2,900marks ($690.20).
This figure was applied to the cases discharged during 1897 to 1906,
and for 159,802 patients there was calculated a net gain to the inva
lidity insurance institution of 4,631,300 marks ($1,102,249.40).
It is admitted that objections may be raised against this estimate,
but these are considered in detail, and the conclusion is reached that
the facts warrant the assumption that the estimate of gain is prob
ably under rather than over the actual amount realized. It is stated
1 Under the new regulations o f the Im perial Insurance Office the period o f observation
o f post-discharge results has been extended to six years.
22
BULLETIN OF THE BUBEAU OF LABOB.
that the average mean after-lifetime in the case of tuberculous dis
ability annuitants is only four years for men and six years for
women, or five years for both sexes combined, and that it may be
safely assumed that of the 34 per cent of tuberculous patients main
taining their earning capacity up to the fifth year a considerable
number would retain their earning ability subsequent to that period
of time. It was also argued that vast financial gains must result to
poor-law authorities and decrease the cost of public support of
dependent survivors of those prematurely dying from the disease.
In addition to the financial results which it was claimed would
accrue to the German invalidity insurance institutions from the suc
cessful treatment and care of tuberculous wage earners in special
sanatoria erected for the purpose, it was estimated by Bielefeldt that
upon the assumption of an average daily wage of only 2 marks
(48 cents) (the net gain in wages earned as the result of prolonged
lifetime plus restored partial or complete earning capacity), the
159,802 patients treated and cared for during the period 1897 to
1906 represent for the five years of subsequently observed experience
a gain of 235,000,000 marks ($55,930,000) in wages. It was also
stated that while the cost of such treatment to the insurance institu
tions was 56,000,000 marks ($13,328,000), the gross saving in dis:
ability annuities was 60,500,000 marks ($14,399,000), or a net gain
of 4,500,000 marks ($1,071,000). To this must be added the gain to
poor-law authorities and sick funds and the addition to national
wealth and material well-being, approximately represented by 237,000,000 marks ($56,406,000) in additional wages earned by those
whose wage-earning capacity was restored for an average of at least
five years as the result of systematic and effective treatment and care
in special institutions established for that purpose.
LEGAL PROVISION FOR TREATMENT AND CARE BY INVALIDITY
INSURANCE INSTITUTIONS.
The suggestion that the invalidity insurance institutions should
avail themselves of the favorable opportunities offered by the special
exertions of the sick funds to diminish the mortality and morbidity
from tuberculosis of the lungs in cases in which the insured was
capable of recovery or improvement for the purpose of lessening the
burden of disability annuities originated in the imperial insurance
department. The favorable experience of sanatoria previous to 1899
led to an extensive financial support of the efforts of the insurance
institutions and, according to Bielefeldt, brought about the adoption
in the amended invalidity insurance law of January 1,1900, of para
graphs 18 to 23 and 47, which give legal sanction for the cooperation
of invalidity insurance institutions in the treatment and care of the
tuberculous wage earners insured with them.
CAKE OF TUBEBCULOUS WAGE EABNEBS IN GEBMANY.
23
All limitations concerning the extent or the method of treatment
which might have existed according to the law of 1891 were done
away with, and the invalidity insurance institutions were therefore
permitted to use their own best judgment as to the amounts to be
expended and the time for which they were to regard themselves as
responsible in undertaking cases for the treatment of the disease.1
The insurance institutions were permitted to send the sick persons
to hospitals or sanatoria for consumptives, or to health resorts or to
convalescent homes or to watering places, or even into private care,
and were further permitted to pay the traveling expenses to and from
these places as an essential element of cost in the treatment and care
of tuberculous wage earners insured with them. The treatment may
not be forced upon the members, andthe matter is entirely voluntary,
except in so far that the refusal to undergo such treatment might be
taken into account in the possible subsequent payment of disability
annuities conditioned more or less by optional advantages to the
family of the insured. The address already quoted concluded with
the suggestive statement that—
The conviction may be expressed, after the experience of several
years, that an effective battle against consumption among the work
ing classes would have been all but impossible without the workmen’s
insurance of the German Empire, and by the support of their power
ful pecuniary resources, and with the aid of rational social regula
tions, in the end we are quite certain to be victorious.
NUMBER OF GERMAN WAGE EARNERS RECEIVING SANATORIUM
TREATMENT IN 1910.
In 1910, 46,717 patients received full institutional treatment on
account of tuberculosis of the lungs, or at the rate of 3.19 per 1,000
of the population subject to the German compulsory invalidity insur
ance laws as determined by the occupation census of 1907. The rate
of admission varied considerably from 0.67 per 1,000 for the Invalid
ity Insurance Institution of Mecklenburg, to 6.71 per 1,000 for the
Grand Duchy of Baden and 7.17 per 1,000 for the pension fund of
the imperial railways. The details of admissions for each of the 41
institutions established to carry into effect the provisions of the
invalidity insurance law of 1900 are given in the table which follows:
1 B ielefeldt, The battle against consumption as a sickness o f the people; address at the
British Congress for Tuberculosis, London, 1911.
24
BULLETIN OF THE BUREAU OF LABOR,
NUMBER OF PERSONS RECEIVING TREATMENT ON ACCOUNT OF TUBERCULOSIS
OF THE LUNGS, ACCORDING TO TERRITORIAL INSURANCE INSTITUTION, DURING
1910.
[From Statistik der Heilbehandlung bei den Versicherungsanstalten und zugelassenen
Kasseneinricbtim gen der Invalidenversicherung, p. 168. Published by Behrend & Co.,
Berlin, 1911.]
Persons treated.
Territorial invalidity insurance institutions.
Insured population.
Number.
Per 1,000.
East Prussia....................................................................................
West Prussia...................................................................................
Berlin..............................................................................................
Brandenburg...................................................................................
Pomerania..'!...................................................................................
Posen...............................................................................................
Silesia..............................................................................................
Saxony-Anhalt................................................................................
Schleswig-Holstein..........................................................................
Hanover..........................................................................................
Westphalia......................................................................................
Hesse Nassau...................................................................................
Rhine Province...............................................................................
Upper Bavaria............................. -.................................................
Lower Bavaria................................................................................
Pfalz................................................................................................
Upper Pfalz and Regensburg..........................................................
Upper Franconia.............................................................................
Middle Franconia............................................................................
Lower Franconia and Aschaflenburg..............................................
Swabia and Neuberg.......................................................................
Kingdom of Saxony........................................................................
Wurttemberg...................................................................................
Baden..............................................................................................
Hesse (Grand Duchy).....................................................................
Mecklenburg....................................................................................
Thuringia........................................................................................
Oldenburg.......................................................................................
Brunswick.......................................................................................
Liibeck, Bremen, and Hamburg....................................................
Alsace-Loraine.................................................................................
Prussia-Hesse Railroad Employees.................................................
North German Miners* Fund..........................................................
Saarbrucken Miners* Association....................................................
Bavarian Traffic Employees...........................................................
Saxony Railroad Employees* Fund...............................................
Saxony Miners* Fund.....................................................................
Baden Railroad and Salt Works Fund...........................................
Imperial Railroad Pension Fund....................................................
Bochum Miners* Union...................................................................
Marine Employees* Fund...............................................................
435,571
307,435
649,527
945,939
375,524
351,877
1,224,366
715,914
375,769
665,270
655,380
449,204
1,357,952
322,224
125,677
161,130
89,938
113,668
199,633
102,971
141,418
1,243,992
469,486
439,610
246,735
194,967
345,619
75,897
130,467
376,441
354,555
323,613
117,147
48,036
33,673
29,306
29,275
18,353
17,993
299,838
70,000
412
236
3,961
2,458
264
686
2,727
1,642
540
1,670
3,193
1,980
5,393
1,859
177
555
213
273
941
227
268
2,865
1,759
2,948
1,278
131
1,026
201
396
1, /ol
1,390
1,427
599
72
216
81
30
115
129
596
52
0.95
.77
6.10
2.60
.70
1.95
2.23
2.29
1.44
2.51
4.87
4.41
3.97
5.77
1.41
3.44
2.37
2.40
4.71
2.20
1.90
2.30
3.75
6.71
5.18
.67
2.97
2.65
3.04
4.60
3.92
4.41
5.11
1.50
6.41
2.76
1.02
6.27
7.17
1.99
.74
Total......................................................................................
14,631,093
46,717
3.19
COST OF SANATORIUM TREATMENT OF GERMAN WAGE EARNERS IN
1910.
The cost of treatment and care per person under treatment is here
only briefly referred to, since the facts are more fully discussed in
another section of this report. The cost averaged 374 marks ($89)
per person treated and cared for during 1910, the cost having been
lowest in the case of the Invalidity Insurance Institution of Upper
Bavaria, or 154.74 marks ($36.83), and highest in the case of the
General Miners’ Union of Bochum, or 714.39 marks ($170.02). The
details of the expenditures for each of the 41 institutions are given
in the table which follows:
25
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
COST OP TREATMENT OF PERSONS TREATED ON ACCOUNT OF TUBERCULOSIS OF
THE LUNGS, ACCORDING TO TERRITORIAL INSURANCE INSTITUTION, DURING
1910.
[Prom Statistik der Heilbehandlung bei den Versicherungsanstalten und zugelassenen
Kasseneinrichtungen der Invalidenversicherung, p. 168. Published by Behrend & Co.,
Berlin, 1911.]
Cost of treatment.
Territorial invalidity insurance institutions.
Persons
treated.
Amount.
412
134,035
East Prussia....................................................................................
West Prussia...................................................................................
22,089
Berlin..............................................................................................
465,851
3,961
Brandenburg...................................................................................
2,458
245,736
264
25,334
Pomerania. „T..................................................................................
Posen..............................................................................................
61,640
686
Silesia..............................................................................................
2,727
263,649
Saxony-Anhalt...............................................................................
1,642
153,507
Schleswig-Holstein..........................................................................
540
34,731
133,369
Hanover..........................................................................................
1,670
199,541
3,193
Westphalia......................................................................................
156,787
Hesse Nassau..................................................................................
1,980
463,142
5,393
Rhine Province...............................................................................
68,463
Upper Bavaria................................................................................
1,859
13,613
Lower Bavaria................................................................................
177
47,838
Pfalz................................................................................................
555
14,528
Upper Pfalz and Regensburg.........................................................
213
22,633
Upper Franconia............................................................................
273
941
78,645
Middle Franconia............................................................................
23,014
Lower Franconia and Aschaffenburg.............................................
227
21,791
Swabia and Neuberg......................................................................
268
275,840
Kingdom of Saxony........................................................................
2,865
W urttemberg..................................................................................
160,969
1,759
269,181
Baden..............................................................................................
2,948
109,666
1,278
Hesse (Grand Duchy)....................................................................
11,889
Mecklenburg...................................................................................
131
74,188
Thuringia........................................................................................
1,026
19,833
Oldenburg.......................................................................................
201
24,051
Brunswick......................................................................................
396
165,805
Liibeck, Bremen, and Hamburg....................................................
1,731
120,569
1,390
Alsace-Lorraine...............................................................................
143,159
Prussia-Hesse Railroad Employees...............................................
1,427
53,449
599
North German Miners’ Fund.........................................................
3,691
Saarbrucken Miners’ Association...................................................
72
25,852
Bavarian Traffic Employees...........................................................
216
11,298
81
Saxony Railroad Employees’ Fund..............................................
2,858
Saxony Miners’ Fund....................................................................
30
15,724
115
Baden Railroad and Salt Works Fund...........................................
12,202
Imperial Railroad Pension Fund...................................................
129
101,335
Bochum Miners’ Union.................................................................
596
7,061
52
Marine Employees’ Fund..............................................................
Total......................................................................................
46,717
4,158,555
Per
person
treated.
$82.61
93.60
236
117.61
99.97
95.96
89.85
96.68
93.49
64.32
79.86
62.49
79.18
85.88
36.83
76.91
86.19
68.20
82.90
83.58
101.38
81.31
96.28
91.51
91.31
85.81
90.76
72.31
98.67
60.74
95.79
86.74
100.32
89.23
51.26
119.69
139.48
95.26
136.73
94.59
170.02
135.78
89.02
The total amount expended for treatment and care of tuberculous
wage earners in the German Empire during 1910 in special sanatoria
erected for the purpose was 17,472,920 marks ($4,158,555). In addi
tion to this amount large expenditures have been incurred in methods
of prevention and in a systematic national campaign against tubercu
losis, which has had the active cooperation of insurance institutions
and of the governing authorities of the Empire and of the several
States, principalities, municipalities, and communes. The amount
expended on account of tuberculosis prevention in the United States
in 1909, according to the assistant secretary of the National Associa
tion for the Study and Prevention of Tuberculosis, was $8,025,000, of
which 53.5 per cent was from public funds. In 1910 the amount was
26
B U LLETIN OF TH E BUREAU OF LABOR.
$14,740,000, of which 62.6 per cent was from public funds, and in
1911 the amount expended was $14,450,000, of which 66.2 per cent
was derived frompublic revenues. It is extremely suggestive that the
amount expended through associated effort in the United States in
the campaign against tuberculosis shouldhave progressively decreased
from $975,000 in 1909 to $500,000 in 1911; that the amount expended
on account of miscellaneous tuberculosis work should have decreased
from $1,800,000 in 1910 to $1,300,000 in 1911, and that the amount
expended on account of tuberculosis dispensaries, which constitute
one of the most effective aids in the campaign against the disease,
should have decreased from $890,000 in 1910 to $850,000 in 1911. It
may further be stated that the amount expended on account of
sanatoria in the United States increased from $11,300,000 in 1910 to
only $11,800,000 in 1911, but how much of this expenditure was for
the benefit of tuberculous wage earners is not a matter of record.1 i
The progressive increase in the amounts expended by German
invalidity insurance institutions indicates that the German effort to
control and slowly eradicate the disease rests upon a more secure
foundation. In part this result is to be ascribed to the financial
interest which German invalidity insurance institutions have in the
actual reduction in the mortality and morbidity from tuberculosis,
as well as in the cure of patients wrhose invalidity would entail a con
siderable economic burden upon the institutions, aside fromthe addi
tional, cost of support for dependent widows and orphans, either
through the invalidity insurance institutions or public and private
poor relief. The importance of the economic aspects of the subject
warrants a somewhat more extended statement of the views and con
clusions of recognized German authorities on the subject.
RESTORATION OF EARNING CAPACITY OF WAGE EARNERS RESULTING
FROM SANATORIUM TREATMENT.
In an important statistical study of the results of sanatorium
treatment for tuberculosis of the lungs, by Dr. Otto Baer,2based on
the experience of 22 sanatoria, with 8,568 patients, it was ascertained
that 3,932, or 45.9 per cent, were in the first stage of the disease;
2,904, or 33.9 per cent, were in the second stage; and 1,732, or 20.2
per cent, were in the third stage. It was pointed out that the results
must depend largely upon the condition of the patients on admission,
and that, of course, if the proportion of patients in the advanced
stages of the disease is too large the results could not possibly be
satisfactory. On discharge 3,850, or 44.9 per cent, had their earning
capacity fully restored; 3,760, or 43.9 per cent, had their capacity
1 The Survey, Jan. 20, 1912.
2 Statistische Beitraege zur Beurteilung des Wertes der Heilstaettebehandlung bei Lungentuberkulose, von Dr. Otto Baer. Bucbdruckerei Hermann & Otto Hallanzy, Zweibruecken, 1909.
,
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
27
partly restored; and only 958, or 11.2 per cent, were entirely unsuc
cessful cases. Taking the patients admitted in the third stage o f the
disease only, the results were naturally much less satisfactory, and
only 5.2 per cent were discharged with their earning capacity fully
restored; 46.6 per cent with their earning capacity partly restored;
and 30 per cent were entirely unsuccessful cases. Even to this extent,
however, it would seem that the results o f the treatment were not
disproportionate to the probable expense.
The same writer found that out o f 2,255 patients admitted to the
sanatoria at Belzig during the period 1900 to 1906, 13.1 per cent
had been discharged as cured; 61.7 per cent as im proved; 19.3 per
cent as unchanged; 5 per cent as worse, and 0.9 per cent as having
died. In the experience o f the sanatoria at Marienheim 57 women'
patients had been under observation for nine years, and o f these
78.9 per cent were still in fu ll possession o f their earning capacity,,
19 per cent were partly able to earn their living, and only 1.8 per1
cent were entirely incapacitated.
An analysis o f 1,668 cases o f tuberculosis patients reexamined after
they had been two years discharged from the sanatorium at Holsterhausen-Werden-by-Essen, in the Rhine Province,1 where they were
treated, showed that 61.2 per cent were still in possession o f their
full earning capacity, 17.5 per cent retained a partial capacity for
work, 7.1 per cent were unable to work, and 14.2 per cent had died.
O f 879 patients controlled or supervised* for four years and re
examined, 53.5 per cent had retained their full earning capacity,
14.2 per cent had retained a partial earning capacity, 7.1 per cent
were unable to work, and 25.2 per cent had died. These percentages,
however, must be accepted with some caution, in that they appar
ently do not have reference to the original numbers discharged, but
to the numbers fo r which the inform ation could be secured. It is to be
assumed, however, that the number o f cases for which no inform a
tion could be obtained was relatively small. In the opinion o f this
authority the results achieved had exceeded the expectations, but the
effort would have been hopeless but for the financial and general
cooperation on the part o f the invalidity insurance institutions.
The same writer estimates the number o f tuberculous patients in
the German Empire at 800,000, for which, o f course, the means do
not exist to afford to each sufferer effective treatment in a sanatorium
especially established for the purpose. Assuming for the present
discussion that the number o f such patients is as stated, the 46,717
patients provided with treatment during 1910 constituted 5.8 per
cent o f the total number o f tuberculous patients in the German Em
pire, exclusive o f the patients afflicted with tuberculosis other than
1Die Lungenheilst&tten im Lichte der historischen Entwicklung der Tuberkulose-Bek&mpfung yon Chefarzt Dr. F. Kohler, Heilst&tte-Holsterhausen-Werden bei Essen (Ruhr).
B U LLETIN OF TH E BUREAU OF LABOR*
28
tuberculosis of the lungs and larynx. Of course, the German cam
paign against tuberculosis comprehends a vast .organization sub
sidiary to the sanatorium treatment and care of tuberculous wage
earners at the expense of the invalidity insurance institutions.
In discussing the statistical data o f sanatorium treatment as subse
quently considered in detail, the German Central Committee empha
sizes especially the remarkable results obtained for employees through
sanatorium treatment in behalf o f the members o f the pension fund
o f the Prussian-Hessian railways.1 The general data o f this fund for
each year, 1904 to 1910, are given in tabular form as follow s:
TREATMENT AND CARE, ON ACCOUNT OF TUBERCULOSIS OF THE LUNGS, OF
MEMBERS OF THE PRUSSIAN-HESSIAN RAILWAYS PENSION FUND, BY YEARS,
1904 TO 1910.
Patients
treated on Rate per Cost of treatment
Average
account of
and care (includ
1,000
membership. tubercu members.
ing family sup
losis of the
port).
lungs.
Years.
1904 ......................................................................
1905........................................................................
1906........................................................................
1907........................................................................
1908........................................................................
1909........................................................................
1910........................................................................
256,934
272,478
292.435
324,241
327.436
314,268
319,694
716
810
1,180
955
1,152
1,268
1,422
2.79
2.97
4.04
2.95
3.52
4.04
4.45
$92,571.36
116,635.92
132,818.56
111,556.55
124,586.08
132,980.42
143,145.99
The experience o f the fund since 1904 is given in detail in the fo l
low ing table, with the statistics for 1905 carried forward to 1910:
ECONOMIC RESULTS OF SANATORIUM TREATMENT FOR TUBERCULOSIS OF
THE LUNGS, OF EMPLOYEES OF THE PRUSSIAN-HESSIAN RAILWAYS SYS
TEM, BY YEARS, 1904 TO 1910.
Years.
1904.................
1905.................
1906.................
1907.................
1908.................
1909.................
1910.................
i,
Patients fully able to work after—
Number
of pa
tients un
lyear.
2 years.
3 years.
4 years.
5 years.
6 years.
der full
treat
ment. Num Per Num Per Num Per Num Per Num Per Num Per
ber. cent. ber. cent. ber. cent. ber. cent. ber. cent. ber. cent.
716
810
1,180
955
1,152
1,268
1,422
585
691
1,013
775
951
1,095
1,221
81.7
85.3
85.8
81.0
82.6
86.4
85.9
534
621
921
697
869
917
74.6
76.7
78.1
73.0
75.4
72.3
477
582
861
658
866
66.6
71.9
73.0
68.9
75.2
451
552
824
626
63.0
68.2
69.8
65.6
427 59.6
528 65.2
815 69.0
519
64.0
The importance of concentrating the treatment upon patients in
the second stage of„the disease is emphasized by the physician in
charge of the Muellrose Sanitarium,2in the belief that patients in the
1 Annual report for 1911, p. 20.
2 Das Krankenmaterial und die therapeutischen Leistungen der Lungenheilstaetten,
von Dr. H. Ulrici, Chefarzt der Heilstaette Muellrose. Reichs-Medizinal-Anzeiger, Jahrg.
1910 (Sonderabdruck).
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
29
first stage could, to advantage, be taken care o f in less expensive and
less highly specialized institutions. F or these he recommended con
valescing homes or forest camps, except in the case o f patients in the
first stage with fever and who have bacilli in the sputum; such, o f
course, should be treated in a sanatorium. A further recommenda
tion was made that all such patients should continue under medical
observation fo r at least one year.
The hope was held out that the results o f sanatorium treatment
may be further improved and that it may safely be expected that at
least in 70 per cent o f the cases the earning capacity o f the patients
can be restored for a reasonable period o f time. The actual cost o f
515 marks ($122.57) per case o f successful treatment, including the
expense o f the unsuccessful cases, was considered as fu lly justified
by the results.
According to the experience o f Dr. W eicker, o f Gobersdorf,1 pub
lished in 1905, on the basis o f 3,299 cases treated in his institution
during the period 1895 to 1900, the conclusion seemed warranted that
cases in the incipient stage o f the disease did not necessarily produce
the best results. The statement is made that even fairly advanced
cases gave promise o f successful results, provided the treatment was
effected under otherwise satisfactory conditions. According to this
authority, o f those discharged from his institution, who, on admis
sion, were in the second Turban stage o f the disease, there were, after
three years, still 51 per cent in full possession o f their earning ca
pacity, and after four years 50.9 per cent; even o f those admitted in
the third stage o f the disease after four years there were still 17.8
per cent able to work.
The fact that the results o f treatment had gradually improved and
that successful cures, with a complete restoration o f earning capacity,
had been obtained among patients even in the third or far advanced
stage o f the disease was emphasized in 1901 by the director o f the
Friederichsheim Sanatorium.2 He stated that, as a rule, incapacity
fo r work fo r a more or less extensive period o f time precedes the
admission o f patients in the second and third stages o f the disease,
leaving the question open whether such economic disability was very
much less frequent among patients in the first Turban stage o f the
disease.3 O f all the patients treated, 42.6 per cent were in the first
stage, 21*6 per cent in the second stage, and 36.1 per cent in the third
stage.4 Evidently a disproportionately large number were in the
1Beitraege zur Frage der Volksheilstaetten, yon Dr. Weicker, Gorbersdorf. Berlin,
1905; Verlag: Medizinischer Verlag.
2Beitrag zur Bewertung der Heilstaettebehandlung Lungenkranker, von Direktor Dr.
E. Rumpf, Heilstaette Friederichsheim, Separatabdruck aus der Muenchener medizinischen
Wochenschrift, No. 38. 1904.
8 For classification of stages of tuberculosis, see p. 83.
4 These are the percentages given in the original report
Since they add to 100.3, there
Is apparently an error, but it is not of material importance.
30
BU LLETIN OF TH E BUREAU OF LABOR.
third or far advanced stage o f the disease. According to the analysis
o f the patients in the first stage o f the disease, there were after four
years still 70 per cent in possession o f their earning capacity, while
the corresponding proportion o f the patients who had died in the
third stage o f the disease was 63 per cent. In other words, nearly
as large a proportion o f those admitted in the third stage o f the dis
ease for treatment had died as were still at work after four years o f
those admitted in the first stage o f the disease. The proportion
retaining their earning capacity admitted in the second stage o f the
disease was 55 per cent and in the third stage 23 per cent. These
results, it is declared, furnish conclusive evidence that the treatment
and care o f tuberculous wage earners in sanatoria must be considered
a success, and the rule is laid down, on the basis o f actual experience,
that it may safely be expected that o f the patients admitted in the
first Turban stage o f the disease three-fourths, and o f those in the
second stage over one-half, and o f those in the third stage at least
one-fourth w ill retain their earning capacity for from three to four
fu ll years after their discharge and to this extent relieve the inva
lidity insurance institutions from the payment o f disability annuities.
In an extended discussion on the importance o f sanatoria in the
warfare against tuberculosis as a wage earners’ disease, one medical
authority1 considers the entire available material and comes to the
conclusion that the economic results in the case o f patients admitted
in the first stage o f the disease may be placed at 72 per cent, in the
second stage at 57 per cent, and in the third stage at 22 per cent;
but in the event that the tuberculin method is employed the results
are materially improved, with respectively 95 per cent for patients
in the first stage, 82 per cent fo r the second stage, and 50 per cent
fo r the third stage. The opinion is emphatically expressed that the
results o f sanatorium treatment, from an economic point o f view,
have fu lly justified the large expenditures incurred and that the oppo
site conclusions o f Cornet are disproved by the facts o f actual and ex
tensive experience. W ith regard to the cost o f treatment the author
points out that the average expense per bed per day may be placed
at from 5 to 7 marks ($1.19 to $1.67), and that the average expense
per day for board and treatment may be placed at 3 marks 50 pfennigs
to 4 marks ($0.83 to $0.95). Large institutions are not favored, but
sanatoria with from 100 to 150 beds are preferred. It is pointed out
that during 23 years the m ortality from tuberculosis in the German
Em pire has been decreased about 50 per cent, and that this result, in
part at least, has been through the systematic and effective treatment
o f patients in special sanatoria. However, the necessity for munici
i Die Bedeutung der deutschen Lungenheilst&tten fuer die Bekampfung der Tuberkulose als Volkskrankheit, von Dr. med. Fr. ScMrmann, Stadtassistenzarzt, Dusseldorf.
Sonderabdruck aus der Vierteljahrsschrift fuer gerichtl. Medizin und oeffentliches
Sanitatswesen 3. Folge. XLI. 1.
CAKE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
31
pal and rural dispensaries, as well as day camps and other institutions
for the treatment o f cases not suitable for sanatoria, is emphasized.
In conclusion, suggestion is made as to the importance o f providing
suitable employment for discharged patients, and the official notifica
tion o f cases o f tuberculosis is regarded as absolutely essential.
The annual report o f the German Central Committee fo r 1911 di
rects especial attention to the results obtained by the Hanseatic
League, which is the invalidity insurance institution established for
the free cities o f Hamburg, Bremen, and Liibeck. According to this
experience, o f the male patients under treatment during the period
1895 to 1901 for a longer period than four weeks, there were at the
end o f 1910, o f those admitted in the first stage o f the disease, 63 per
cent in fu ll possession o f their earning capacity; in the second stage,
52 per cent; and in the third stage, 22 per cent. The corresponding
per cents for women were 66 for the first stage, 66 for the second
stage, and 26 for the third stage. In addition thereto a fairly large
proportion had retained a limited earning capacity. O f the male
patients in the first stage, 25 per cent had died; in the second stage,
31 per cent; and in the third stage, 65 per cent. The corresponding
percentages fo r the female patients were 11 for the first stage, 12
for the second stage, and 59 for the third stage.
In an address before the International Congress on Social Insur
ance, held in Vienna in 1905,1 the statement was made that o f 100
tuberculous male annuitants in the experience o f German invalidity
insurance institutions, at ages 25 to 29, there survived after one year
only 17 and after four years only 4, so that in all probability the
maximum duration o f the disease in moderately advanced cases
entitling the insured to a disability annuity would be less than five
years. In contrast, it was pointed out that o f every 100 nontuberculous disability annuitants, ages 25 to 29, there were, after one
year, still 69 in receipt o f their annuities, proving the much more
serious and fatal character o f tuberculosis o f the lungs when con
trasted with other diseases considered as a group.
In this connection it may be stated that out o f 366,327 disability
annuitants under observation during the period 1891 to 1899, only
5,474 had been discontinued up to 1903 as recipients o f annuities on
account o f the recovery o f their earning capacity.2 In other words,
when once a disability annuity is granted it is a question o f remote
contingency whether the same w ill be discontinued within a reason
able period o f time on account o f restored earning capacity. This,
o f course, in German experience, may be due to the fact that such
annuities are granted only when the disease causing the disability has
1 Invalidenversicherung und Volksgesundheit (Heilverfahren), von. Bielefeldt. Internationaler Arbeiterversicherungs-Kongress, 17. bis. 23. September. Wien, 1905.
2 Amtliche Nachrichten des Reichsversicherungsamts, 1906, I Beiheft, pp. viii and ix.
32
BU LLETIN OF TH E BUREAU OF LABOR.
been determined to be o f a sufficiently serious nature, and it requires
to be said that no such annuities are granted until after the sick
ness has continued 26 weeks, during which time the sick funds are
responsible fo r the maintenance and medical care o f the insured.
COMPARATIVE RESULTS OF INSTITUTIONAL AND NONINSTITUTIONAL
TREATMENT.
An attempt has been made to determine the comparative results
o f tuberculous patients treated in sanatoria and tuberculous patients
treated in their homes. From a study o f the sickness records o f the
Leipzig Communal Sick Fund, o f 188 tuberculous male patients ob
served during the period 1890 to 1893, when no sanatorium treat
ment had been in use, it was ascertained that after three years 74
per cent had died; after four years, 88 per cent; and after five years,
93 per cent.1 Granting objections to the absolute accuracy o f the
data and admitting the probably serious or advanced condition o f
the patients, the facts themselves can not be set aside as irrelevant
or inconclusive.
A special inquiry,2 however, was made with regard to 502 pa
tients— constituting 4.6 per cent o f all the tuberculous patients under
consideration by the Invalidity Insurance Institution o f the Hanse
Towns in 1901—who had been for various reasons rejected or con
sidered unsuitable fo r treatment. These patients were carefully ob
served and reexamined from time to time, and it was ascertained in
1907—that is, after six years—that 41.8 per cent were drawing dis
ability annuities, 30.3 per cent had died, and only 18.5 per cent were
at work and still members o f the insurance institution. Bielefeldt
compares these results with 715 tuberculous members, who, in 1900,
upon their own application, had been treated and cared for in the
sanatoria o f the Invalidity Insurance Institution o f the Hanse
Towns. B y 1905—that is, after six years—only 11 per cent o f these
patients were drawing disability annuities and only 18 per cent had
died, leaving 49.9 per cent in possession o f their fu ll earning capacity
and 15.4 per cent without a serious impairment o f their earning
capacity, or 65.3 per cent o f the patients after six years were not
drawing any disability annuities on account o f the disease fo r which
they had been successfully treated in the sanatoria provided for that
purpose. According to Bielefeldt’s special investigations, after six
years, o f those who had not been treated and cared for in sana
toria, 72 per cent had died, against 29 per cent o f those who had
been treated and cared fo r in sanatoria during the same period o f
time. There was therefore a substantial saving in life and in earning
capacity which may safely be considered conclusive evidence o f the
1 Die bisherigen Leistungen der Heilstatten by von Bielefeldt.
2 Transactions German Central Committee, Berlin, May 23, 1907.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
33
social and economic value o f systematic and effective treatment o f
tuberculous wage earners in special institutions provided for that
purpose.
COMPARATIVE RESULTS OF HOSPITAL AND SANATORIUM TREATMENT.
An examination was made by B aer1 into the point raised by
Cornet, that similar results could have been secured in ordinary hos
pital practice. Making a comparison between the data o f hospital
treatment furnished by De la Camp o f the patients admitted in 1895,
only 28 per cent were in possession o f their earning capacity in 1899;
but according to the data furnished by Seiche for tuberculous pa
tients treated in sanatoria, 80 per cent o f those admitted in 1895 were
still able to earn their living in 1899. Similar results in favor o f
sanatorium treatment, from an economic point o f view, are given for
subsequent years, so that the contention by Comet* may be consid
ered as having been conclusively disproved. Burckhardt, among
others, is quoted in the statement that—
It is self-evident that the results o f sanatorium treatment are de
cidedly more satisfactory than those secured by other methods o f
treatment for tuberculosis o f the lungs, but particularly in two direc-.
tions, i. e., the death rate is less and the duration o f continued earning
capacity is much longer.
A table derived from the data o f hospital treatment furnished by
Stadler and the sanatorium statistics furnished by W alther, compar
ing the subsequent mortality o f 100 patients, is given below :
COMPARATIVE MORTALITY IN HOSPITALS AND SANATORIA OF PATIENTS TREATED
FOR TUBERCULOSIS OF THE LUNGS.
Percentageofmortality.
Duration.
After 1 year______- ______
After 2 years......... ............
After 3 years......................
After 4 years......................
Hospital Sanatorium
treatment treatment
(Stadler). (Walther).
4.8
18.3
27.3
33.0
4.2
10.7
15.8
18.7
Percentage ofmortality.
Duration.
After 5 years....................
After 6 years....................
After 7 years....................
Hospital Sanatorium
treatment treatment
(Stadler). (Walther).
40.3
45.9
55.8
20.2
21.5
23.0
The foregoing comparison seems to show conclusively the decided
advantage o f sanatorium over hospital treatment for tuberculosis
o f the lungs in so far as a material reduction in the death rate is con
cerned. Stadler estimates that by means o f sanatorium treatment it
is possible to secure at least an average duration o f subsequent earning
capacity o f five years; and Baer states that the average annual mor
tality rate may be assumed to be 5 per cent. These, o f course, are
1 Statistical Contributions to the Tuberculosis Question, by Dr. Otto Baer. Zweibriieken,
1909.
49397°— 12----- 3
34
BU LLETIN OF TH E BUREAU OF LABOR.
very much better than the corresponding results secured by the usual
methods o f hospital treatment for tuberculosis o f the lungs. Baer
sums up his conclusions as follow s: The sanatorium treatment un
questionably has been a success, but preference in the admission o f
patients should, o f course, be given to those who are in the first and
second stages o f the disease. Patients in the third stage, with only
one lung involved, may be admitted with the reasonable expectation
that a fairly large proportion o f successful results w ill be secured.
Special attention is necessary in the case o f patients who are treated
at home on account o f the liability to infect other members o f the
fam ily. The duration o f treatment may safely be diminished in the
case o f patients in the first stage o f the disease, but the duration
should be adjusted to the particular circumstances and no hard and
fast rule should be adopted. Patients in the third stage o f the disease
should be treated in small hospitals or small special institutions to
avoid the discouraging surroundings resulting from a large number
o f cases o f incurables.
ORGANIZATION AND ACTIVITIES OF THE GERMAN CENTRAL COM
MITTEE FOR THE PREVENTION OF TUBERCULOSIS.
The foregoing brief account has been lim ited to the general aspects
o f the tuberculosis problem in Germany so far as the prevalence o f
the disease is a question o f public concern, with special reference to
the financial burdens resulting therefrom to the invalidity insurance
institutions. In addition thereto, o f course, a vast amount o f effort
exists in connection with the administrative control o f tuberculosis,
and numerous philanthropic and other institutional efforts are being
made to reduce the liability to the disease by various methods, which
are more or less the same throughout the civilized world. The ac
count would not be complete, however, without at least a brief ex
planation o f the activity o f the German Central Committee for the
Prevention o f Tuberculosis,1 which has been in active operation
since 1896.
Am ong other subjects discussed in the annual report o f the com
mittee are the questions o f fam ily support during the treatment o f a
patient and the care o f the patient after discharge from the sana
torium ; the importance o f supplementary treatment is recognized,
and the establishment o f convalescing homes and day and night
camps is advised to a much larger extent than is at present the case,
although much progress has been made in this direction during recent
years. It is pointed out that in all such cases it is o f the utmost im
portance that the patient, after discharge, shall continue the sanitary,
wholesome, and otherwise healthful mode o f life acquired while in the*
*Der Stand der Tuberkulose-Bekaempfung im Fruehjahre 1911, yon Prof. Dr. Nietner,
Generalsekretaer des Zentral-Komitees. Berlin, 1911.
CARE OP TUBERCULOUS WAGE EARNERS IN GERM ANY.
35
sanatorium, and this, o f course, to a certain extent necessitates med
ical and other supervision for a reasonable period o f time after dis
charge. It is properly pointed out that it serves no real economic
purpose to provide adequate treatment and care in special insti
tutions i f after discharge through lack o f proper care a relapse
occurs. It is therefore suggested that the term “ able to work ” be
construed with more caution, and that as far as practicable tuber
culous patients discharged from public sanatoria should be provided
with work suitable to their condition as a reasonable safeguard
against a relapse.
In conclusion, the prevention o f the disease is enlarged upon and
the duty o f intelligent public education in the essential factors o f
the problem is emphasized, with particular reference to tuberculosis
exhibits. It is pointed out that tuberculosis is largely a social disease
and most intimately related to housing and living conditions. It is
stated also in this connection that much is being done by German in
validity insurance institutions to bring about better housing conditions
fo r the wage-earning population, and that up to December 31, 1911,
the immense sum o f 318,016,000 marks ($75,687,808) had been loaned
fo r building purposes at rates o f interest not exceeding 3.5 per cent.1
DISPENSARIES AND INFORMATION BUREAUS.
In the report for 1911 emphasis is laid upon the imperative neces
sity for more tuberculosis dispensaries, including information bureaus,
which are now considered as absolutely essential in the active warfare
against the disease. A special commission was authorized to promote
efforts in this direction and to collect all necessary inform ation having
reference thereto. W ith regard to organization, the question was
debated as to the sources from which income should be derived, and
the best means o f securing the cooperation o f physicians, nurses, etc.,
as well as all other public and private institutions having an active
interest in welfare work. The specific objects o f dispensaries o f this
kind were stated to be (1) competent advice to and provision for the
care o f tuberculous patients; (2 ) competent medical examination o f
members o f the patients’ fam ilies; (3) education and instruction with
regard to the risk o f infection, the conditions o f work in their rela
tion to the disease, etc.; (4) the collection o f the sputum; (5) the sani
tary handling o f the patients’ laundry; (6) the effective isolation o f
the patient in the hom e; (7) the disinfection o f homes infected by
tuberculous patients; and (8) material or pecuniary assistance. In
addition thereto the commission considered the best method o f utiliz
ing the scientific material obtained through establishments o f this
kind.
On January 1,1911, the committee had a membership o f 1,501 per
sons, and its income during 1910 was derived from 39,877 marks
1 Amtliche Nachrichten des Reichsversicherungsamts, No. 3, p. 529. Berlin, 1912.
36
B U LLETIN OF TH E BUBEAU OE LABOR.
($9,491.76) in membership fees, an imperial subsidy o f 60,000 marks
($14,280), a g ift o f 15,000 marks ($3,570) from the Association for
W elfare Stamps, and 16,245 marks ($3,866) from other sources. It
had on hand on January 1, 1911, funds to the amount o f 370,349
marks ($88,143.06), and it made during the year the follow ing dis
bursements: The sum o f 177,300 marks ($42,197.40) was paid out on
account o f financial aid to sanatoria and other tuberculosis institu
tions; 30,000 marks ($7,140) was expended on account o f lupus
treatment; 33,317 marks ($7,929.45) fo r tuberculosis exhibits; 29,081
marks ($6,921.28) on account o f administrative expenses; and the
remainder for printing, meetings, exhibits, traveling, etc.
TREATMENT AND CARE OE TUBERCULOUS CHILDREN.
The treatment and care o f tuberculous children is brought forward
as a rather new but most important question in the administrative
control o f tuberculosis, and startling evidence has been adduced to
show that the disease is usually contracted in childhood but remains
latent until early adolescence, when, under favorable conditions, the
disease becomes active in an acute or chronic form , as the case may
be. This, however, is a medical rather than an economic question,
but it may be said that the imperative need o f adequate medical
inspection o f school children and the equally important medical
supervision o f children and young persons at work are recognized as
necessary steps toward the gradual reduction and eradication o f the
disease. Special emphasis, however, is placed upon the duty o f
employers to provide more satisfactory working conditions, par
ticularly with regard to the prevention o f industrial dust. In addi
tion to all o f the foregoing, attention is directed to the importance
o f personal hygiene and o f outdoor exercise and light manual labor
in gardens and on farms, to the prevention o f infection in convey
ances used for purposes o f public transportation, to the prevention
o f spitting in public places, and to the intimate relation o f tubercu
losis to abuse o f alcoholic drinks.
PRESENT STATUS OF AGENCIES FOR PREVENTION AND CURE OF
TUBERCULOSIS.
SANATORIA.
Summarizing the status o f tuberculosis prevention and cure in the
German Empire in the spring o f 1911, it is stated that there were
then in Germany 99 public sanatoria and three other institutions for
tuberculous patients in the various stages o f the disease. These 102
institutions provided 6,706 beds for male patients and 4,301 for female
patients, and 1,058 beds for both male patients and female patients, a
total o f 12,065 beds. In addition thereto 34 private sanatoria pro
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
37
vided 2,121 beds, or a total o f 14,186 beds for adult curable tuber
culous patients. Therefore, on the basis o f an average length o f
stay o f three months, the bed accommodation provides for 56,700
patients. F or tuberculous children there are now 22 sanatoria, with
1,000 beds; and in 86 institutions, with 8,122 beds, provision is made
for tuberculous and scrofulous children, chiefly, however, during the
summer months.
FOREST HOMES AND AGRICULTURAL COLONIES.
There are 99 forest convalescing homes or camps, chiefly open
during the daytime, but in some cases also for night accommodation
during the summer months. A very small number remain open
during the winter months. In some o f the forest homes provision is
made for-the education o f tuberculous children receiving treatment
therein. The number o f such forest schools, in which a fu ll course
is provided, is at the present time 15. The number o f agricultural
colonies remains rather small, the experiment not having been found
entirely satisfactory. Convalescing homes exist for tuberculous per
sons, in addition to persons suffering from pther causes, but the
number o f such is not stated. For a careful selection o f patients
preliminary to admission to sanatoria, 34 observation stations or
special dispensaries have been established.
HOMES AND INSTITUTIONS FOR ADVANCED CASES.
F or tuberculous patients in the advanced stage o f the disease there
are 144 invalidity homes or asylums, or special sections in general
hospitals. Institutions o f this kind, however, have not met with much
favor among wage earners, who, in the advanced stage o f the disease,
prefer to remain with their families. On account o f this fact it has
been found necessary to concentrate recent efforts upon the further
establishment o f tuberculosis dispensaries, clinics, and information
bureaus, o f which there are now 525, exclusive o f 537 tuberculosis
associations in the Grand Duchy o f Baden, which exercise somewhat
similar functions. There are also 20 polyclinics, which provide
much the same accommodation and treatment as tuberculosis dis
pensaries, the chief point o f difference being that these institutions
also provide fo r other patients and only in rare cases fo r the ma
terial needs o f the patients5 families.
CONCLUSIONS IN REGARD TO WORK OF GERMAN CENTRAL COMMITTEE.
The activities o f the German Central Committee are so extensive
and varied that the foregoing account portrays but inadequately the
work which is done through its organization in the warfare in the
German Empire against tuberculosis, chiefly among the wage earners.
38
B U LLETIN OP T H E BUBEAU OF LABOR.
The organization has the active and intelligent cooperation o f the
numerous official bodies and authorities charged with public health
or police functions, as well as a large number o f philanthropic and
other organizations engaged in similar efforts, though, o f course, on
a lesser scale than the central committee itself. Foremost among
the public authorities engaged in the active warfare against tuber
culosis are the imperial board o f health and the health authorities
o f the principal States and o f the larger cities and communes. It
may be said, in conclusion, that the Empire itself contributes annu
ally 100,000 marks ($23,800) toward the campaign against tuber
culosis, and that o f this sum 60,000 marks ($14,280) is paid to the
German Central Committee. It is evident, therefore, that the
administrative control o f the disease o f tuberculosis has been intelli
gently coordinated to the nation-wide effort to reduce, for humane,
social, and economic reasons, the m ortality and m orbidity to a mini
mum. It is further made evident by the statistical account o f
tuberculosis frequency in the German Empire that these efforts have
been quite successful. Finally, it is shown by the experience data o f
German invalidity insurance institutions that the expenditures in
curred in the systematic and effective treatment o f the disease have
been justified by the economic results secured. T o the extent that
this has been the case the material welfare o f the German Em pire
in general, and its wage-earning population in particular, has been
substantially advanced during the last two decades, and probably
more so in this respect than in any otjier country in the world.
TREATMENT OF TUBERCULOUS WAGE EARNERS IN PUBLIC INSTITU
TIONS, 1896 TO 1901.
In 1908 the German Im perial Board o f Health published a com
prehensive report on the results o f institutional treatment for tuber
culosis, derived from the experience o f 21 large public sanatoria
and 12 small institutions. In addition, the investigation included
the experience o f 2 large and 3 small private institutions fo r the
treatment and cure o f tuberculosis. The data, derived from the
experience o f the years 1896 to 1901, represented 15,869 male and
4,008 female patients in public sanatoria and 833 males and 469
female patients in private sanatoria. The method o f inquiry was by
means o f special cards provided by the imperial board o f health,
one being provided fo r each patient under systematic treatment and
care, excluding all those who had undergone less than six weeks’
treatment in sanatoria. A further exclusion was made o f those pa
tients in whom tuberculosis was only suspected, the investigation be
ing limited to patients in whom the disease had been objectively
established either by bacteriological or clinical methods or by means
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
39
o f the tuberculin test. Since the patients in private institutions were
only to a lim ited extent o f the wage-earning class, and comparatively
few in number, it would serve no useful purpose to consider the
same in the present investigation, and the follow ing discussion is
therefore limited to patients in public institutions, chiefly such as
were maintained by German invalidity insurance institutions.
HOW COST OP TREATMENT IS PROVIDED POR.
In the case o f patients in public sanatoria, the cost o f treatment
o f 79.5 per cent o f the males and o f 77.9 per cent o f the females was
provided for by these institutions. In addition, the sick funds on their
own account provided treatment fo r 6.1 per cent o f the male patients
and 1.2 per cent o f the female patients, while the industrial accident
associations paid for 0.6 per cent o f the male patients and for 0.07
per cent o f the female patients. In the aggregate, therefore, 86.2
per cent o f the male patients and 79.2 per cent o f the female patients
had their treatment provided fo r in accordance with provisions o f
the imperial social insurance laws. O f the remainder, the cost o f
treatment was provided for by public authorities in the case o f 2.3
per cent o f the male patients and o f 0.2 per cent o f the female
patients. Employers o f labor paid for 1.1 per cent o f the male
patients and for 0.07 per cent o f the female patients. The poor-law
authorities provided for 0.2 per cent o f the male patients and for 2.5
per cent fo r the female patients, while private benevolence paid for
1.4 per cent o f the male patients and for 5.2 per cent o f the female
patients. The proportion o f patients providing for their own insti
tutional support or having the same provided for by their families
was 8.4 per cent fo r males and 11.8 per cent for females. The sup
port was derived from other sources in the case o f 0.3 per cent for
male patients and o f 0.9 per cent fo r female patients.
In the private institutions, the experience o f which was included
in the collective investigation, the support o f patients was provided
fo r by State invalidity insurance institutions in the case o f 3.8 per
cent o f the male patients and o f 4.1 per cent o f the female patients.
It is, therefore, evident that nearly all the patients in public sana
toria had their expenses provided fo r through the State invalidity
insurance institutions, the sick fund, or the industrial accident asso
ciations, all established and maintained in conform ity to the imperial
social insurance laws.
40
BU LLETIN OF TH E BUREAU OF LABOR.
AGE, SEX, AND CONJUGAL CONDITION OF PATIENTS UNDER TREATMENT.
The number o f patients under treatment in public sanatoria by
single years during the period 1896 to 1901, with distinction o f sex,
was as follow s:
NUMBER OF PATIENTS TREATED IN GERMAN PUBLIC SANATORIA FOR TUBERCU
LOSIS OF THE LUNGS, BY YEARS, 1896 TO 1901.
Males.
Year.
Females.
cent
Per cent
Number. Per
of total. Number. of total.
Total.
1896.............................................................................
1897.............................................................................
1898.............................................................................
1899.............................................................................
1900.............................................................................
1901.............................................................................
377
907
1,857
3,238
4,762
4,728
90.4
82.4
85.7
85.1
76.3
76.9
40
194
310
565
1,476
1,423
9.6
17.6
14.3
14.9
23.7
23.1
417
1,101
2,167
3,803
6,238
6,151
Total.................................................................
15,869
79.8
4,008
20.2
1 19,877
According to this table the number o f male patients under observa
tion increased from 377 in 1896 to 4,728 in 1901. The number o f
female patients increased from 40 in 1896 to 1,423 in 1901. The age
distribution o f 15,770 male patients and 3,991 female patients, or
99.4 per cent and 99.6 per cent, respectively, o f the total number o f
patients in public sanatoria was as follow s:
AGE DISTRIBUTION OF PATIENTS TREATED IN GERMAN PUBLIC SANATORIA FOR
TUBERCULOSIS OF THE LUNGS, DURING THE PERIOD 1896 TO 1901.
Females.
Males.
Age.
Total.
Per cent
of total.
Number.
Per cent
of total.
Under 15 years..................................
15 to 19 years.....................................
20 to 24 years....................................
25 to 29 years....................................
30 to 34 years...................................
35 to 39 years....................................
40 to 49 years....................................
50 to 59 years....................................
60 years and over.............................
50
1,608
3,459
3,480
2,734
2,014
2,008
390
27
0.3
10.2
21.9
22.1
17.3
12.8
12.7
2.5
.2
39
773
1,440
865
461
239
141
27
6
1.0
19.4
36.1
21.7
11.6
6.0
3.5
.7
.2
89
2,381
4,899
4,345
3,195
2,253
2,149
417
33
0.5
12.0
24.8
22.0
16.2
11.4
10.9
2.1
.2
Total.......................................
15,770
100.0
3,991
100.0
19,761
100.0
Number.
Number.
Per cent
of total.
O f the male patients 44.0 per cent o f the cases, and o f the female
patients 57.8 per cent, were o f the age period 20 to 29 years, inclusive.
A much larger proportion o f female patients were o f the younger
ages, or 19.4 per cent at ages 15 to 19 years, against 10.2 per cent for
males. In marked contrast, the proportion o f tuberculous male
patients was much larger at the older ages, or, for illustration, 25.5
per cent at ages 35 to 49 years, inclusive, against only 9.5 per cent
for females. These differences are partly the result o f variations in
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
41
the age distribution o f male and female wage earners and they are
also no doubt partly due to the more health-injurious effects o f male
employments, particularly occupations with exposure to industrial
dust.
The information as regards the conjugal condition o f the patients
was obtained only in the case o f 13,898 males and 3,815 females. O f
the males, 55.4 per cent and o f the females 20.6 per cent were mar
ried. The difference is partly explained by the larger proportion
o f women o f ages under 25 and partly by the fact that married
women are to a less extent insured against the financial consequences
o f invalidity and, according to experience, are less readily induced
to submit to a long separation from the fam ily. The distribution o f
patients according to conjugal condition is, therefore, not to be con
sidered o f value as evidence whether tuberculosis o f the lungs is rela
tively more common among the married or the unmarried.
The same conclusion applies to the proportionate distribution o f
patients according to occupation. The analyses o f the returns do
not differentiate occupations in detail, but the results are considered
by groups, partly on account o f the fact that the statistical material
would not have been sufficient in most cases to warrant safe con
clusions.
PROPORTION OP INDOOR AND OUTDOOR WORKERS.
The occupation was ascertained for 15,743 male patients and for
3,993 female patients. In the case o f males, 53.9 per cent were indoor
factory workers, 16.9 per cent were outdoor workers, 16.2 per cent
were home workers, 4.2 per cent were employed underground, and
8.1 per cent were general laborers or laborers not otherwise specified.
Am ong the specific employments mercantile occupations contributed
6.3 per cent, machinists 6.1 per cent, carpenters and joiners 5.9 per
cent, printers 4.8 per cent, clerks 4.2 per cent, miners 4.1 per cent, and
masons 2.7 per cent. Among female patients 42.7 per cent were home
workers and 34.5 per cent were indoor factory workers. The pro
portion o f housewives and daughters was 14.9 per cent. The propor
tion o f outdoor workers among women was only 0.6 per cent. The
specific occupations were in the proportion o f 19.2 per cent among
domestic servants, 7.9 per cent among seamstresses, 7.1 per cent among
saleswomen, 6.6 per cent among textile workers, and 4.7 per cent
among office employees; 4.6 per cent were tailoresses.
DUST AND EUMES AS PREDISPOSING CAUSES OE TUBERCULOSIS.
W ith a further regard to the health-injurious consequences o f cer
tain occupations predisposing to tuberculosis, largely because o f the
exposure to the inhalation o f industrial dust, the report contains
inform ation for 12,284 male patients and 3,523 female patients. In
the case o f 3,913 male patients and o f 855 female patients it is stated
42
B U LLETIN OE TH E BUREAU OF LABOR.
that the inhalation o f dust was a predisposing cause favorable to
the disease, accounting for relatively 31.9 per cent o f the male patients
and 24.3 per cent o f the female patients. Every form and kind o f dust
exposure is represented in the detailed analysis, but the chief forms
o f dust were as follow s, fo r male patients: M etallic dust, 437 patients;
and specifically, iron dust, 35 patients; lead dust, 195 patients; chalk
dust, 56 patients; stone dust, 181 patients; coal dust, 65 patients;
paint-colors dust, 17 patients; flour dust, 68 patients; tobacco dust,88
patients; wood dust, 286 patients, and wool dust, 159 patients.
Am ong female patients the only important kinds o f industrial dust
specifically mentioned were wool dust with 124 patients, and tobacco
dust with 23 patients.
In the case o f 415 male patients and o f 53 female patients it would
seem that the disease had been favored in its development by the
inhalation o f smoke, gas, vapors, or steam. The more important
causes o f this kind are given in the case o f male patients as general
smoke exposure 85, poisonous gases 77, chemical vapors 25, alkali
vapors 14, acid vapors 113, and coal smoke 46.
UNFAVORABLE OCCUPATIONAL CONDITIONS.
Am ong other unfavorable occupational conditions, mention is made
in the case o f male patients o f 128 working in badly ventilated rooms,
568 working in close rooms combined with an unfavorable bodily
position, 296 cases with exposure to radiating heat and abnormal
temperature, 83 working in damp rooms, 360 exposed to an unfavor
able climate, and 597 subject to excessive bodily strain. Am ong
female patients there were 26 cases o f patients working in badly
ventilated rooms, 262 working in close rooms combined with an
unfavorable bodily position, 81 working in damp rooms, and 425
subject to excessive bodily strain. It is, therefore, shown that in the
case o f 52.4 per cent o f the male patients and o f 49.8 per cent o f the
female patients the development o f the disease was partly, at least,
attributable to unfavorable occupational conditions. In the case o f
only 173 male patients and only 40 female patients the occupation
itself, however, was specifically mentioned as a predisposing cause
o f the disease. The 173 male patients included 18 miners, 17 masons,
16 tailors, 15 brickyard workers, 14 printers, 13 cigar makers, 12
paint makers, 9 stonecutters, 5 millers, and 5 weavers. Am ong the
40 female patients there were 9 tailoresses, 6 domestic servants, 6
printers, and 5 cigar makers. The foregoing facts would warrant
the conclusion that the unfavorable occupational influences were, as
a rule, incidental to the occupation rather than comprehending the
entire field o f occupational activity. To the extent, therefore, that
the factors in industry which produce ill health, such as dust, smoke,
vapors, polluted air, etc., are reduced to a minimum by effective
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
43
factory control, the predisposing causes to the disease w ill be corre
spondingly reduced. It, may be pointed out in this connection as a
very suggestive result o f the more lim ited investigation into the
experience o f private institutions, with a much more favorably situ
ated class o f patients, that the occupation factors, as predisposing
causes, were mentioned in the case o f only 12 per cent o f the male
patients and 3.6 per cent o f the female patients.
SOCIAL CONDITION.
The social condition o f patients was ascertained for 11,858 males
and 3,799 females. F or males the social condition was returned as
good fo r 51.7 per cent o f the total, as medium for 36.9 per cent, and
as bad fo r 11.5 per cent. F or women patients the social condition
was good in 55.9 per cent o f the total, medium in 26.6 per cent, and
bad in 17.5 per cent. W ith regard to unfavorable housing conditions
the per cents were 4.2 for male patients and 9 for female patients.
W ith regard to insufficient food the per cents were 2.5 for male
patients and 6 fo r female patients.
PATIENTS WITH A FAMILY HISTORY OF TUBERCULOSIS.
Inform ation as to probable predisposition to the disease was ascer
tained for 14,997 male patients and 3,927 female patients. O f this
number 61.7 per cent o f the males and only 50.2 per cent o f the females
came from presumably healthy fam ilies; that is, such as were free
from a tuberculous taint. A history o f tuberculosis on the father’s
side was traced with certainty in the case o f 13.2 per cent o f the male
patients and o f 21 per cent o f the female patients, and on the mother’s
side in the case o f 9.1 per cent o f the male patients and o f 15.9 per
cent o f the female patients. In addition to the foregoing, the propor
tion o f cases in which both parents were tuberculous was 2.1 per cent
for the male patients and 4.9 per cent for the female patients. In
cluding brothers and sisters, as well as remote relatives, a fam ily
history o f the disease was ascertained with certainty in the case o f
29.1 per cent o f the male patients and o f 43.3 per cent, o f the female
patients. I f doubtful cases are included, the number o f male patients
with a fam ily history o f tuberculosis was 37.9 per cent, and in the case
o f female patients it was 50.5 per cent. The experience would, there
fore, seem quite conclusive that a fam ily history o f tuberculosis was
ascertained with certainty in about one-third o f the cases o f male
patients treated for the disease and in about one-half o f the female
patients.
The foregoing information was amplified with regard to the con
dition o f health o f the members o f married patients’ families. It
was ascertained that among 7,701 married male patients, 86.6 per
cent reported their wives as being in entirely good health. In 243
44
B U LLETIN OF TH E BUREAU OF LABOR.
cases, however, or 3.2 per cent, the w ife was reported as suffering
from tuberculosis, and 278, or 3.6 per cent additional, suffered from
diseases o f the chest. The proportion o f women without children was
7.2 per cent. O f the 6,569 families with children, 82.4 per cent had
entirely healthy children, but in 191 families, or 2.9 per cent, there
were tuberculous children, and in 145 families, or 2.2 per cent addi
tional, children suffered from diseases o f the chest, and in 163 fam i
lies, or 2.5 per cent additional, children suffered from scrofula.
Am ong 781 married women patients 603, or 77.2 per cent, reported
their husbands as being in entirely good health. In 94 cases, or 12
per cent o f the total, the husband was tuberculous, and in 44 cases,
or 5.6 per cent, the husband was suffering from some disease o f the
chest. The proportion o f childless marriages was 11.3 per cent. In
44 families, or 7.6 per cent o f the 581 fam ilies having children,
there were tuberculous children, and in addition 4.1 per cent had
children who were suffering from some disease o f the chest and 4.3
per cent had children who were suffering from scrofula. W hile
these conclusions require to be accepted with caution, since the in
form ation was derived from the patients themselves and without
further medical inquiry, it is quite clear that to a not inconsiderable
extent the families o f the patients were affected by the disease and
particularly was this true of-th e husbands and children o f tuber
culous married women.
PREDISPOSING OR COMPLICATING CAUSES IN TUBERCULOSIS.
The inquiry was extended to preceding diseases favorable or con
tributory to the development o f tuberculosis ascertained to have oc
curred in the case o f 7,258 male patients and o f 2,413 female patients,
or 43.5 per cent and 53.9 per cent, respectively, o f the total number o f
persons under observation. The information secured was neither
entirely trustworthy nor conclusive, in that it was frequently im
possible to ascertain whether the contributory or collateral diseases
were properly to be considered predisposing or com plicating causes
o f existing tuberculosis o f the lungs. Foremost among the com plicat
ing diseases was influenza, with 1,787 cases among male patients, or
10.7 per cent o f the total number under observation, and 657 cases
among female patients, or 14.7 per cent. The next most important
collateral or contributory disease was pneumonia, reported in the
case o f 1,366 male patients and o f 382 female patients, or 8.2 per cent
and 8.5 per cent, respectively. Pleurisy was reported in 1,177 male
patients, or 7 per cent o f the total, and in 253 female patients, or 5.7
per cent. Bronchial catarrh was reported in 691 o f the male patients,
or 4.1 per cent o f the total, and in 106 o f the female patients, or 2.4
per cent. Catarrh o f the lungs, which, o f course^ is a rather indefinite
term, particularly when reported by the patients themselves, was
CABS OP TUBERCULOUS WAGE EARNERS IN GERMANY.
45
found in the case o f 537 male patients and o f 96 female patients, or
3.2 per cent and 2.1 per cent, respectively. Am ong the remaining
complications the most important among women patients was chronic
anemia, returned in the case o f 712 patients, or 15.9 per cent o f the
total. The other complications are too numerous and in most cases
numerically too unimportant to require separate consideration.
In the case o f 4,861 male patients and o f 1,126 female patients, or
respectively, 29.1 per cent and 25.2 per cent o f the total patients, the
existing tuberculosis o f the lungs was complicated by other diseases.
The inform ation obtained was from the patients and therefore sub
ject to the criticism o f possible inaccuracy in the statement o f medical
facts. The principal complications were bleeding o f the lungs, re
turned in the case o f 3^535 male and 501 female patients. The next
most important complication was pleurisy, accounted fo r in the case
o f 533 male and 131 female patients. Catarrh o f the larynx was
present in the case o f 311 male and 154 female patients, and tubercu
losis o f the larynx in the case o f 146 male and 38 female patients.
These were the principal complications, but a large number o f others
occurred, which, however, can not be considered to be o f material
importance in affecting the course or the seriousness o f the cases in
the aggregate. In other words, the most important complications
were nontubercular lung diseases, emphasizing the close relation
which exists, unquestionably, between tubercular and nontubercular
lung diseases.
PREVIOUS SANATORIUM TREATMENT.
Previous treatment in sanatoria or allied institutions was reported
to have occurred in the case o f 1,880 out o f 15,869 male patients, or
11.8 per cent, and in the case o f 383 out o f 4,008 female patients, or 9.6
per cent. Am ong the former, 157 had been two or more times m an
institution for the treatment o f the disease, and 28 o f the latter, or
respectively, 1 per cent and 0.7 per cent o f the total. In the case o f
1,554 male patients and o f 327 female patients the previous treat
ment had been at least six weeks. In the case o f 326 male patients
and o f 56 female patients the previous treatment had been o f less
than six weeks’ duration. The relation o f such treatment to the
ultimate restoration or maintenance o f wage-earning capacity was not
ascertainable.
PREVIOUS DURATION OF DISEASE.
The commencement o f the disease was ascertained for 15,170 male
patients and fo r 3,812 female patients. O f the male patients 54.4
per cent, and o f the female patients 54.6 per cent, had on their
admission a record o f less than one year’s sickness duration. The
details by years and periods o f years are given in the follow ing
46
BU LLETIN OF TH E BUREAU OF LABOR.
table, according to which it is shown that there was a previous
duration o f sickness o f one year and over in the case o f 45.6 per
cent o f the male patients and in the case o f 45.4 per cent for the
female patients.
DURATION OF DISEASE PREVIOUS TO ADMISSION FOR TREATMENT IN GERMAN PUB.
LIC SANATORIA FOR TUBERCULOSIS OF THE LUNGS, BY SEX OF PATIENTS, FOR
THE PERIOD 1896 TO 1901.
Females.
Males.
Previous duration.
Number.
Per cent
of total.
Number.
Total.
Per cent
of total.
Number.
Per cent
of total.
Under 1 year......... ..........................
1 to 2 years........................................
2 to 3 years.......................................
3 to 5 years.......................................
5 to 7 years.......................................
7 to 10 years......................................
10 to 15 years....................................
Over 15 years....................................
8,251
2,512
1,417
1,434
630
476
298
152
54.4
16.6
9.3
9.5
4.2
3.1
2.0
1.0
2,082
682
361
367
140
98
51
31
54.6
17.9
9.5
9.6
3.7
2.6
1.3
.8
10,333
3,194
1,778
1,801
770
574
349
183
54.4
16.8
9.4
9.5
4.1
3.0
1.8
1.0
Total.......................................
15,170
100.0
3,812
100.0
18,982
100.0
The proportion o f cases with a duration o f from two to five years’
previous sickness was 18.8 per cent fo r male patients and 19.1 per
cent fo r female patients. In a fa ir proportion o f cases the previous
disease had been o f longer duration, extending in some cases to 15
years and over. O f the total male patients 10.3 per cent had a
previous sickness record o f over five years, the corresponding pro
portion for female patients being 8.4 per cent. The results o f this
investigation, therefore, conclusively prove that in quite a number o f
cases tuberculosis had been a preexisting disease o f considerable du
ration previous to admission for institutional treatment. It is selfevident that as a rule the chances o f recovery must be in an inverse
proportion o f the duration o f the disease, but a satisfactory result is
occasionally secured even in quite an advanced stage o f the disease.
It o f course does not necessarily follow that the seriousness o f the
lung impairment is always in proportion to the duration o f the dis
ease, but the chances o f recovery are decidedly in favor o f incipient
cases or those with a comparatively short duration o f preexisting
disease.
RELATION OF TREATMENT TO STAGE OF DISEASE.
The more complex interrelation o f degree o f seriousness o f the
disease and its duration previous to admission to institutional treat
ment is shown in some detail in the follow ing table, in which the
cases are grouped according to the Turban stage1 o f the disease on
admission and by previous duration o f sickness by single years and
periods o f years.
1 For explanation of “ Turban stage,” see p. 83.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
47
TURBAN STAGE OF DISEASE OF MALES AND OF FEMALES ON ADMISSION FOR
TREATMENT IN GERMAN PUBLIC SANATORIA FOR TUBERCULOSIS OF THE LUNGS,
BY PREVIOUS DURATION OF DISEASE, FOR THE PERIOD 1896 TO 1901.
NUMBER.
Male patients admitted in Turban Female patients admitted in Turban
stage—
stage—
Previous duration of disease.
I.
I-H.
H.
H-HI.
HI.
I.
I-H .
II.
II-III.
HI.
Under 1 year........................... 2,588 1,767 1,758
1 year to 2 years.......................
765
480
519
244
282
2 years to 3 years.....................
466
250
3 years to 5 years.....................
402
312
101
5 years to 7 years.....................
186
127
7 years to 10 years...................
119
71
126
54
87
51
10 years to 15 years..................
Over 15 years..........................
44
17
27
880 1,126
303
411
173
234
170
287
82
123
88
67
50
53
20
41
689
138
77
79
28
16
11
5
467
177
79
90
32
20
6
4
424
166
101
93
33
32
17
11
224
93
49
54
20
12
10
7
251
96
54
48
25
17
7
4
Total.............................. 4,657 2,984 3,202
1,745 2,363
1,043
875
877
469
502
PER CENT.
55.6
16.4
10.0
8.6
4.0
2.6
1.9
.9
59.2
16.1
8.2
8.4
3.4
2.4
1.8
.6
54.9
16.2
8.8
9.7
4.0
3.9
1.6
.8
50.4
17.4
9.9
9.7
4.7
3.8
2.9
1.1
47.7
17.4
9.9
12.1
5.2
3.7
2.2
1.7
66.1
13.2
7.4
7.6
2.7
1.5
1.1
.5
53.4
20.2
9.0
10.3
3.7
2.3
.7
.5
48.3
18.9
11.5
10.6
3.8
3.6
1.9
1.3
47.8
19.8
10.4
11.5
4.3
2.6
2.1
1.5
50.0
19.1
10.8
9.6
5.0
3.4
1.4
.8
Total.............................. 100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
Under 1 year...........................
1 year to 2 years......................
2 years to 3 years.....................
3 years to 5 years.....................
5 years to 7 years.....................
7 years to 10 years...................
10 years to 15 years..................
Over 15 years..........................
The larger ratio o f fatal cases in the advanced stage o f the disease
precludes accurate conclusions for a statistical comparison o f this kind,
and the table fails to fully confirm the previous observation that, as a
general rule, the seriousness o f the lung involvement is in proportion
to the duration o f the disease. F or illustration, however, o f 4,657
male patients in Turban stage I, the proportion having a previous dis
ease record o f over five years was 9.4 per cent, against 10.3 per cent o f
the 3,202 patients in Turban stage I I and 12.8 per cent o f the
2,363 patients in Turban stage III. The general results for female
patients are about the same. Conclusions based upon these data
require, however, to be applied to individual cases with extreme
caution, for serious chronic cases may occur with a long previous
duration o f disease, and relatively light cases in an acute form may
terminate fatally after a short duration, being commonly known as
“ galloping consumption.”
CONDITION OF PATIENTS ON ADMISSION.
The general condition o f the patients on admission was reported
for 15,844 male and 3,863 female patients, and considered good in the
case o f 32.9 per cent o f the form er and in the case o f 28.2 per cent o f
the latter. The condition was reported as medium in the case o f 36.8
per cent o f the male patients and o f 31.7 per cent o f the female
patients and as bad in the case o f 30.2 per cent o f the males and o f
48
B U LLETIN OF TH E BUBEAU OF LABOR.
40.1 per cent o f the females. According to this analysis, the propor
tion o f cases was about the same for male patients fo r the three
groups, but for the female patients the proportion in bad general
condition on admission was somewhat larger.
The bodily condition of the patient at the time o f admission was
ascertained in the case o f 15,868 male patients and o f 4,002 female
patients. O f the male patients 17.9 per cent and o f the female
patients 18 per cent were stated to have been in a condition o f satis
factory nutrition. In the case o f 48.9 per cent o f the male patients
and o f 44.5 per cent o f the female patients the condition o f nutrition
on admission was reported as medium, while in the case o f 38.2 per
cent o f the male patients and o f 37.5 per cent o f the female patients
the condition was reported as bad. The proportion o f patients o f
satisfactory nutrition was, therefore, relatively quite small, and the
results o f the analysis disclose the intimate relation which unques
tionably exists between tuberculosis o f the lungs and impaired or
defective nutrition or malassimilation. The inform ation with re
gard to nutrition is, o f course, subject to the criticism that it depends
more or less upon methods o f medical diagnosis and that there is an
element o f reasonable doubt, which impairs the value o f the results.
The close correspondence, however, between the respective percent
ages for male and female patients would seem to warrant the conclu
sion that, in a general way, the large m ajority o f patients on admission
were in an impaired or defective state o f bodily nutrition.
RELATION OE TREATMENT TO GAIN IN BODY WEIGHT.
The relation o f treatment to body weight was ascertained in the
case o f 15,576 male patients and o f 3,964 female patients. O f the
male patients 93.6 per cent increased in weight during treatment and
o f the female patients 92.3 per cent. In the case o f 3.4 per cent for
males and o f 3.7 per cent fo r females the weight remained the same,
while in the case o f 3 per cent for males and 4.1 per cent for females
the weight decreased. The average increase in weight during the
time o f treatment was 5.9 kilograms (13 pounds) for males and 5.2
kilograms (11.6 pounds) for females. Since the normal average
weight o f women is less than the average weight o f men, the increase
in weight is proportionately about the same for both sexes. When the
increase in body weight is ascertained, with a due regard to the con
dition o f nutrition on admission, it is almost invariably found that
the gain is greatest in the case o f those who were most impaired in
physique. In the case o f male patients, for illustration, who on ad
mission were in a good physical condition, the gain was 5.7 kilograms
(12.6 pounds), in the case o f those who were in a medium condition
5.9 kilograms (13 pounds), and in the case o f those who were in poor
physical condition 6.1 kilograms (13.4 pounds). The respective gain
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
49
in weight o f females was 4.9 kilograms (10.8 pounds) for the first,
5.2 kilograms (11.6 pounds) fo r the second, and 5.4 kilograms (11.9
pounds) for the third class. Even in the case o f patients who were
in the third Turban stage o f the disease, numbering 2,871 males and
509 females, a gain in weight was obtained in the case o f 89.6 per
cent o f the form er and o f 88.5 per cent o f the latter, the average gain
in weight being 5.6 kilograms (12.3 pounds) for males and 4.4 kilo
grams (9.7 pounds) for females.
CHANGES IN PHYSICAL CONDITION DURING TREATMENT.
The changes in condition resulting from the course o f systematic
treatment were ascertained for 15,740 males and for 3,857 females.
The results o f the analysis are set forth in tabular form , as follow s:
RESU LTS
OF
S A N A T O R IU M
TREATM ENT.
Males.
Females.
Physical condition of patient.
Number. Per cent. Number. Per cent.
Very much improved..................................................................
Improved....................................................................................
Not improved..............................................................................
Worse................................. ........................................................
Very much worse........................................................................
3,126
5,929
6,305
292
88
19.9
37.7
40.1
1.9
.6
1,036
1,237
1,482
70
32
26.9
32.1
38.4
1.8
.8
According to this table a favorable or promising medical result o f
treatment was secured in the case o f 57.6 per cent o f the male patients
and o f 59.0 per cent o f the female patients. In further illustration o f
the results o f treatment, it may be stated that in the case o f male
patients only 0.1 per cent were in very good general condition on
admission, but 3.2 per cent on discharge; the proportion in good gen
eral condition on admission was 32.8 per cent, but 76.2 per cent on
discharge. In contrast, the proportion o f patients in medium condi
tion on admission ranged from 36.9 per cent to 15.6 per cent on dis
charge; while the proportion o f patients in bad general condition
ranged from 30.2 per cent on admission to 4.6 per cent on discharge.
The results were much the same for females; or, for illustration, 28.1
per cent were in good general condition on admission, against 71.5
per cent on discharge, and 31.7 per cent were in medium general con
dition on admission, against 18.6 per cent on discharge. The propor
tion in bad general condition was 40.1 per cent on admission, against
6.6 per cent on discharge. The general results o f treatment were
therefore much the same for both sexes, and throughout the marked
benefits resulting from sanatorium treatment are exhibited by the
much larger proportion o f patients on discharge in improved general
condition, with a corresponding increase in disease-resisting power,
which, o f course, chiefly conditions the ultimate outcome o f sys
tematic diatetic-hygienic institutional treatment.
49397°— 12------4
50
BU LLETIN OF TH E BUBEAU OF LABOB.
COUGH AND EXPECTORATION ON ADMISSION AND DISCHARGE.
W ith regard to expectoration and cough on admission and dis
charge, the required inform ation was ascertained for 15,838 male
patients and for 3,989 female patients. O f this number 91.1 per cent
o f the males and 65.7 per cent o f the females had cough and expecto
ration on admission, 4.5 per cent o f the males and 18.4 per cent o f
the females had cough without expectoration, and 4.4 per cent o f the
males and 15.9 per cent o f the females had neither cough nor expecto
ration on admission. It is therefore shown that by far the large
m ajority o f patients had cough and expectoration on admission, which
conclusively proves that they were in a condition o f health not only
dangerous to themselves, but to the public at large. O f the patients
with cough and expectoration combined, 22.8 per cent o f the males and
26.2 per cent o f the females improved during treatment to the extent
that both cough and expectoration had disappeared, and in addition
4.7 per cent o f the males and 9.6 per cent o f the females on discharge
were free from expectoration but retained their cough, while 72.5 per
cent o f the males and 64.2 per cent o f the females retained both cough
and expectoration at the time o f their discharge. W hile, therefore,
the treatment resulted in a material improvement in general condi
tion, it did not, to more than a rather lim ited extent, result in remov
ing the most striking physical evidences o f lesions or impairment o f
the lungs. It is quite clear that the medical condition o f most o f the
patients on discharge was not so favorable as would have been desir
able or perhaps necessary to provide a sound physical basis as a pre
liminary condition fo r subsequently sustained wage-earning capacity.
On account o f the very much smaller number o f patients without
cough, or without cough and expectoration, it does not seem neces
sary to consider the details o f this experience at length. In brief, o f
the patients with cough and expectoration on admission, about onefourth were free from cough and expectoration on discharge. O f
those with cough only, more than one-half, or 56.1 per cent, o f the
males, and 57.3 per cent o f the females, were free from cough on dis
charge, and, finally, o f the patients free from cough and expectora
tion on admission, 90.5 per cent o f the males and 89.7 per cent o f the
females were still free therefrom on discharge.
TUBERCULOUS BACILLI IN THE SPUTUM ON ADMISSION AND DISCHARGE.
Even more important than the mere fact o f cough and expectora
tion is, o f course, the bacillary contents o f the latter, as determined
by recognized bacteriological methods. Inform ation with regard to
the results o f examination o f the expectoration was obtained for
14,313 male patients and fo r 3,296 female patients. O f these, 6.7
per cent o f the males and 29.5 per cent o f the females were excluded,
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
51
since throughout their stay in the institution they were free from
expectoration, although unquestionably tuberculous in one o f the sev
eral stages o f the diseasa O f the remaining patients, numbering
12,631 males and 2,265 females, the bacilli o f tuberculosis were found
in the sputum o f 47.3 per cent o f the male patients and o f 41.1 per
cent o f the female patients. F or some o f these the information as to
condition on discharge was not ascertained, but 3,462 o f the male
patients and 698 o f the female patients, or 65.6 per cent and 75 per
cent, respectively, o f the patients having bacilli o f tuberculosis in
their expectoration on admission still retained the bacteriological
evidence o f the disease in their expectoration on discharge. The
significance o f these facts can hardly be overrated. It is evident
that while the patients on discharge may have been in a satisfactory
general condition, while they had gained in weight and were other
wise perhaps relatively free from serious physical impairment on
account o f the disease, they carried the bacilli o f tuberculosis in their
expectoration, which they retained on discharge, and to that extent,
o f course, they were not only a menace to themselves, on account
o f the risk o f reinfection, but a menace to the community, and par
ticularly other employees, on account o f the risk o f spreading infec
tion by carelessness or indifference with regard to expectoration.
The details o f the presence o f the bacilli o f the disease in the ex
pectoration according to Turban stage o f the disease are given in
tabular form , as follow s:
NUMBER AND PER CENT OF MALE AND FEMALE TUBERCULOUS PATIENTS HAVING
BACILLI IN THEIR EXPECTORATION, ACCORDING TO TURBAN STAGE OF DISEASE.
Males.
Females.
Turban stage.
Number. Per cent. Number. Per cent.
I ........................................................................................................
I -I I ..............................................................................................
n
.......................................................................
TT-TTT................................................................................................
H I.....................................................................................................
968
909
1,358
1,032
1,765
30.4
34.3
49.7
64.3
78.6
79
94
180
227
362
18.0
21.0
35.1
63.9
77.4
This table shows that o f the male patients in Turban stage I,
30.4 per cent were ascertained to have the bacilli o f tuberculosis in
their expectoration. The proportion o f bacillary expectorations in
creased with the advancing stages o f the disease to 49.7 per cent
fo r stage I I and 78.6 per cent for stage III. Throughout the per
centages are lower for female patients, having been 18.0 per cent for
Turban stage I, 35.1 per cent for stage II, and 77.4 per cent for
stage II I.
Under treatment the tendency is naturally for the bacilli to dis
appear from the sputum and this, o f course, in itself is one o f the
most important factors in physical diagnosis. It was brought out
52
BU LLETIN OF TH E BUREAU OF LABOR.
by the investigation that o f the patients with bacilli in their sputum,
but in Turban stage I o f the disease, 59.3 per cent o f the male patients
had expectoration free from bacilli on discharge, the corresponding
per cent for females being 55.1. The proportion o f cases with favor
able results naturally decreases with the advancing stages o f the dis
ease, and, accordingly, for males the per cent with no bacilli in their
sputum in the Turban stage I I was only 36.5 and in stage I I I 21.1.
For females, the corresponding percentages were 37.1 for Turban
stage I I and 11.8 for stage III. Summarizing the foregoing data,
which have a most important bearing upon public considerations o f
tuberculosis o f the lungs as a labor problem, it is shown that o f the
11,145 male patients with expectoration on admission 5,275, or 47.3
per cent, had bacilli o f tuberculosis in their sputum, against 3,650, or
32.8 per cent, on discharge. O f the 2,265 female patients 931, or 41.1
per cent, had bacilli in their expectoration on admission, but 739,
or 32.6 per cent, retained bacilli in their sputum on discharge. In
other words, while a fair amount o f good resulted from the treat
ment, it is quite evident that much too large a proportion o f the
patients under treatment were discharged with established evidence
o f the bacilli o f the disease in their sputum, involving, o f course, the
serious risk o f self-infection and the infection o f others, particularly
members o f the fam ily and fellow employees.
DURATION OF TREATMENT.
The duration o f treatment, excluding those who were less than six
weeks in the institution and those who died, was ascertained for
15,802 male and 3,998 female patients. The duration is given in
tabular form below :
DURATION OF TREATMENT OF TUBERCULOUS PATIENTS IN GERMAN SANATORIA,
FOR THE PERIOD 1896to 1901, BY SEX.
Males.
Duration of treatment.
Females.
Number Per cent. Number Per cent.
of cases.
of cases.
6 to 8 weeks................................................... .............................
8 to 10 weeks................................................................................
10 to 12 weeks........................................................... ...................
12 to 14 weeks..............................................................................
14 to 16 weeks..............................................................................
16 to 20 weeks..............................................................................
20 to 26 weeks..............................................................................
Over 26 weeks..............................................................................
1,501
1,760
3,442
4,877
1,307
1,593
794
528
9.5
11.1
21.8
30.9
8.3
10.1
5.0
3.3
307
352
751
1,540
312
390
230
116
7.7
8.8
18.8
38.5
7.8
9.8
5.8
2.9
Total..................................................................................
15,802
100.0
3,998
100.0
According to this table, in about one-third o f the cases the patients
, underwent treatment fo r from 12 to 14 weeks. Most o f the patients
were from 10 to 14 weeks in the institution, which is chiefly due to
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
53
the fact that in the large m ajority o f cases the treatment was pro
vided for by invalidity insurance institutions. The average duration
o f treatment was 89.2 days for males and 94.4 days fo r females.
MEDICAL RESULTS OF TREATMENT.
The general medical results o f institutional treatment were ascer
tained fo r 15,231 male patients and 3,921 female patients. The con
dition o f these patients on discharge was as follow s:
Entirely cured, 573 males, or 3.8 per cent o f the total; and 149
females, or also 3.8 per cent o f the total number discharged. B y
entirely cured is meant a complete restoration o f the lungs to their
normal condition, as determined clinically and by careful physical
examination.
The number and proportion relatively cured was 1,349 male pa
tients, or 8.9 per cent, and 450 female patients, or 11.5 per cent. By
relatively cured is meant such a decided improvement in the general
condition o f the patient and disappearance o f the cough and expec
toration that only slight evidences remained o f an impaired condi
tion o f the lungs.
The number and proportion o f patients materially improved, in
cluding an advance from a lower to a higher Turban stage, was 5,691
males, or 37.4 per cent, and 1,320 females, or 33.7 per cent.
The number and proportion o f patients who improved, but without
a change from the Turban stage in which they were on admission,
was 5,205, or 34.2 per cent, males and 1,051, or 26.8 per cent, females.
The number o f patients with their condition remaining unchanged
was 1,570 males, or 10.3 per cent, and 666 females, or 17 per cent.
The number o f patients whose general condition was worse,
although remaining within the same Turban stage o f the disease as
observed on admission, was 372 males and 116 females, and the num
ber o f patients decidedly worse, with a change to a less favorable
stage o f the disease, was 413 males and 160 females. The number o f
deaths was only 58 males and 9 females, or 0.4 per cent and 0.2 per
cent, respectively. The analysis with regard to condition on dis
charge was made in considerable detail, which, however, is too tech
nical and medical for the present purpose with regard to the eco
nomic results; that is, the proportion o f patients discharged with
their earning capacity restored within a reasonable period o f time.
Considering the entirely cured and relatively cured as a group,
there were 1,922 male patients o f this class and 599 female patients,
or, respectively, 12.7 per cent and 15.3 per cent o f the total patients
discharged during the period 1896 to 1901. The average duration o f
treatment o f the cured or materially improved cases was 91.5 days
for males and 100.9 days for females. The rate o f recovery, as diag
nosed from a medical point o f view and having reference to restored
54
B U LLETIN OF TH E BUREAU OF LABOR.
earning capacity, according to ages on admission, is shown in tabular
form , as follow s:
RATE OF RECOVERY IN TUBERCULOSIS OF THE LUNGS UNDER SANATORIUM
TREATMENT DURING THE PERIOD 1896 TO 1901, FOR PATIENTS OF EACH SEX.
Males.
Ages on admission.
Females.
Number
Number
of
of
Number
Number
of
Per cent patients
of
patients
Per cent
under patients cured.
under patients cured.
treat
cured.
treat
cured.
ment.
ment.
Under 15 years...........................................
15 to 19 years..............................................
20 to 24 years..............................................
25 to 29 years..............................................
3 0 to 34 years..............................................
35 to 39 years..............................................
40 to 49 years..............................................
50 to 59 years..............................................
60 years and over.......................................
50
1,608
3,459
3,480
2,734
2,014
2,008
390
27
16
251
504
450
307
210
145
27
32.0
15.6
14.6
12.9
11.2
10.4
7.2
6.9
39
773
1,440
865
461
239
141
27
6
8
132
235
135
53
19
12
2
2
20.5
17.1
16.3
15.6
11.5
7.9
8.5
7.4
33.3
Total.................................................
15,770
1,910
12.1
3,991
598
15.0
According to this table, the recovery rate was highest at the
younger and lowest at the higher ages, ranging, fo r males, from 82
per cent at ages under 15 years to only 6.9 per cent at ages 50 to 59
years. F or females, the range in the recovery rate was from 20.5
per cent at ages under 15 years to 7.4 per cent at ages 50 to 59 years.
A t ages 60 years and over the numbers are too small for a safe con
clusion.
ECONOMIC RESULTS OF TREATMENT.
The economic results o f treatment were ascertained in the case o f
15,636 male patients and o f 3,953 female patients, or, relatively, 98.5
per cent and 98.6 per cent o f the total number o f patients under treat
ment. It is pointed out that the economic results—that is, the re
stored earning capacity—were not in all cases determined by identical
methods, but in a large m ajority o f the institutions by fu ll restored
earning power is meant a recovered earning capacity o f from 75 per
cent to 100 per cent o f the form er earnings, while by partial recovery
is meant a restored earning capacity o f from 33£ to 75 per cent o f the
form er wages. Persons able to earn less than 33J per cent o f their
form er earnings are considered as not having their earning capacity
restored to them, or, in other words, as unsuccessful cases from an
economic point o f view. Excluding, therefore, from the follow ing
comparison the returns which are not strictly comparable, upon the
basis o f the preceding explanation, as to the terms used, the facts were
utilized for 13,070 male patients, and fo r 2,356 female patients, as
follow s:
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
55
ECONOMIC RESULTS OF SANATORIUM TREATMENT FOR TUBERCULOSIS OF THE
LUNGS DURING THE PERIOD 1896 TO 1901, FOR PATIENTS OF EACH SEX.
Males.
Females.
Condition on discharge.
Number. Per cent. Number. Per cent.
Earning capacity fully restored with return to usual occupation.
Earning capacity fully restored with return to another occupa
tion...........................................................................................
Earning capacity partly restored................................................
Unable to work...........................................................................
Died.............................................................................................
Total..................................................................................
8,891
68.0
1,685
71.5
1,161
1,745
1,221
52
8.9
13.4
9.3
.4
53
283
329
6
2.2
12.0
14.0
.3
13,070
100.0
2,356
100.0
According to this table 68.0 per cent o f the male patients and 71.5
per cent o f the female patients had their earning capacity fully re
stored and were able to take up again the occupation at which they
had been employed before admission to the sanatorium. In the cases
o f 8.9 per cent o f the male patients and o f 2.2 per cent o f the female
patients the earning capacity was fully restored, but at a different
and more suitable occupation or industry in place o f the one form erly
follow ed. The proportion o f patients with their earning capacity
only partially restored, within the meaning o f the term, as previously
defined, was 13.4 per cent for males, and 12.0 per cent for females.
The proportion o f entirely unsuccessful cases, from an economic point
o f view, was 9.3 per cent for males and 14.0 per cent for females. In
addition thereto 0.4 per cent o f the male patients and 0.3 per cent o f
the female patients had died during the course o f treatment, but it
requires to be recalled that all patients under six weeks’ treatment
were excluded from the analysis o f the collective experience for the
period.
IMPORTANCE OF TREATMENT IN THE INCIPIENT STAGE OF DISEASE.
The importance o f early treatment, in its relation to restored
earning capacity, is brought out in the follow ing table, which shows
the relation o f successful treatment to the Turban stage o f the
disease on admission:
RELATION OF ECONOMIC RESULTS OF SANATORIUM TREATMENT FOR TUBERCU
LOSIS TO THE TURBAN STAGE OF THE DISEASE ON ADMISSION, DURING THE
PERIOD 1896 TO 1901, FOR PATIENTS OF EACH SEX.
Turban stage of disease on admission.
I ......................................................................................
I-II..................................................................................
II.....................................................................................
n -m .......................................................................................................
Males.
Females.
Per cent
Per cent
with fully with partly
restored
restored
earning
earning
capacity! capacity.
Per cent
Per cent
with fully with partly
restored
restored
earning
earning
capacity. capacity.
80.7
78.4
69.1
52.5
36.3
15.6
17.3
22.0
31.9
37.0
88.2
84.2
72.3
55.4
30.6
6.9
9.3
14.2
24.9
27.2
56
BU LLETIN OF TH E BUBEAU OF LABOB.
It is shown by this table that, leaving out o f consideration the
minor exceptions o f no material importance, the percentage o f cases
successfully treated, from an economic point o f view, diminishes
progressively with the increasing stage o f seriousness o f the disease,
emphasizing therefore the economic importance o f early treatment,
when the outlook fo r recovery is reasonably assured.
GERMAN SANATORIUM EXPERIENCE, 1896 TO 1901.1
The final results o f the collective investigation o f 1896 to 1901 are
briefly summarized as follow s:
The average duration o f treatment o f 15,869 male and o f 4,008
female patients was 89.2 and 94.4 days, respectively.
The patients were almost exclusively o f the wage-earning element
o f the nation, or 99.4 per cent in the case o f males and 85.1 per cent
in the case o f females.
The cost o f treatment was in most cases provided for by the
invalidity insurance institutions, or other institutions and funds
established to carry out the German compulsory insurance laws.
O f the male patients, 86.2 per cent, and o f the female patients, 79.2
per cent, were provided for at the expense o f compulsory social
insurance institutions.
O f the male patients 44.0 per cent were o f the age period 20 to 29
years, and o f the female patients 57.8 per cent. O f the male pa
tients 80.1 per cent, and o f the female patients 17.6 per cent, were
o f the age period 80 to 39 years. The large m ajority therefore were
admitted fo r treatment at a period o f life when the economic and
social value o f health is a matter o f most serious concern to the indi
vidual and to the State.
A fam ily history o f tuberculosis was established with certainty
in the case o f 20.2 per cent o f the male and 32 per cent o f the
female patients, and with reasonable probability, including the pre
vious proportion, in 26.4 per cent o f the male and 36.7 per cent o f the
female patients. The proportion o f tuberculous brothers and sisters
o f the patient was ascertained with certainty, or reasonable proba
bility, in the case o f 16.5 per cent o f the males and o f 21.2 per cent of
the females.
Over one-half o f the patients—that is, 54.4 per cent o f the males
and 54.6 per cent o f the females—were admitted to treatment in the
same year in which the symptoms o f the disease were first recognized.
In the case o f 9.8 per cent o f the males and o f 8.2 per cent o f the
females there was a record o f previous treatment o f at least six weeks’
duration in sanatoria or some special institution for the treatment o f
tuberculosis o f the lungs.
1 For summary account of the experience data for the period 1902-1904, see p. 162.
CARE OE TUBERCULOUS WAGE EARNERS IN GERMANY.
57
The bodily condition on admission, as determined by the evidence
o f nutrition, was good in the case o f 17.9 per cent o f the male and o f
18 per cent o f the female patients, and medium in the case o f 48.9
per cent o f the male and o f 44.6 per cent o f the female patients. The
condition was bad in the case o f 33.2 per cent o f the males and o f 37.5
per cent o f the females.
The bodily condition, or nutrition, was improved, as determined by
an increased weight, in the case o f 93.6 per cent o f the males and o f
92.3 per cent o f the females. The average gain in weight was 5.9
kilograms (13 pounds) and 5.2 kilograms (11.6 pounds), respectively,
in the case o f male and female patients.
The general condition o f the patients on admission was good in the
case o f 32.9 per cent o f the male and 28.2 per cent o f the female patients.
It was medium in the case o f 36.8 per cent o f the male and 31.7 per cent
o f the female patients; and, finally, it was bad in the case o f 30.2 per
cent o f the male patients and o f 40.1 per cent o f the female patients.
The general condition was improved during treatment in the case
o f 57.5 per cent o f the male and 59 per cent o f the female patients.
Cough and expectoration were present on admission in the case o f
91.1 per cent o f the male and 65.7 per cent o f the female patients, but
cough without expectoration was present in only 4.5 per cent o f the
male patients and in only 18.5 per cent o f the female patients. O f
the form er, 22.8 per cent o f the males and 26.2 per cent o f the females
were free from cough and expectoration on discharge, and dry cough,
present on admission, disappeared in the case o f 56.1 per cent o f the
male and 57.3 per cent o f the female patients during treatment.
The sputum o f patients was ascertained with certainty to contain
the tubercle bacillus in the case o f 45.3 per cent o f the male patients
and o f 30 per cent o f the female patients. O f this group o f patients,
separately considered, 34.4 per cent o f the males and 25 per cent o f
the females were free from tubercle bacillus on discharge.
Fever was present on admission in the case o f 13.8 per cent o f the'
male and 19.4 per cent o f the female patients. The fever disappeared
during treatment in the case o f 68.6 per cent o f the male and 63.3
per cent o f the female patients.
Night sweats were observed on admission in the case o f 29.8 per
cent o f the male and 27.3 per cent o f the female patients. Night
sweats disappeared during treatment in the case o f 90.7 per cent o f
the male and 85.2 per cent o f the female patients.
The seriousness o f the disease, or the degree o f lung impairment, as
determined by the Turban stage o f the disease, was as follow s:
O f the male patients, 31.3 per cent, and o f the female patients 28.4
per cent, were in stage I o f the disease, and 19.9 per cent o f the males
and 22.9 per cent o f the females were in stage I - I I o f the disease. O f
the patients in stage I I o f the disease, the proportion o f males was 21.3
58
BU LLETIN OF TH E BUREAU OF LABOR.
per cent and o f the females 23.1 per cent, and in stage I I -I I I , 11.7
per ceiit and 12.5 per cent, respectively. The proportion o f patients
in stage I I I , or the far-advanced stage o f the disease, was 15.8 per
cent for males and 13.2 per cent fo r females.
Only one lung was affected in the case o f 25 per cent o f the male
and 19.7 per cent o f the female patients. O f these, 62.6 per cent and
63.1 per cent, respectively, had the right lung affected, and 37.4 per
cent and 36.9 per cent, respectively, had the left lung affected.
Rales were observed in the case o f 93.4 per cent o f the male and
87.3 per cent o f the female patients, and o f this group rales combined
with consolidation was observed in the case o f 79.8 per cent o f the
males and o f 74.6 per cent o f the females.
A cure, from a medical point o f view, was obtained in the case
o f 12.7 per cent o f the male and 15.3 per cent o f the female patients.
A material improvement, including the cured cases, was obtained in
the case o f 50 per cent o f the male and 48.9 per cent o f the female
patients. A relative improvement was secured in the case o f 34.2
per cent o f the male and 26.8 per cent o f the female patients, and
10.3 per cent and 17 per cent, respectively, o f the patients remained
unchanged. In the case o f 5.1 per cent o f the male and 7.1 per cent
o f the female patients the condition on discharge was worse than on
admission, but the percentage o f deaths during the period o f treat
ment was only 0.4 fo r male patients and only 0.2 fo r female patients.
An economic result, with entire restoration o f earning capacity,
was obtained in the case o f 76.9 per cent o f the male and 73.7 per cent
o f the female patients, but in addition thereto 13.4 per cent o f the
males and 12 per cent o f the females had their earning capacity par
tially restored to them, while only 9.3 per cent o f the male patients
and only 14 per cent o f the female patients were unsuccessfully treated
from an economic point o f view.1
TREATMENT AND CARE OF TUBERCULOUS WAGE EARNERS BY GER
MAN INVALIDITY INSURANCE INSTITUTIONS, 1897 TO 1909.
The combined experience data o f the German territorial govern
ment invalidity insurance institutions have been published for a
number o f years in the form o f statistical summaries, including all
the essential facts emphasizing the financial, medical, and social re
sults o f institutional or other treatment for the purpose o f preventing
or restoring the loss o f earning power through debilitating diseases
o f long duration. The latest available report2 is fo r the year 1910,
1 See page 162 for summary of experience, 1902-1904, published by the Imperial Board
of Health in 1912.
2Amtliche Nachrichten des Reicbs-Versicherungsamts 1910. 2. Beiheft. Statistik der
Heilbehandlung bei den Versicherungsanstalten und zugelassenen Kasseneinrichtungen
der Invalidenversicherung. Berlin, 1910.
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
59
including the experience data for the period 1897 to 1909. The chief
object o f the statistical investigation is to ascertain from year to year
the actual results o f the special treatment extended to invalids, ac
tual or prospective, undertaken at the expense o f the invalidity in
surance institutions for the purpose o f preventing premature physical
infirmity and the resulting loss o f wage-earning capacity.1 On ac
count o f the fact that tuberculosis o f the lungs is one o f the chief
causes o f physical impairment and resulting loss o f earning power,
the experience data throughout differentiate the statistics o f treat
ment fo r tuberculosis o f the lungs and other diseases. W hile in the
main the sanatoria or the other special healing and curative institu
tions have been established fo r the purpose o f granting special treat
ment in behalf o f Government invalidity insurance institutions, it re
quires to be taken into account that under the invalidity-insurance law
reasonable expenses may also be incurred by the insurance institu
tions in behalf o f the general welfare in the furtherance o f public
measures and methods for the prevention o f sickness, invalidity, and
premature death.
In addition to the separation made in the statistical analysis o f
the data concerning patients treated on account o f tuberculosis o f the
lungs and those treated on account o f other diseases, a further sepa
ration o f the facts is made regarding patients receiving full treatment,
which in practically all cases is institutional, and o f patients receiv
ing only partial treatment, which is largely o f the nature o f medical
consultations, prescriptions, dispensary service, dental work, etc. For
the present purpose only the full treatment o f patients is o f practical
and conclusive value, since the final results o f partial treatment must
in most cases be more or less a matter o f conjecture. The fact
also that the treatment o f patients for diseases other than tuber
culosis o f the lungs includes a considerable variety o f medical and
other causes precludes the scientific utility o f the data concerning
this group, and that this fact has been recognized by the Im perial
Insurance Office is made evident by a recent ruling, under which the
subsequent effects o f full or partial treatment for causes other than
tuberculosis o f the lungs2 w ill not longer be observed and reported
upon. Unless otherwise stated, therefore, the present discussion is
lim ited entirely to members o f Government invalidity insurance in
stitutions receiving full and systematic treatment as patients suffer
ing from tuberculosis o f the lungs and chiefly in special institutions
erected fo r the purpose or maintained by the insurance institutions
as an essential and more or less effective step toward the prevention
o f premature invalidity brought about by tuberculous diseases.
1 For a full statement of the legal provisions governing the treatment and care o$
members of invalidity insurance institutions, see Appendix IV.
2 This, term as used in the discussion is always inclusive of tuberculosis of the larynx.
B U LLETIN OF TH E BUREAU OF LABOR.
60
NUMBER OE PATIENTS TREATED, B Y SEX.
According to the report for 1910, the aggregate number o f patients
treated for all causes during the period 1897 to 1909 was 619,005, o f
whom 275,207, or 44.5 per cent, received treatment on account o f
tuberculosis o f the lungs. The details, by years, are given in the
table which follow s, according to which the percentage o f persons
treated on account o f tuberculosis o f the lungs, o f the total number
receiving treatment for all causes, has increased from 31.9 in 1897
to 42.4 in 1909.
NUMBER OF PERSONS TREATED ON ACCOUNT OF TUBERCULOSIS OF THE LUNGS IN
BEHALF OF GERMAN STATE INVALIDITY INSURANCE INSTITUTIONS, BY SEX AND
BY YEARS, 1897 TO 1909
Year.
Number of persons Per
treated.
cent of
tubercular
patients
On
of per
account
For all of tuber sons
causes. culosis
of treated
for all
thelungs. causes.
Per cent.
Males
treated
for tuber
culosis of
the lungs.
Females
treated
for tuber
culosis of
Fe
the lungs. Males. males.
1897.....................................................
1898.....................................................
1899.....................................................
1900.....................................................
1901.....................................................
1902.....................................................
1903.....................................................
1904.....................................................
1905.....................................................
1906.....................................................
1907.....................................................
1908.....................................................
1909.....................................................
10,564
13,758
20,039
27,427
32,710
35,949
43,593
49,491
56,420
66,883
74,023
86,990
101,158
3,374
4,937
7,759
11,150
14,757
16,516
20,171
23,511
26,834
31,375
32,543
39,340
42,940
31.9
35.9
38.7
40.7
45.1
45.9
46.3
47.5
47.6
46.9
44.0
45.2
42.4
2,625
3,822
6,074
8,469
10,862
12,205
14,956
16,985
19,241
22,172
22,557
26,790
29,747
749
1,115
1,685
2,681
3,895
4,311
5,215
6,526
7,593
9,203
9,986
12,550
13,193
77.8
77.4
78.3
76.0
73.6
73.9
74.1
72.2
71.7
70.7
69.3
68.1
69.3
22.2
22.6
21.7
24.0
26.4
26.1
25.9
27.8
28.3
29.3
30.7
31.9
30.7
Total..........................................
619,005
275,207
44.5
196,505
78,702
71.4
28.6
The available information concerning the general results o f sys
tematic and full treatment o f German invalidity insurance institu
tions is limited to the period 1897 to 1909. During this period 272,480
members received fu ll and systematic treatment on account o f tuber
culosis, and o f this number 194,787 patients were men and 77,693
patients were women. The proportion o f male patients, therefore,
was 71.5 per cent. In addition, 2,727 members received temporary
treatment on account o f tuberculosis, and o f this number 1,718 were
men and 1,009 were women. The number and proportion o f patients
receiving temporary or partial treatment on account o f tuberculosis
were, therefore, relatively small. During 1909 the number o f mem
bers receiving full treatment on account o f tuberculosis was 42,232,
and o f this number 29,277, or 69.3 per cent, were males. During the
same year the number o f members receiving temporary or partial
treatment on account o f tuberculosis o f the lungs was 708, and o f this
number 470, or 66.4 per cent, were males. Data fo r each year, 1897
to 1909, are given in the follow ing table:
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
61
NUMBER (BY SEX) AND PER CENT OF TOTAL PERSONS RECEIVING FULL TREAT
MENT AND PARTIAL OR TEMPORARY TREATMENT ON ACCOUNT OF TUBERCU
LOSIS OF THE LUNGS IN BEHALF OF GERMAN STATE INVALIDITY INSURANCE
INSTITUTIONS, BY YEARS, 1897 TO 1909.
Persons receiving full treatment.
Year.
Males.
Females.
Total.
Persons receiving temporary or partial
treatment.
Per
cent of
total
Males.
number
treated.
Females.
Total.
Per
cent of
total
number
treated.
1897..................................
1898..................................
1899..................................
1900..................................
1901..................................
1902..................................
1903..................................
1904..................................
1905..................................
1906..................................
1907..................................
1908..................................
1909..................................
2,598
3,806
6,032
8,442
10,812
12,187
14,937
16,957
19,085
21,959
22,258
26,437
29,277
736
1,104
1,666
2,652
3,844
4,302
5,211
6,520
7,536
9,063
9,816
12,288
12,955
3,334
4,910
7,698
11,094
14,656
16,489
20,148
23,477
26,621
31,022
32,074
38,725
42,232
98.8
99.5
99.2
99.5
99.3
99.8
99.9
99.9
99.2
98.9
98.6
98.4
98.4
27
16
42
27
50
18
19
28
156
213
299
353
470
13
11
19
29
51
9
4
6
57
140
170
262
238
40
27
61
56
101
27
23
34
213
353
469
615
708
1.2
.5
.8
.5
.7
.2
.1
.1
.8
1.1
1.4
1.6
1.6
Total......................
194,787
77,693
272,480
99.0
1,718
1,009
2,727
1.0
EXPENDITURES ON ACCOUNT OE TREATMENT AND CARE, 1897 TO 1909.
The total cost o f treatment and care fo r all causes fo r the period
1897 to 1909 was 151,217,587 marks ($35,989,774). O f this sum
99,673,647 marks ($23,722,328) was on account o f expenses incurred
for full treatment o f tuberculous wage earners, and 71,480 marks
($17,012) was paid out on account o f temporary treatment fo r tuber
culosis, making a total expenditure o f 99,745,127 marks ($23,739,340),
or 66 per cent o f the expenditures on account o f all diseases, including
tuberculosis. W hile the total expenses on account o f treatment for
all diseases have increased from 2,011,148 marks ($478,653) in 1897
to 24,275,577 marks ($5,777,587) in 1909, the expenses for full treat
ment on account o f tuberculosis have increased from 1,024,507 marks
($243,833) in 1897 to 16,303,618 marks ($3,880,261) in 1909. The
expenses on account o f irregular or temporary treatment on account
o f tuberculosis have increased from 2,589 marks ($616) in 1897 to
16,983 marks ($4,042) in 1909. The details by years are given in
the two tables which fo llo w :
BU LLETIN OF TH E BUBEAU OF LABOR,
62
AMOUNTS EXPENDED ON ACCOUNT OF TREATMENT AND CARE FOR TUBERCULOSIS
OF THE LUNGS IN BEHALF OF GERMAN STATE INVALIDITY INSURANCE INSTITU
TIONS, BY YEARS, 1897 TO 1909.
Year.
1897.............
1898.............
1899.............
1900.............
1901.............
1902.............
1903.............
1904.............
Total amount expended on Per cent
account of treatment for— of total
expend
iture on
account
of treat
ment of
All causes. Tuberculosis
of the lungs. tubercu
losis of
the
lungs.
$478,653.40
659,100.59
965,560.10
1,478,151.44
1,883,108.32
2,155,385.26
2,737,286.90
3,030,949.25
$244,448.94
368,510.66
572,398.81
896,489.30
1,199,222.83
1,394,957.57
1,763,738.76
2,017,059.55
51.1
55.9
59.3
63.7
64.7
64.4
66.5
Year.
1905
1906
1907
1908
1909
Total amount expended on Percent
account of treatment for— of total
expend
iture on
account
of treat
ment of
All causes. Tuberculosis
of the lungs. tubercu
losis of
the
lungs.
..................
$3,438,625.19
..................
3,965,185.93
..................
4,273,220.03
..................
5,146,960.15
..................
5,777,587.33
$2,305,233.88
2,734,988.26
2,830,847.68
3,527,141.20
3,884,303.04
67.0
69.0
Total.. 35,989,773.90 23,739,340.46
66.0
66.2
68.5
67.2
AMOUNTS EXPENDED ON ACCOUNT OF FULL TREATMENT AND CARE AND ON
ACCOUNT OF PARTIAL OR TEMPORARY TREATMENT AND CARE FOR TUBER
CULOSIS OF THE LUNGS IN BEHALF OF GERMAN STATE INVALIDITY INSURANCE
INSTITUTIONS, BY SEX OF PATIENTS AND BY YEARS, 1897 TO 1909.
Amounts expended on account of full treatment
and care.
Year.
Males.
Females.
Per
cent
oftotal
expen
ditures Males.
for
tuber
culosis.
Females.
Total.
Per
cent
of total
expen
ditures
for
tuber
culosis.
$243,832.73
368,128.58
571,594.45
896,108.77
1,198,281.60
1,394,350.42
1,763,458.75
2,016,878.99
2,303,729.23
2,732,962.05
2,828,889.90
3,523,851.56
3,880,261.08
99.75 $395.31 $220.90 $616.21
99.90
158.20
223.87
382.07
804.36
99.86
573.58
230.78
99.96
243.83
136.70
380.54
941.23
99.92
705.34
235.89
99.96
513.77
93.37
607.15
280.01
225i 04
99.98
54.97
102.71
77.85
180.55
99.99
99.93
918.91
585.74 1,504.64
99.93
891.27 1,134.93 2,026.20
787.54 1,957.79
99.93 1,170.25
99.91 1,770.72 1,518.92 3,289.64
99.90 2,720.34 1,321.61 4,041.95
0.25
.10
.14
.04
.08
.04
.02
.01
.07
.07
.07
.09
.10
Total... 17,544,561.95 6,177,766.17 23,722,328.12
99.93 10,389.27 6,623.06 17,012.34
.07
1897...............
1898...............
1899...............
1900...............
1901...............
1902 ...............
1903...............
1904...............
1905...............
1906...............
1907...............
1908...............
1909...............
$182,553.23
$61,279.60
278,543.63
89,584.95
445,489.33
126,105.12
693,424.86
202,683.90
896,977.42
301,304.17
1,044,766.99
349,583.43
1,329,012.77
434,445.98
1,509,013.60
507,865.39
1,727,466.05
576,263.18
2,033,071.47
699,890.58
2,056,997.59
771,892.31
2,530,635.44
993,216.13
2,816,609.57 1,063,651.51
Total.
Amounts expended on account of par
tial or temporary treatment and care.
O f the total number o f male patients treated and cared for, 48.7
per cent were treated on account o f tuberculosis o f the lungs. The
corresponding proportion fo r female patients was 36.5 per cent.
Since 1897 the number o f persons treated and cared fo r in special
institutions owned or controlled by the State invalidity insurance in
stitutions has increased nearly tenfold. In ’ 1909, o f all persons
treated and cared fo r 42.4 per cent were treated on account o f tuber
culosis o f the lungs, and o f these 98.4 per cent received fu ll, sys
tematic, and largely indoor or special institutional treatment. The
CARE OP TUBERCULOUS WAGE EARNERS I N GERM ANY.
63
tendency toward special institutional treatment o f tuberculous mem
bers o f the German State invalidity insurance institutions is ex
plained on the ground that from a considerable amount o f experi
ence it has been shown that only by means o f such treatment can
the required economic results be secured. The considerable finan
cial expenditures on this account are justified by the fact that tuber
culosis o f the lungs, according to the investigations o f 1896 to 1899,
holds the third position as the primary cause o f invalidity among
men, and the second position as the primary cause o f invalidity
among women insured with German State invalidity insurance insti
tutions.
During the period 1897 to 1909, out o f 619,005 patients treated and
cared for on account o f all diseases, 275,207 were treated and cared
fo r on account o f tuberculosis o f the lungs, at an expense o f nearly
100,000,000 marks ($23,800,000). The total expenses fo r all causes,
including tuberculosis, during the period were 151,217,537 marks
($35,989,774). A portion o f this expense was refunded to the inva
lidity insurance institutions by sick funds, industrial accident asso
ciations, local authorities, poor funds, etc. In 1909 the refunded
amount was 4,948,044 marks ($1,177,635) out o f a total expense on
account o f all causes o f 24,275,577 marks ($5,777,587), leaving a net
expense on account o f treatment and care incurred by the in
validity insurance institutions during the year o f 19,327,533 marks
($4,599,953).
Summarizing the general results o f the experience fo r the period
1897 to 1909, it is shown by the report fo r 1910 that the total ex
penses on account o f treatment and care amounted to 151,217,537
marks ($36,454,588). O f this amount the sum o f 27,807,094 marks
($6,618,088) was refunded by sick funds, industrial accident associa
tions, local authorities, poor funds, etc., leaving a net aggregate ex
pense paid for by the invalidity insurance institutions o f 123,410,443
marks ($29,371,685). O f this sum 16,902,514 marks ($4,022,698)
was paid for the support o f dependent members o f the patients’
families, equivalent to 11.2 per cent o f the total disbursements for
all causes.
INCREASE IN EXPENDITURES ON ACCOUNT OF TREATMENT AND CARE.
The expenditures on the part o f invalidity insurance institutions
on account o f treatment and care for diseases o f all kinds have
steadily risen from year to year. In 1897 the amount expended on
this account was 1.6 per cent o f the total amount paid in contribu
tions by the members o f the State invalidity insurance institutions,
increasing gradually to 6.6 per cent in 1903, and finally reaching
10.3 per cent in 1909. The average expenditure for treatment and
care during the period 1897 to 1909 was 6.3 per cent o f the in
64
B U LLETIN OF TH E BUREAU OF LABOR.
come derived from contributions and exclusive o f the income derived
from interest or other sources.
COMPARISON OF CONTRIBUTIONS AND EXPENDITURES FOR TREATMENT.
On the basis o f the annuity payments to beneficiaries o f the State
invalidity insurance institutions the expenditures fo r treatment and
care were 3.4 per cent o f this amount in 1897, increasing to 8.3 per
cent in 1903, and to 12.2 per cent in 1909. During the period 1897 to
1909 the average expenditure fo r treatment and care was 8.5 per
cent o f the total payments made on account o f disability and other
annuities payable in conform ity to the provisions o f the compulsory
invalidity insurance law.
EXPENDITURES DURING 1909.
W hile the foregoing expenditures include the treatment and care
o f patients fo r all diseases, the expenditures for particular classes o f
patients, with distinction o f sex, but only fo r the year 1909, are given
in the table below :
EXPENDITURES FOR TREATMENT AND CARE OF INVALID MEMBERS OF GERMAN
STATE INVALIDITY INSURANCE INSTITUTIONS DURING 1909, BY SEX.
Expenditures on account of—
Tuberculosis of the lungs, full treatment:
Males.............................................................................................................
Females.........................................................................................................
Tuberculosis, temporary or partial treatment:
Males.............................................................................................................
Females.......................................................................................................
All other diseases, full treatment:
.Males.............................................................................................................
Females.........................................................................................................
All other diseases, temporary or partial treatment:
Males.............................................................................................................
Females.........................................................................................................
Amount.
Per cent
$2,816,610
1,063,652
48.75
18.41
2,720
1,322
.05
.02
1,098,034
612,943
19.00
10.61
97,384
84,923
1.69
1.47
Total on account of tuberculosis................................................................
Total on account of other causes and diseases...........................................
3,884,304
1,893,284
67.23
32.77
Total expenditures for all causes...............................................................
5,777,588
100.00
According to this table, the total expenditures for treatment and
care for all diseases and causes during 1909 amounted to 24,275,577
marks ($5,777,588). O f this expenditure 67.23 per cent was on
account o f tuberculosis o f the lungs and 32.77 per cent on account
o f other diseases and causes. On account o f male patients receiving
fu ll treatment and care fo r tuberculosis o f the lungs 11,834,494 marks
($2,816,610) was expended during the year, or 48.75 per cent o f the
total expenditures for all diseases and causes. The expenditure on
account o f female patients treated and cared for during the year was
4,469,124 marks ($1,063,652), or 18.41 per cent o f the total expendi
tures for all diseases and causes. The expenditures on account o f
tuberculosis o f the lungs for temporary or partial treatment are only
a minor consideration. The analysis clearly shows that over two-
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
65
thirds o f the expenditures on account o f treatment and care were
incurred on account o f tuberculosis o f the lungs. It, o f course, is
well known that the membership o f invalidity insurance institu
tions constitutes practically the total active wage-earning popu
lation o f the German Empire. Whatever, therefore, is done in this
respect, or in this direction, is prim arily for the uplift, protection,
and care o f the men and women engaged in German industry at the
present time.
PROPORTION OF INSURED POPULATION TREATED AND CARED FOR
DURING 1909.
In 19071 the population liable to insurance in conform ity to the
compulsory invalidity insurance laws was ascertained to be 14,631,390.
Since the total number o f persons receiving treatment and care on
account o f tuberculosis o f the lungs in 1909 was 42,940, the rate o f
persons receiving treatment and care on account o f this disease was
29.35 per 10,000. F or purposes o f comparison it may be stated that
the number o f persons receiving treatment on account o f diseases
and causes other than tuberculosis o f the lungs was 58,218, or at the
rate o f 39.79 per 10,000 o f population within the scope o f the com
pulsory insurance laws. The total number o f persons receiving
treatment for all causes was 101,158 during 1909, or at the rate o f
69.14 per 10,000 o f insurable population. In marked contrast are
the results for 1897, when the population subject to the insurance
laws was ascertained to be 11,813,259, and the total number o f persons
receiving treatment and care for all causes was only 10,564, or at the
rate o f 8.94 per 10,000 o f insurable population. The actual number
o f persons receiving treatment for all causes has, therefore, increased
857.6 per cent between 1897 and 1909, while the rate per 10,000 o f
insurable population has increased 673.4 per cent.
PROPORTION OF PATIENTS TREATED, B Y SELECTED STATES.
The foregoing estimate applies to the German Empire as a whole.
The rate varies considerably for the different States or territorial
divisions o f the Empire, prim arily, o f course, because o f the greater
or lesser proportion o f the population within the scope o f the in
surance laws. In Berlin, for illustration, in 1909 the ratio o f total
persons receiving treatment for all causes was 171 per 10,000 o f in
surable population, for Upper Bavaria the rate was 153, for Baden
144, and for the Thuringian States 127. The lowest rate was 14
per 10,000 for Mecklenburg, which is almost exclusively an agri
cultural section. It is hardly necessary to emphasize in this discussion
that tuberculosis, as well as many other diseases, is generally much
1 The date of the last industrial census.
49397°—12----- 5
66
B U LLETIN OF TH E BUREAU OF LABOR.
more common among the industrial than among the agricultural pop
ulation and more common among the population o f cities with con
gested districts than among the population o f rural districts.1 These
conditions largely govern the relative proportion o f insured members
receiving treatment in special institutions, the range being, as stated,
between a minimum o f 14 and a maximum o f 171 per 10,000. These
rates have no reference to the membership o f supplementary asso
ciations or institutions within the scope o f the compulsory invalidity
insurance laws, limited practically to railways and mines, and for
which the rates o f members treated and cared for have ranged from
4 to 208 per 10,000 employees.
NOTIFICATION OF ARM Y RECRUITS WHO W E R E REJECTED ON ACCOUNT
OF TUBERCULOSIS.
F or the purpose o f securing the earliest possible information con
cerning incipient cases o f tuberculosis o f the lungs, a regulation was
adopted in 1907, under which inform ation concerning army recruits
rejected on account o f tuberculosis o f the lungs was required to be
communicated to the State invalidity insurance institutions o f which
they were members. In 1909 notifications o f 575 cases o f incipient
tuberculosis, and o f 587 recruits otherwise diseased, were communi
cated to the insurance institutions for the purpose o f providing, if
advisable, the required treatment in anticipation o f a cure. O f this
number, however, only 218 o f the tuberculous subjects received insti
tutional treatment, and o f these 180, or 82.6 per cent, were subse
quently discharged as cured, in conform ity to section 4, paragraph
5, o f the invalidity insurance law [art. 1255, par. 2, o f the W ork
men’s Insurance Code o f July 19, 1911]. In the case o f those not
treated, the reasons for declining action on the part o f the insurance
institutions were chiefly the probability o f noneffectiveness o f the
treatment, or noneligibility to treatment on the part o f the insurance
institutions. In some cases the disease had advanced too far, and in
some others it was o f too incipient a nature to warrant the anticipa
tion o f invalidity within a reasonable period o f time. In a general
way it would appear that while much had been expected from this
cooperation between the m ilitary authorities and the insurance insti
tutions, the actual results have not been as satisfactory as had been
assumed would be the case. W hile the number o f cases may seem
relatively small, it requires to be considered that every case o f in
validity involves a serious possibility o f material expense on the part
o f the insurance institutions, aside from the humanitarian considera
tions, which make it o f the utmost importance that every case o f
incipient tuberculosis shall, i f practicable, be treated systematically
and effectively from the earliest stage o f the disease.
1 There are, however, exceptions to the rule, which have no bearing upon the present
discussion.
OAEE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
67
FINANCIAL AID GIVEN BY IN VALID ITY INSURANCE INSTITUTIONS IN
THE CAMPAIGN AGAINST TUBERCULOSIS.
In common with other civilized countries there are throughout
Germany to-day a large number o f voluntary associations for aid
and assistance o f wage earners and others in the event o f sickness,
but there are also many institutions other than those maintained by
charitable or philanthropic contributions, supplementary to the
institutions maintained by the State insurance funds. A s an en
couragement and aid in the campaign against tuberculosis, the State
invalidity insurance institutions during 1909 paid out 288,365 marks
($68,631), against 248,805 marks ($59,216) in 1908. O f the expendi
tures during 1909 the sum o f 116,175 marks ($27,650) was for con
tributions and aid to societies, committees, etc., organized for the
establishment o f day camps, forest convalescing homes, etc. The sum
o f 159,265 marks ($37,905) was paid out for the establishment or
maintenance o f bureaus o f information and dispensaries for the
benefit o f persons afflicted with tuberculosis, while 12,925 marks
($3,076) was paid out in grants for miscellaneous similar purposes.
W hile these amounts are relatively not very large, the aid rendered
is often substantial and practically indispensable to the further
ance o f the aims and objects o f the general campaign or warfare
against tuberculosis. F or illustration, the Invalidity Insurance In
stitution o f Berlin, in 1909, paid out 40,550 marks ($9,651), o f which
30,000 marks ($7,140) was paid to the central committee for instruc
tion and care o f tuberculous persons in Berlin and vicin ity; 50 marks
($11.90) to the German Central Committee for the establishment o f
institutions, day camps, etc., for tuberculous persons; 500 marks
($119) for the Provincial Antituberculosis Association o f Branden
burg; and 10,000 marks ($2,380) to the Red Cross Society for the
establishment o f public sanatoria. Some o f the other territorial in
surance institutions make even more varied contributions, partly for
educational purposes, but largely in aid o f direct efforts to combat
the disease by the institutional segregation and treatment o f patients
and their effective, systematic care.
In addition to the foregoing, the invalidity insurance institutions
make grants o f variable sums to communities in aid o f the establish
ment or maintenance o f dispensaries, hospitals, district nursing asso
ciations, etc. During 1909 the sum o f 288,449 marks ($68,651) was
paid out on this account by all o f the State invalidity insurance
institutions, against 214,093 marks ($50,954) paid out in 1908. The
m ajor portion o f this sum was in behalf o f the campaign against
tuberculosis and on account o f cases not suitable for institutional
treatment.
68
FAM ILY
BU LLETIN OP TH E BUBEAU OF LABOB.
SUPPORT
OF
TUBERCULOUS WAGE
SANATORIA.
EARNERS
IN
PUBLIC
T o encourage invalid members to make use o f institutions for the
treatment and cure o f tuberculosis o f the lungs the invalidity insur
ance law provides for grants o f financial aid to dependent members
o f the patient’s fam ily in excess o f the amount payable in conform ity
to the sickness insurance laws. The use which is made o f this author
ity varies considerably with different insurance institutions. The
institution o f East Prussia, fo r illustration, grants double the amount
o f legal aid to dependents in the event o f sickness, while Berlin and
Brandenburg provide, on the consideration o f cases on their indi
vidual merits, to the extent o f three times the minimum legal aid.
Hanover provides in individual cases supplementary aid to depend
ents to a maximum amount o f 15 marks ($3.57) a week, but in
most cases the aid is limited to double the amount receivable in the
event o f ordinary sickness, the supplementary assistance being
granted as an inducement fo r those in apparent need to make use at
the earliest possible moment o f the institutions providing fo r the
effective treatment o f diseases, chiefly tuberculosis o f the lungs. As
has been previously stated, during 1909, 3,221,957 marks ($766,826)
was paid out by invalidity insurance institutions on account o f the
- support o f dependent members o f the patients’ families—that is, on
account o f patients treated for all diseases and causes, including
tuberculosis o f the lungs—the expense being considered necessary,
and in fact indispensable, to induce patients in the incipient stage
o f the disease to seek treatment when the outlook is most favorable.
W ith further reference to the amounts disbursed in aid o f de
pendents o f tuberculous patients it was brought out by the investiga
tion o f 1909 that during that year, on account o f 4,456 patients
under treatment fo r tuberculosis o f the lungs the sum o f 122,985
marks ($29,270) was paid as supplementary aid to dependent mem
bers o f the families, in addition to the aid provided in conform ity
to the sickness insurance laws. The particular importance attached
to this form o f support in behalf o f effective measures against tuber
culosis is brought out by the fact that for all other diseases dealt
with by State invalidity insurance institutions during 1909 on ac
count "of 1,993 patients, only 25,152 marks ($5,986) was paid out in
aid o f dependent members o f the patients’ families.
Summarizing the special expenditures on account o f treatment and
care o f invalid members o f State invalidity insurance institutions it
has been shown that the amount paid on this account to local authori
ties for general sick aid was 288,449 marks ($68,651); in behalf o f
the general warfare against tuberculosis, 288,365 marks ($68,631);
on account o f disinfection o f premises, 3,770 marks ($897); and for
increased aid fo r dependent members o f the patients’ fam ilies.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
69
122,985 marks ($29,270). Out o f 17,024,170 marks ($4,051,752)
paid for treatment and care on account o f tuberculous patients in
State invalidity insurance institutions 703,569 marks ($167,449), or
4.1 per cent, was paid for special purposes in behalf o f the general
campaign against tuberculosis or in behalf o f other measures and
means for effective treatment and the reduction o f the death rate.
Efforts have been made within recent years to enforce the general
laws and local regulations providing for the disinfection o f rooms
occupied by tuberculous patients, and particularly rooms in which
deaths from tuberculosis have occurred. The State invalidity insur
ance institutions extend financial aid in behalf o f this movement in
special cases, and in 1909 the amount o f 3,770 marks ($897) was ex
pended on this account. As a general rule the expenses o f disinfec
tion are paid for by the local authorities, under police supervision.
METHODS
OE TREATMENT
AND
CARE.
The methods o f treatment and care naturally vary more or less with
the different territorial State invalidity insurance institutions, but
the general principle o f the so-called hygienic-dietetic treatment has
been almost universally adopted. This method affords abundant fresh
air and nutritious diet, systematic care o f the skin, and a wholesome
mode o f life generally. The use o f mineral baths or spas is rather
limited, and during 1909 the number o f tuberculous patients making
use o f this form o f treatment was only 3,374. The use o f baths, how
ever, is increasing, as is shown by the fact that in 1905 the number
o f tuberculous patients at baths was only 1,457. O f the total number
o f 42,232 tuberculous patients receiving treatment and care during
1909, as many as 36,785, or 87.1 per cent, received such treatment
in sanatoria or other special institutions especially established for
the most effective and systematic treatment o f tuberculosis o f the
lungs. As has been previously stated, the number o f tuberculous
patients treated at baths during 1909 was 3,374, or 8 per cent.
In addition, 1,298, or 3.1 per cent, were treated at day camps or con
valescing homes; 757, or 1.8 per cent, in general and special hospitals
and clinics, and 13 in private homes or on farm s; for 5 the method
o f treatment was not obtainable. It is evident, therefore, that the
large m ajority o f tuberculous patients treated or cared for in be
half o f German State invalidity insurance institutions receive such
treatment and care in special institutions established for the most
effective and systematic treatment o f the disease. The foregoing
numbers, however, have reference only to such tuberculous patients
as received a fu ll and systematic treatment, and they have no refer
ence to the relatively small number o f patients who received tem
porary or partial treatment, chiefly in the form o f medical consulta
tions, dispensary treatment, etc.
70
BU LLETIN OF TH E BUBEAU OF LAB OB,
The inform ation is shown in detail fo r each territorial insurance
institution in the table which follow s:
NUMBER OF PEBSONS BECEIVING FULL TKEATMENT AND CABE ON ACCOUNT OF
TUBERCULOSIS OF THE LUNGS, IN TEBRITORIAL AND EMPLOYEES INSURANCE
INSTITUTIONS DURING 1909, BY KIND OR METHOD OF TREATMENT.
Territorial and employees’ insurance
institutions.
East Prussia...................................................
West Prussia..................................................
Berlin.................... ........................................
Brandenburg..................................................
Pomerania. 7 . ..................................................
Posen..............................................................
Silesia..............................................................
Saxony-Anhalt...............................................
Schleswig-Holstein..........................................
Hanover..........................................................
Westphalia.....................................................
Hesse Nassau..................................................
Rhine Province..............................................
Upper Bavaria................................................
Lower Bavaria................................................
Pfalz................................................................
Upper Pfalz and Regensburg.........................
Upper Franconia............................................
Middle Franconia...........................................
Lower Franconia and Aschaffenburg.............
Swabia and Neuburg......................................
Kingdom of Saxony........................................
Wurttemberg..................................................
Baden.............................................................
Hesse (Grand Duchy)....................................
Mecklenburg...................................................
Thuringia........................................................
Oldenburg......................................................
Brunswick......................................................
Liibeck, Bremen, and Hamburg....................
Alsace-Lorraine...............................................
Prussia-Hesse railroad employees...................
North German miners’ fund...........................
Saarbmcken Miners’ Association....................
Bavarian traffic employees............................
Saxony railroad employees’ fund..................
Saxony miners’ fund......................................
Baden railroad and salt works fund...............
Imperial railroad pension fund......................
Bochum Miners’ "union..................................
Marine employees’ fund................................
Total......................................................
In
gen
eralor
special
hospi
tals.
In institutions
for the treat In con
ment of
vales At In pri
tuberculosis.
cent
vate Not Total.
homes, baths,
homes, speci
day spas,
etc.
etc. fied.
Num
Per camps,
etc.
ber.
cent.
357
159
3,890
1,707
179
730
1,728
1,554
219
1,291
1,935
1,138
3,968
1,319
122
508
110
251
823
209
281
2,428
1,610
2,429
1,071
108
775
204
397
1,302
1,316
1,126
531
8
157
59
16
132
154
443
41
92.0
92.4
100.0
83.8
71.3
99.9
66.0
99.7
42.4
99.2
68.4
61.2
76.9
83.2
79.2
100.0
93.2
100.0
100.0
100.0
99.6
96.6
99.3
95.7
99.8
99.1
97.6
100.0
100.0
81.9
100.0
88.8
100.0
100.0
99.4
100.0
100.0
100.0
100.0
94.5
97.6
757 36,785
87.1
20
7
84
49
1
37
15
9
3
29
323
14
28
i
2
11
110
1
9
2
1
1
11
1
17
245
6
843
2
1
9
1
277
93
889
599
869
2
250
4
1
5
1
1
1
7
82
2
2
1
18
69
2io
140
1
25
1,298 3,374
13
5
388
172
3,890
2,036
251
731
2,617
1,558
517
1,301
2,827
1,860
5,160
1,585
154
508
118
251
823
209
282
2,514
1,621
2,539
1,073
109
794
204
397
1,590
1,316
1,268
531
8
158
59
16
132
154
469
42
5 42,232
There are throughout Germany a number o f forest and air cure
establishments, which are made use o f jointly by members o f sick
funds, industrial accident associations, and State invalidity insur
ance institutions. The exact number o f tuberculous patients at these
establishments is not known, but the aggregate number o f persons
receiving treatment, either on account o f tuberculosis or on account
o f other diseases, in 1909 was 1,481 males and 1,330 females. The
form er received 46,381 days’ treatment and the latter 40,856 days.
The average number o f days’ treatment per patient, therefore, was
31.3 for males and 30.7 for females. The total expenditure on account
o f these establishments was 100,500 marks ($23,919) fo r males and
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
71
05,747 marks ($15,648) for females. The increasing use which is
made o f them is illustrated by the fact that the corresponding ex
penditures for 1907 were only 66,579 marks ($15,846) fo r males and
26,997 marks ($6,425) for females.
F or the treatment and care o f tuberculous patients in the advanced
stages o f the disease, unfit on account o f their condition fo r treat
ment in sanatoria or other special institutions, so-called invalid
homes are maintained by many o f the State invalidity insurance
institutions. The treatment is more in the nature o f a humane con
sideration for the well-being and com fort o f hopeless cases than for
the economic object o f restoring the wage-earning capacity o f afflicted
members. During 1909 the number o f tuberculous patients taken
care o f in institutions o f this kind was 1,047 males and 300 females.
O f this number 229 males and 77 females died during the year, prov
ing conclusively that these patients were in an advanced stage
o f the disease when admitted. A t the end o f 1909 the number re
maining under treatment and care was 294 males and 108 females,
against 196 males and 82 females receiving care and treatment at the
end o f 1908. The use o f these institutions is therefore increasing.
The treatment and care o f tuberculous members o f German State
invalidity insurance institutions is largely confined to sanatoria, hos
pitals, etc., owned, maintained, and managed by the insurance insti
tutions themselves. The number o f owned sanatoria, etc., fo r the
treatment o f tuberculosis o f the lungs has increased from 1 in 1895
to 18 in 1903 and 37 in 1909, as is shown in the follow ing table:
NUMBER OF SPECIAL INSTITUTIONS FOR THE TREATMENT AND CARE OF INVALID
MEMBERS, OWNED BY GERMAN STATE INVALIDITY INSURANCE INSTITUTIONS,
BY YEARS, 1895 TO 1909.
Year.
Institu
tions for General
the treat hospitals
ana con
ment of valescent
tuber
homes.
culosis.
1895.......................
1896.......................
1897.......................
1898.......................
1899.......................
1900.......................
1901.......................
1902.......................
1
1
3
5
8
9
11
15
1
2
5
7
12
Total.
1
1
3
6
10
14
18
27
Year.
1903.....................
1904.....................
1905.....................
1906.....................
1907.....................
1908.....................
1909.....................
Institu
General
tions for
the treat hospitals
ana
con
ment of valescent
tuber
homes.
culosis.
18
22
26
26
30
36
37
17
19
21
25
26
29
34
Total.
35
41
47
51
56
65
71
The first institution owned by an invalidity insurance fund was the
sanatorium o f Hanover, opened for the treatment o f patients on May
1, 1895. These institutions are not necessarily located within the
territorial boundaries o f the State insurance institutions, but they
are often located where the topography, natural drainage, forest
environment, climate, etc., are most suitable. The insurance institu
tion o f Berlin owns also a tuberculin station, which is utilized to a
72
BULLETIN OF THE BUREAU OF LABOR,
limited extent by other insurance institutions. Full details con
cerning the accommodation o f the principal institutions in active
operation at the present time, together with the most important
financial and other statistics, are set forth in the table which follow s:
FINANCIAL AND OTHER STATISTICS OF INSTITUTIONS FOR THE TREATMENT OP
TUBERCULOSIS OF THE LUNGS, OWNED BY GERMAN STATE INVALIDITY INSUR
ANCE INSTITUTIONS, 1909.
Num
ber of
insur
ance
insti
tu
tion.
Name of hospital or sanatorium.
fBeelitz.....................................................................................
Beelitz annex...........................................
3 <
(
Tuberculosis station.................................
4 Cottbus...........................................................
6 Crown Prince W inj a m ....................................
....... .....................................................
8 fip.hipjo
Konigsbergbei Goslar.....................................
Schwarzenbach bei Clausthal.........................
10 ■ Erbprinzentanne bei Zellerfeld.......................
An d rp.fl-gTip.im
st. Andreasberg..................
Stiibeckshom bei Soltau................................
13 Ronsdorf.........................................................
16 Pfalzische Sanatorium in Ramberg................
21 Wasach bei Obertiefenbach............................
22 Hohwald bei Neustadt...................................
/ W iihp.lmsTiPim bei Oppenweiler............................
23 \tiberruh bei Bolstemang................................
|Friedrichsheim bei Marzell.............................
24 JT.nigp.nTiPim "bei ‘MVurr.ftll..................................
1Nordrach Colony............................................
26 /^mst-biidwig Sanatorium..............................
.................................................
i Rfimhilri
27 Sophia Sanatorium.........................................
/ Albrechtshaus bei Stiege................................
29 iMarie Home...................................................
nderberg-^ftbbard^hftini................................
30 * Gluckauf in St. Andreasberg.........................
Gross-Hansdorf...............................................
f TjAopo1dinftnliP.in\_______________________
31 1Tannenberg.....................................................
/Stadtwald
bei Mp.ignngp.n...............................
32 \Moltkefels........................................................
33 Miners Sanatorium—Siilzhayn........................
38 Frederick-Hilda Sanatorium...........................
40 August-Victoria Sanatorium...........................
i To Dec. 31,1909.
Number of beds
for—
Date of
Land
estab
area
lish
occupied
ment. Males. Females. (acres).
1902
1907
1908
1900
1903
1905
1895
1899
1898
1903
1902
1909
1905
196
294
20
100
143
70
70
65
138
61
1905
1904
1908
1899
1905
1908
1901
260
177
1908
1897
1899
1897
1901
1908
1903
1907
1904
1904
1898
1907
1904
120
86
1902
234
iio
132
180
32
140
120
104
130
59
118
Cost of
grounds
73
283
346.0
$95,788.10
110
40.5
33.6
81.9
18.1
36.8
36.3
29.8
73.8
91.5
64.0
68.2
56.0
18.4
75.6
53.9
37.7
45.5
27.4
22,597.15
9,064.47
28,384.83
4,093.60
5,331.20
11,233.60
232.5
3.6
1.6
144.8
11.4
56.2
10.6
25.9
42.1
53.2
23.5
24.2
456.4
68,091.80
63
43
180
1.99
80
36
100
92
30
* Leased.
8.2
m
(2)
29,585.78
14,125.06
19,168.28
17,046.75
8,752.45
15,654.21
6,323.66
14,267.15
26,180.00
14,586.31
1,214.28
(2)
(2)
13,621.45
4,163.10
18,271.02
14,756.00
5,950.00
17,124.34
16,933.94
7,278.04
13,140.69
14,280.00
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY,
73
FINANCIAL AND OTHER STATISTICS OF INSTITUTIONS FOR THE TREATMENT OF
TUBERCULOSIS OF THE LUNGS, OWNED BY GERMAN STATE INVALIDITY INSUR
ANCE INSTITUTIONS, 1909—Continued.
Num
ber of
insurance
insti
tu
tion.
Cost of—
Name of hospital or sanatorium.
Buildings.1
Interior
furnish
ings, etc.1
Expenditures during
1909.
Total.
fBeelitz............................................................. $2,471,433.41 $261,272.35 $586,509.11
Beelitz annex........................................... 1,364,826.95 134,835.57
3 <
[
Tuberculosis station.................................
1,767.39
9,769.90
4 'Cottbus...........................................................
128,792.99 40,554.01 30,869.31
6 Crown Prince William....................................
140,398.58 16,254.45 34,725.39
196,368.80 21,950.74 52,136.28
8 Schielo.............................................................
fKOnigsberg bei Goslar....................................
64,902.60 13,328.00 16,780.67
Schwarzenbach bei Clausthal.........................
67,330.20 13,827.80
9,663.28
Erbprinzentanne
bei
Zellerfeld.............
........
55,573.00
10
16,112.60 14,978.77
Andreasheim bei St. Andreasberg;................
18,159.40
8,896.44
11,380.92
41,792.80 17,969.00 17,696.25
Sttibeckshom bei Soltau................................
138,040.00 13,090.00 54,205.69
13 Ronsdorf.........................................................
16 Pfalzische Sanatorium in Ramberg................
192,193.81 17,058.89 24,674.65
2,323.12
21 Wasach bei Obertiefenbach............................
467,067.15 46,418.33 89,085.78
22 Hohwald bei Neustadt..................................
/Wilhelmsheim
bei
Oppenweiler.....................
251,069.77
30,964.28 59,957.44
23 Uberruh bei Bolstemang................................
426,162.80 41,320.37 61,238.11
IFriedrichsheim bei Marzell.............................
395,592.65 42,092.92 86,539.89
259,749.63 27,013.24 50,428.39
24 ■Luisenheim bei Marzell..................................
Nordrach Colony............................................
65,130.37 20,855.70 60,229.71
265,961.19 43,956.70 46,895.28
25 Emst-Ludwig Sanatorium..............................
111,788.36
/Romhild..........................................................
10,545.30 20,879.26
27 ySophia Sanatorium........................................
69,328.21
7,140.00 31,491.92
44,684.50
/Albrechtshaus
bei
Stiege................................
7,665.74 17,432.79
29 \Marie Home....................................................
20,384.70
4,059.80
6,644.01
[Oderberg-Gebhardsheim................................
292,176.18 34,124.44 79,249.48
138,400.09 12,110.39 37,163.70
30 ■{Gliick auf in St. Andreasberg.........................
6,270.82 13,111.18
[Gross-Hansdorf...............................................
43,901.24
62,545.21
9,864.86 27,975.95
31 /Leopoldinenheim............................................
yTannenberg.....................................................
134,487.85 24,664.42 58,106.27
219,476.46 17,508.47 51,641.72
/Stadtwald bei Melsxmgen...............................
32 \Moltkefels.......................................................
181,292.93 15,811.53 48,590.32
206,004.71 16,660.00 44,075.46
33 Miners Sanatorium—Stilzhayn.......................
103,099.93 13,969.41 27,702.49
38 Frederick-Hilda Sanatorium...........................
460,233.93 25,331.29 79,422.98
40 August-Victoria Sanatorium...........................
i
To Dee. 31,1909.
For food
and drink.
$121,133.91
2,671.79
12,900.31
16,122.83
28,894.50
7,167.37
4,278.76
5,228.86
3,526.92
7,490.57
25,278.69
9,622.58
30,417.11
28,793.95
21,172.48
46,690.36
25,334.15
24,991.19
18,975.50
7,956.82
15,039.46
10,689.53
3,651.63
31,912.94
12,490.72
5,902.64
15,112.52
27,885.51
22,550.74
19,924.41
18,165.11
14,205.74
23,719.08
74
BULLETIN OF THE BUBEAU OF LABOR,
FINANCIAL AND OTHER STATISTICS OF INSTITUTIONS FOR THE TREATMENT OF
, TUBERCULOSIS OF THE LUNQS, OWNED BY GERMAN STATE INVALIDITY INSUR. ANCE INSTITUTIONS, 1909-Conoluded.
Total
days of
treatment
and
Days of
support
treat
of and
Num ment Num Days
sup days of
and
ber.
ber. port.
sup
sup
port.
port.
Patients.
Num
ber of
insur
ance
insti
tu
tion.
3
4
6
8
10
13
16
21
22
23
24
25
27
29
30
: 31
32
33
38
40
Name of hospital or sanatorium.
[Beelitz.............................................
Beelitz annex...........................
Tuberculosis station.................
Cottbus...........................................
Crown Prince William....................
Schielo.............................................
fKonigsberg bei Goslar....................
Schwarzenbach bei Clausthal.........
«Erbprinzentanne bei Zellerfeld.......
Andreasheim bei St. Andreasberg..
Stiibeckshom bei Soltau.................
Ronsdorf.........................................
Pfalzische Sanatorium in Bamberg.
Wasachbei Obertiefenbach...........
Hohwald bei Neustadt...................
[ W ilhelmsheim bei Oppenweiler....
\TJberruh bei Bolstemang................
(Friedrichsheim bei Marzell.............
•jLuisenheim bei Marzell..................
INordrach Colony.............................
Emst-Ludwig Sanatorium..............
fBomhild..........................................
\Sophia Sanatorium........................
fAlbrechtshaus bei Stiege................
\Marie Home....................................
|Oderberg-Gebhardsheim................
\ Gluck auf in St. Andreasberg.........
[Gross-Hansdorf...............................
fLeopoldinenheim............................
\Tannenberg.....................................
fStadtwald bei Melsungen...............
\Moltkefels........................................
Miners Sanatorium—Stilzhayn.......
Frederick-Hilda Sanatorium..........
August-Victoria Sanatorium...........
\
[
4,478 301,224
Employees.
Per capita cost per
day of food and #
drink.
Pa
Treat
ment Pa- tients
and tients and
em
sup only. ploy
port.
ees.
166 60,296 361,520 $1.42 $0.40
493
496
560
640
330
187
279
158
272
669
329
6,669
40,000
34,415
51,250
21,278
11,139
18,730
12,906
18,908
47,254
22,175
8 2,320
21 7,537
21 7,591
27 9,355
10 3,403
10 2,511
10 3,758
8 2,558
12 4,204
30 10,751
16 5,530
1,388
1,064
869
1,233
970
565
727
372
548
361
136
905
433
383
491
838
703
537
556
299
465
77,209
59,579
63,272
81,892
71,452
37,033
45,043
24,949
34,449
22,370
8,718
51,243
31,316
9,462
29,435
50,231
44,431
38,503
37,699
24,957
37,224
44
37
41
42
27
32
25
16
17
10
7
43
20
10
18
20
25
25
32
19
37
$0.34
8,989
47,537
42,006
60,605
24,681
13,650
22,488
15,464
23,112
58,005
27,705
1.47
.77
1.01
1.02
.79
.87
.80
.88
.94
1.15
1.11
.40
.32
.47
.41
.34
.38
.28
.27
.40
.54
.43
.30
.27
.38
.35
.29
.31
.23
.23
.32
.44
.35
14,756 91,965
13,650 73,229
13,721 76,993
19,056 100,948
11,290 82,742
11,076 48,109
5,860 50,903
6,021 30,970
6,367 40,816
4,302 26,672
2,742 11,460
13,418 64,661
5,744 37,060
3,136 12,598
5,701 35,136
7,084 57,315
9,830 54,171
9,531 48,034
10,156 47,855
6,868 31,825
11,431 48,655
1.15
1.01
.97
1.06
.71
1.63
1.04
.84
.91
.78
.76
1.55
1.19
1.39
.95
1.16
1.16
1.26
1.17
1.11
2.13
.40
.48
.34
.57
.35
.67
.42
.32
.44
.48
.42
.62
.40
.62
.51
.55
.51
.52
.48
.57
.64
.33
.39
.28
.46
.31
.52
.37
.26
.37
.40
.32
.49
.34
.47
.43
.49
.42
.41
.38
.45
.49
F or purpose o f illustration, mention may here be made o f the sana
torium at Beelitz, maintained by the Berlin Invalidity Insurance
Institution, established in 1902, with an accommodation o f 196 beds
fo r men and 73 beds fo r women. B y December 31, 1909, the cost
o f the land had been 402,471 marks ($95,788), the cost o f buildings
10,384,174 marks ($2,471,433), and the cost o f installation, furniture,
etc., 1,097,783 marks ($261,272). This institution was enlarged by an
annex in 1907, providing 294 more beds for men and 283 more beds
fo r women, at an additional cost fo r buildings o f 5,734,567 marks
($1,364,827) and an additional cost o f installation o f 566,536 marks
($134,836). The cost o f maintenance fo r all purposes in 1909 was
2,464,324 marks ($586,509), o f which 508,966 marks ($121,134) , or
20.6 per cent, was on account o f the board and other personal mainte
nance o f the patients. The number o f male patients treated at the
institution, including the annex, during 1909 was 2,659, and the num
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
75
ber o f female patients was 1,819, or a total o f 4,478. The number o f
days’ treatment and care received by these patients was 801,224. The
number o f attendants and other employees in 1909 was 45 males and
121 females, who received 60,296 days o f personal support. The total
number o f days’ board or support and care, therefore, was 361,520
fo r the year 1909. The per capita cost per day for all purposes was
5.96 marks ($1.42), but considering expenditures for food and other
personal needs only, the cost was 1.41 marks (34 cents) per capita
per day, and excluding employees and other attendants, 1.69 marks
(40 cents) for patients only. Since full details concerning the per
capita cost per day o f treatment and o f other important financial
items are given in the table, it is not necessary to further enlarge
upon this subject.
PER CAPITA COST OP TREATMENT AND CARE.
The per capita cost o f treatment is necessarily higher in the case
o f tuberculous patients than in the case o f patients generally who are
treated fo r other diseases, and the same is true o f the length o f treat
ment, which in the case o f tuberculosis exceeds considerably the aver
age for other diseases considered as a group. The average cost o f
treatment per patient per day in German sanatoria for the treatment
and care o f tuberculous patients ranged from 3 to 5 marks (71 cents
to $1.19), against a range o f 2.50 to 4.50 marks (60 cents to $1.07)
in the case o f institutions, hospitals, etc., treating diseases other than
tuberculosis o f the lungs. The expense per patient per day for board
in the case o f patients treated in institutions fo r the treatment and
oare o f tuberculous persons ranged between 1 mark and 2.50 marks
(23.8 cents and 60 cents). An analysis o f the total expenditures o f 33
sanatoria fo r the treatment o f tuberculosis shows that the maximum
expenditure per day per patient was 8.96 marks ($2.13), the mini
mum 2.97 marks (71 cents), and the average 4.60 marks ($1.09).
The corresponding expenditures for patients receiving treatment
other than fo r tuberculosis o f the lungs in 29 institutions ranged
from 6.11 marks ($1.45) maximum to 2.06 marks (49 cents) mini
mum. The average was 4.04 marks (96 cents). The average expendi
ture fo r board on account o f tuberculous patients only, and excluding
attendants, was 1.90 marks (45 cents) per patient per day, the maxi
mum having been 2.83 marks (67 cents) and the minimum 1.15 marks
(27 cents). Including attendants, the average cost for board was
1.55 marks (37 cents) per patient per day, the maximum having been
2.18 marks (52 cents) and the minimum 96 pfennigs (23 cents). The
average expenditure on account o f patients only in institutions treat
ing diseases other than tuberculosis was 1.57 marks (37 cents), and
including attendants, it was 1.25 marks (30 cents) per patient per day.
76
BULLETIN OF THE BUREAU OF LABOR.
The follow ing table gives data for 33 institutions operated by the
German State invalidity insurance institutions:
AVERAGE DAILY EXPENDITURES OF SPECIAL INSTITUTIONS FOR TREATMENT,
SUPPORT, AND MAINTENANCE ON ACCOUNT OF TUBERCULOSIS OF THE LUNGS, BY
GERMAN STATE INVALIDITY INSURANCE INSTITUTIONS, DURING 1909.
Expenditures for
food and drink
Num Aggregate of—
ber of expend
institu itures.
tions.
Patients Patients
and em
only.
ployees.
Ma-srimnm cost per capita per day................................................
MtniTnyim cost per capita per day..................................................
Average cost per capita per day.....................................................
33
33
33
$2.13
.71
1.09
$0.67
.27
.45
$0.52
.23
.37
FINANCIAL STATISTICS OF SANATORIA OWNED BY GERMAN INVALIDITY
INSURANCE INSTITUTIONS.
In 1909 there were 37 institutions owned or maintained, or in
course o f construction, in behalf o f State invalidity insurance insti
tutions, providing an accommodation o f 3,134 beds fo r men and
1,289 for women. The cost o f the ground owned was 2,256,438
marks ($537,032); the cost, o f buildings occupied, 38,238,124
marks ($9,100,674); and the cost o f installation, 4,349,854 marks
($1,035,265). A ll o f these items show a substantial increase over
1908. The annual cost for maintenance and board was 7,820,388
marks ($1,861,252) for 1909 against 7,251,910 marks ($1,725,955) in
1908. The number o f patients receiving treatment during 1909 was
16,593 males and 6,141 females. These statistics have reference only
to sanatoria providing systematic treatment fo r tuberculosis o f the
lungs and have no reference to convalescing homes, hospitals, etc.,
provided for other purposes, numbering in 1909 thirty-four, and
providing 1,754 beds for men and 1,117 for women and accommodat
ing 13,804 male patients and 6,940 female patients at an annual ex
penditure o f 2,726,692 marks ($648,953). To what extent this
method o f treatment includes cases o f tuberculosis o f the lungs is
not accurately known.
77
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
In the table which follow s financial data are given relative to
sanatoria belonging to the German State invalidity insurance insti
tutions and which provide systematic treatment fo r tuberculosis o f
the lungs:
GENERAL, FINANCIAL, AND OTHER STATISTICS OF THE SANATORIA OWNED BY
GERMAN INVALIDITY INSURANCE INSTITUTIONS.
Increase during 1909.
1908
1909
Actual.
Number of institutions...................................
Number of beds:
For men...................................................
For women...............................................
Area of land occupied (acres)..........................
Cost of—
Land.........................................................
Buildings.................................................
Furnishings..............................................
Expenditures for all purposes during year___
Number of patients:
Males........................................................
Females....................................................
Per cent.
36
37
1
2.8
2,985
1,276
2,145.6
3,134
1,289
2,329.2
149
13
183.6
5.0
1.0
8.6
$468,630.57
$8,747,025.50
$991,566.07
$1,725,954.58
$537,032.24
$9,100,673.51
$1,035,265.25
$1,861,252.34
$68,401.67
$353,648.01
$43,699.18
$135,297.76
14.6
4.0
4.4
7.8
14,352
5,306
16,593
6,141
2,241
835
15.6
15.7
Total.....................................................
19,658
22,734
3,076
15.6
Percent of male patients................................
73.0
73.0
LOANS PROVIDED FOR THE ERECTION OF PUBLIC SANATORIA.
In conform ity to the provisions o f the invalidity insurance laws,
the State invalidity insurance institutions may advance loans for the
building o f sanatoria for the treatment o f tuberculosis o f the lungs,
to be maintained by associations, trade guilds, etc. U p to the end o f
1909 the amounts lent out for this purpose reached 13,062,625 marks
($3,108,905), o f which 1,252,607.27 marks ($298,121.06) had been
repaid, leaving an outstanding amount o f loans on December 31,
1909, o f 11,810,017.73 marks ($2,810,784.22). The rate o f interest
paid varies from a minimum o f 1.5 per cent to a maximum o f 4 per
cent, but the average rate is between 3 per cent and 3.5 per cent.
Under the revised regulations o f the Im perial Insurance Office, loans
are no longer permitted to be made at a lower rate than 3.5 per cent,
except in cases o f special merit and subject to the approval o f the
Im perial Insurance Office. The largest amount o f outstanding loans
is provided fo r by the State Invalidity Insurance Institution o f
Rhenish Prussia, amounting to 2,645,257.63 marks ($629,571.32) lent
at a uniform rate o f 3 per cent. The next largest amount outstanding
is in the case o f the State Invalidity Insurance Institution o f West
phalia, amounting to 1,515,054.47 marks ($360,582.96) lent out at an
interest rate o f from 3.25 per cent to 3.75 per cent. The State In
validity Insurance Institution o f Alsace-Loraine has lent 400,000
marks ($95,200) at 1.5 per cent. O f the 11,810,017.73 marks
($2,810,784.22) outstanding in the form o f loans provided by 41 in
validity insurance institutions and workmen’s pension funds,
78
BULLETIN OF THE BUREAU OF LABOB.
1,860,929.02 marks ($442,901.11), or 15.8 per cent, was not secured
in conform ity to the requirements applicable to orphans’ and minors’
trust funds.
SUITABLE EMPLOYMENT OF TUBERCULOUS PATIENTS.
In the treatment and care o f patients an increasing amount o f at
tention is being given to their suitable employment, partly for the
purpose o f meeting the cost o f treatment, but largely with the object
o f im proving the chances o f complete restoration o f earning capacity.
Labor is required o f patients able to perform light and suitable
duties in the case o f a few establishments, but as a general principle
the question o f employment is optional. Compulsory labor is the
rule in five institutions, under medical supervision, the labor being
considered an important factor in the effort to secure a permanent
cure. In all o f the institutions preference is given to outdoor labor,
chiefly agricultural, horticultural, or gardening. Domestic labor is
required or expected o f women patients in suitable cases, and to a
very lim ited extent labor is perform ed in workshops, provided
for the purpose. The time o f labor varies in the different insti
tutions, ranging from a maximum o f about five hours to a min
imum o f half an hour per day. The working time o f women is, on
the average, less than that o f men. A small compensation is paid
in some cases—about 10 pfennigs (2.4 cents) per hour. In a few in
stances patients have been dismissed on account o f refusal to per
form suitable duties under medical supervision and at medical
request.
AVERAGE COST AND DURATION OF TREATMENT.
The average cost and duration o f treatment are partly determined
by the provisions o f the invalidity insurance laws. As a general rule
the lim it o f treatment is 90 days, but this may be varied in the dis
cretion o f the insurance institution, and many exceptions are made
where the individual merits o f the case seem to require that this
should be done. It is open to question whether, in the ascertain
ment o f the average cost o f treatment per case per annum all the
items o f expense properly chargeable are included. In the nature
o f the case there must be a considerable number o f items o f general
expense connected with the administration o f the State invalidity
insurance institutions which can not be taken into account in the
ascertainment o f the cost o f treatment in sanatoria, hospitals, or
other institutions. It may be safely assumed, however, that i f the
items o f expense, probably not included, had been taken into account
the reported cost would not be materially increased. The present
discussion is confined to the experience data o f average cost and dura
tion o f treatment for the period 1897 to 1909. The details, by single
years, are fully set forth in the table on page 80. According to this
table the average cost o f treatment fo r male and female patients
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
79
combined increased from 307.29 marks ($73.14) in 1897 to 367.75
marks ($87.52) in 1903 and to 386.05 marks ($91.88) in 1909. The
cost o f treatment per person for male patients increased from 295.24
marks ($70.27) in 1897 to 373.84 marks ($88.97) in 1903 and to
404.22 marks ($96.20) in 1909. The corresponding averages for
women patients do not indicate the same tendency toward an increase,
possibly because the number o f women patients during the early
years was rather small. In 1897 the cost o f treatment per person
for women patients was 349.83 marks ($83.26), changing to 350.30
marks ($83.37) in 1903, and diminishing to 344.97 marks ($82.10)
in 1909. It is therefore shown that the per capita cost o f treatment
was higher for male patients than fo r female patients, and this differ
ence has been maintained during each o f the 10 last years o f the
experience under review.
The per capita cost o f treatment per day for both sexes combined
increased from 4.05 marks (96 cents) in 1897 to 4.81 marks ($1.14)
in 1903 and to 5.41 marks ($1.29) in 1909. Comparing the last year
with the first, there has been an increase o f 34.4 per cent in the per
capita cost o f treatment per day for men and women combined.
Considering male patients only, the per capita cost o f treatment per
day has increased from 4.05 marks (96 cents) in 1897 to 5.77 marks
($1.37) in 1909. The corresponding cost o f treatment per capita
per day for women patients has increased from 4.04 marks (96 cents)
to 4.29 marks ($1.02).
The average duration o f treatment has undergone only slight
changes, having decreased from 76 days for men and women patients
combined during 1897 to 73 days during 1909. F or male patients
the average duration o f treatment has decreased from 73 days in
1897 to 70 days in 1909, and for female patients from 87 days in 1897
to 80 days in 1909. The tendency, therefore, appears to be toward
a slight reduction in the average duration o f treatment, but the
reasons fo r this reduction are obscure and somewhat difficult to deter
mine from the available published information. For medical reasons
a sufficient length o f treatment is o f primary importance, and the
causes o f relapses or ultimately unfavorable results are often directly
traceable-to a curtailed stay in the sanatorium. I f the average re
duction in treatment is the result o f economic reasons, partly because
o f the higher cost o f per capita support at the present time than in
form er years, it does not appear that the slightly shorter treatment
has had injurious effects on the after results since the proportion o f
patients retaining their earning power after five years is more favor
able with patients discharged during recent years than with patients
discharged during the earlier years o f public sanatoria experience.
The follow ing table shows the number o f days o f treatment and
cost per person treated and cost per day o f treatment o f persons re
80
BULLETIN OF THE BUREAU OF LABOR.
ceiving full treatment and care on account o f tuberculosis o f the
lungs by German State invalidity insurance institutions:
NUMBER OF DAYS OF TREATMENT, COST PER DAY OF TREATMENT, AND COST PER
PERSON TREATED, FOR PATIENTS RECEIVING FULL TREATMENT AND CARE, ON
ACCOUNT OF TUBERCULOSIS OF THE LUNGS, BY GERMAN STATE INVALIDITY
INSURANCE INSTITUTIONS, BY SEX OF PATIENTS, 1897 TO 1909.
Number of days treated.
Cost per day of treat
ment.
Cost per person treated.
Year.
Males. Females. Total. Males. Females. Total.
1897.................................
1898................................
1899.................................
1900.................................
1901.................................
1902................................
1903.................................
1904.................................
1905.................................
1906................................
1907.................................
1908.................................
1909.................................
73
73
73
72
72
74
74
75
73
72
71
71
70
87
83
79
80
82
82
83
80
79
80
81
78
80
76
75
74
74
75
76
76
76
75
75
74
73
73
$0.96
1.00
1.01
1.14
1.15
1.16
1.20
1.19
1.24
1.28
1.30
1.35
1.37
$0.96
.98
.96
.95
.96
1.00
1.01
.98
.97
.96
.97
1.03
1.02
$0.96
.99
1.00
1.09
1.09
1.12
1.14
1.13
1.16
1.18
1.19
1.24
1.29
Males. Females. Total.
$70.27
73.19
73.85
82.14
82.96
85.73
88.97
88.99
90.51
92.58
92.42
95.72
96.20
$83.26
81.15
75.69
76.43
78.38
81.26
83.37
77.89
76.47
77.22
78.64
80.83
82.10
$73.14
74.97
74.25
80.77
81.76
84.56
87.52
85.91
86.54
88.10
88.20
91.00
91.88
A ll o f the foregoing observations have reference only to patients,
receiving fu ll institutional treatment and care. In addition to full
treatment a comparatively small number o f patients receive occasional
or irregular treatment, chiefly outside o f institutions, more or less in
the nature o f expert medical advice, dispensary aid, etc. The aver
age cost o f such treatment and care has decreased from 64.73 marks
($15.41) per capita per annum in 1897 for male and female patients
combined, to 23.99 marks ($5.71) per annum in 1909. The amounts
vary for the different years, but the tendency has been toward a re
duction in the expense. It requires to be considered that the number
o f such patients is relatively quite small, and as an element in the
general campaign against tuberculosis the irregular or occasional treat
ment is not a matter o f material importance. The details, by single
years, are given in the follow ing table, according to which the cost
o f such treatment per person has decreased in the case o f male pa
tients from 61.52 marks ($14.64) in 1897 to 24.32 marks ($5.79) in
1909. The corresponding reduction in expenses for females has been
from 71.40 marks ($16.99) in 1897 to 23.33 marks ($5.55) in 1909.
COST OF TEMPORARY OR PARTIAL TREATMENT PER PERSON ON ACCOUNT OF
TUBERCULOSIS OF THE LUNGS BY GERMAN STATE INVALIDITY INSURANCE INSTI
TUTIONS, BY SEX OF PATIENTS, 1897 TO 1909.
Year.
1897........................
1898........................
1899........................
1900........................
1901........................
1902........................
1903........................
Males.
$14.64
9.89
13.66
9.03
14.11
28.54
11.85
Females.
$16.99
20.35
12.15
4.71
4.62
10.37
13.74
Total.
$15.41
14.15
13.19
6.79
9.32
22.49
12.17
Year.
1904........................
1905........................
1906........................
1907........................
1908........................
1909........................
Males.
$3.67
5.89
4.18
3.91
5.02
5.79
Females.
$12.97
10.28
8.11
4.63
5.80
5.55
Total.
$5.31
7.06
5.74
4.17
5.35
5.71
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
81
EEEECT OE PREMATURE DISCONTINUANCE OE TREATMENT.
An important question in connection with sanatorium treatment on
account o f tuberculosis o f the lungs and larynx is the probable effect
o f premature discontinuance o f treatment on the general results. In
the German experience o f 1909 out o f 29,277 males receiving full
treatment on account o f tuberculosis of the lungs and larynx 1,063,
or 3.6 per cent, discontinued the treatment or were discharged for
various reasons from the sanatoria to which they had been admitted
during the first 14 days o f their stay. W hile the *proportion o f
patients treated successfully from an economic point o f view, as
shown by the table on page 88, was 83 per cent for all patients, it
was increased to 86 per cent after eliminating those who had been
discharged from the institutions during the first 14 days o f their
stay. In the case o f women patients, out o f 12,955 the number who
had discontinued the treatment during the first 14 days o f their stay
in the institutions was 358, or 2.8 per cent. The economic results o f
treatment were identically the same on the percentage basis as in
the case o f males; that is, there were 83 per cent o f successful cases,
including those who remained less than 14 days in the institutions,
and 86 per cent after eliminating those discharged or dismissed dur
ing that period o f time.
STATISTICS OE READMISSIONS EOR TREATMENT.
The important question as to the proportion o f cases requiring
readmission to the sanatorium for further treatment is dealt with at
some length in the report for 1909, including, however, only the expe
rience from 1905 to 1909. The aggregate number o f male patients
under treatment during this period was 97,392, o f which 510, or 0.5
per cent, were readmitted to institutional treatment during the year
o f first admission. O f the number under observation one year after
discharge, or 73,055, the number readmitted for treatment was 4,335,
or 5.9 per cent. During the second year the number o f discharged
patients under observation was 51,587, o f which 3,502 required read
mission or further treatment, equivalent to 6.8 per cent o f the total
number under observation. O f the patients under observation for
three years after original discharge, numbering 33,517, the number
readmitted for treatment was 1,515, or 4.5 per cent. The number
under observation during the fourth year after discharge was 15,516,
o f which 506, or 3.3 per cent, were readmitted. It is shown, there
fore, that the proportion o f readmissions was highest during the
second year follow ing tlie original discharge, and that throughout
the five-year period the proportion o f readmissions o f the number
remaining under observation ranged from 3.3 per cent to 6.8 per cent.
The results for women were about the same, but the percentage o f
readmissions was less. Out o f 43,542 women patients during 1905 to
49397°—12----- 6
82
BULLETIN OP THE BUREAU OF LABOR.
1909, 145, or 0.3 per cent, were readmitted for treatment during the
first year o f treatment. During the first year subsequent to the year
o f original admission, out o f 32,748 discharged patients, the number
requiring readmission was 1,654, or 5.1 per cent. During the second
year, out o f 22,237, the number readmitted was 1,078, or 4.8 per cent.
During the third year, out o f 14,020 patients, the number readmitted
was 472, or 3.4 per cent. During the fourth year, out o f 6,272 pa
tients, 145, or 2.3 per cent, were readmitted. The range in readmis-,
sions subsequent to the first year o f treatment was, therefore, from
2.3 to 5.1 per cent.
When the foregoing results concerning readmissions on account o f
tuberculosis o f the lungs are compared with readmissions on account
o f treatment for other diseases, it appears that the necessity for sub
sequent treatment is much greater in the case o f tuberculosis o f the
lungs than in the case o f any other disease. The details regarding
readmissions are set forth in the follow ing tables, including a com
parison o f the period 1905 to 1909. The data are self-explanatory
and do not require extended consideration. It may be said, however,
that against the 17.7 per cent o f readmissions o f all male patients
under observation during the five-year period ending with 1905,
the corresponding percentage o f readmissions during the five years
ending with 1909 was 21.0. For females the percentage o f readmis
sions increased from 14 during the first period to 15.9 during the last.
In this connection it may also be pointed out that the readmission
rate for male patients for treatment on account o f other diseases than
tuberculosis o f the lungs was 15 per cent for the five years ended
with 1909, against 13.1 per cent fo r females.
READMISSIONS FOR TREATMENT OF PATIENTS ON ACCOUNT OF TUBERCULOSIS
OF THE LUNGS, BY SEX AND BY YEARS, 1905 TO 1909.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
83
COMPARATIVE STATISTICS OF READMISSIONS FOR TREATMENT ON ACCOUNT OF
TUBERCULOSIS OF THE LUNGS, BY SEX OF PATIENTS, 1901 TO 1909.
Per cent of discharged male i>atients
readmitted for treatment dunng—
Period of first
treatment.
1901 to 1905..............
1902 to 1906..............
1903 to 1907..............
1904 to 1908..............
1905 to 1909..............
Year
of dis
charge.
0.7
.6
.5
.5
.5
Per cent of discharged female patients
readmitted for treatment during—
First Second Third Fourth
First Second Third Fourth
year
year
year
Year
year
year
year
year
year
after
after
after
after of dis after
after
after
after
dis
dis
dis
dis charge. dis
dis
dis
dis
charge. charge. charge. charge.
charge. charge. charge. charge.
7.1
6.6
6.2
6.0
5.9
4.9
5.1
5.4
6.3
6.8
3.2
3.2
3.4
3.9
4.5
1.8
1.8
2.3
3.1
3.3
0.4
.4
.4
.3
.3
6.0
5.7
5.2
5.2
5.1
4.0
4.1
4.3
4.6
4.8
2.2
2.3
2.3
3.0
3.4
1.4
1.6
1-9
2.6
2.3
CLASSIFICATION OF TUBERCULOSIS ACCORDING TO TURBAN STAGE OF
DISEASE.
The classification o f patients treated in the sanatoria maintained
by German invalidity insurance institutions is in conform ity to the
Turban-Gerhardt (Im perial Board o f Health) method, which has
been quite generally adopted throughout the w orld and, with slight
modification, by the National Association for the Study and Preven
tion o f Tuberculosis in the United States. The classification rests
on an anatomical basis and differentiates three stages, which, in a
general way, correspond to the incipient, the moderately advanced,
and the far-advanced conditions o f the disease as determined by the
usual methods o f physical diagnosis. The follow ing is the most
generally adopted English translation o f the Turban-Gerhardt clas
sification o f tuberculous patients:
INTERNATIONAL STATISTICS ON TUBERCULOSIS (MORBIDITY) CLASSIFICA
TION TURBAN-GERHARDT (IMPERIAL GERMAN BOARD OF H EALTH ).
R = R igh t.
L = L e ft.
1. Disease o f slight severity, limited to small areas o f one lobe,
that, for instance, in case o f infection o f both apices, does not extend
beyond the spine o f scapula and the clavicle, or, in case o f affection
o f one apex, frontal, beyond the second rib.
2. Disease o f slight severity, more extensive than 1, but affecting,
at most, the volume o f one lobe, or, severe disease, extending, at most,
to the volume o f one-half lobe.
3. A ll cases extending beyond 2, and all such with considerable
cavities.
By disease o f slight severity is to be understood disseminated foci
manifested by slight dullness, unclear, rough, or weak vesicular,
vesico-bronchial, or broncho-vesicular breathing and fine and medium
rales.
By severe disease: Compact infiltration recognized by great dull
ness, very weak (indeterminate) broncho-vesicular or bronchial in
definite breathing with or without rales.
Considerable cavities to be recognized by tympanitic sound, am
phoric breathing, and extensive, coarse, consonating rales, come under
3.
Digitized forstage
FRASER
84
BULLETIN OF THE BUREAU OF LABOR.
Pleuritic dullness if only o f a few centimeters extent is to be left
out o f account; if it is considerable, pleuritis should be specially men
tioned under tuberculous complications.
The stage o f disease is to be indicated fo r each side separately.
The case, as a whole, is to be classified according to the more diseased
side; fo r example, B2 L I— Stage 2.1
STATISTICS OF ADMISSION AND DISCHARGE ACCORDING TO TURBAN
STAGE OF DISEASE.
During 1909 the 41 institutions established for the administration
o f the invalidity insurance law treated 29,277 male patients and
12,955 female patients, or a total o f 42,232 persons, on account o f
tuberculosis o f the lungs. O f this number, for 2,434 males and 1,456
females the Turban stage o f the disease was not ascertained, either at
entry or discharge. It was further necessary to exclude 1,553 male
and 1,064 female patients because o f the fact that a different method
than the Turban-Gerhardt classification was adopted. Excluding a
few additional patients for other reasons, there remain 24,766 male
patients and 10,379 female patients, or a total o f 35,145 persons, for
which the stage o f the disease on admission and discharge was ascer
tained in conform ity to the uniform method o f classification ap
proved by the Imperial Board o f Health. It is obvious that one o f
the most certain means o f determining the results o f sanatorium
treatment is to ascertain the stage o f the disease on admission and
on discharge by the same method and, if possible, by the same medi
cal practitioner. A change from one stage o f the disease to a more
favorable one may be considered fairly conclusive evidence that an
improvement has taken place, with a reasonable assurance that the
wage-earning capacity o f the patient has probably been restored and
can be maintained for a considerable period o f time. In cases where
it is shown that the patient has changed to a more serious stage o f
the disease, according to the Turban classification, it is evident that
the treatment has been more or less o f a failure, although even this
conclusion is not warranted in all cases.
O f the 24,766 male patients, 20,567, or 83 per cent, were discharged
from the sanatoria with a reasonable certainty that their wage-earn
ing capacities had been restored for a considerable period o f time.
O f this number 11,111 were in the first Turban stage o f the disease
on admission, o f which 428, or 3.9 per cent, were discharged as being
entirely free from every symptom o f the disease, which, under the
form o f classification adopted, is represented by O in the tabular
analysis o f the collective experience. O f the patients discharged
who were in the first Turban stage on admission, 10,246, or 92.2 per
cent, remained in the same stage o f the disease, 416 were in the sec
ond stage, and 21 were in the third stage. It is, therefore, shown
that the large m ajority o f patients, or 92.2 per cent, maintained the
1Page 12, 4th report King Edward VII Sanatorium, Midhurst.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
85
most favorable stage o f the disease, only a relatively unimportant
proportion, or 3.9 per cent, were in a more serious, or the most seri
ous, stage o f the disease, and 3.9 per cent were entirely cured. In a
general way, however, the analysis proves that for the large m ajority
o f patients admitted while in the first Turban stage o f the disease
the results o f institutional treatment, from the medical and economic
points o f view, were quite favorable.
The number o f male patients admitted while in the second stage o f
the disease and discharged with restored earning capacity was 7,777.
O f this number 107, or 1.4 per cent o f the total number o f the patients
o f this group, were discharged as being entirely free from symptoms
o f active tuberculosis. The number discharged as being in the first
Turban stage o f the disease was 2,206, or 28.4 per cent; in the
second stage o f the disease, 5,402, or 69.5 per cent; and in the third
stage o f the disease, 62, or 0.8 per cent o f the total number admitted
to treatment while in the second stage o f the disease and discharged
with the earning capacity restored for a reasonable period o f time.
It is shown, therefore, that nearly 30 per cent o f the patients in the
second stage o f the disease on admission were in a more favorable
stage o f the disease on discharge, while only about 1 per cent were in
a more serious stage o f the disease, or, in other words, in a condition
warranting the conclusion that the treatment had been unsuccessful.
The number o f male patients discharged with their earning capacity
restored, who, on admission, were in the third stage o f the disease, was
1,679. O f this number only 4 were entirely free from active symp
toms o f the disease, and only 148, or 8.8 per cent, were in the first
stage o f the disease on their discharge. Even this relatively small
number, equivalent to not quite 10 per cent o f the total, is conclu
sive evidence that in the advanced stages o f the disease the outlook
for successful treatment is not entirely hopeless. The number o f
patients in the second stage o f the disease was 484, or 28.8 per cent
o f the total number in this group, while the number o f patients in
the third stage o f the disease was 1,043, or 62.1 per cent. In other
words, nearly two-thirds o f the patients who, on admission, were in
the third stage o f the disease, but who were discharged with restored
earning capacity fo r a reasonable period o f time, had sufficiently
improved to advance to a more favorable stage o f the disease, war
ranting the conclusion that the treatment had been at least fairly
successful.
It would serve no practical purpose to extend this analysis to the
patients who had been unsuccessfully treated from an economic
point o f view ; that is, those who did not have their wage-earning
capacity restored on discharge; but it may be stated that in a fair
proportion o f these cases a more favorable stage o f the disease had
BULLETIN OP THE BUREAU OF LABOR.
8 6
been attained on discharge than had been ascertained to exist at the
time o f admission to institutional treatment.
The results with regard to female patients were equally favorable
and so nearly like those obtained for male patients that it would
serve no practical purpose to discuss the statistical results in detail.
It needs only to be stated that o f the 10,379 women patients treated
and cared fo r on account o f tuberculosis o f the lungs, 8,562, or 82.5
per cent, were discharged with restored earning capacity fo r a
reasonable period o f time. Some additional details for both male and
female patients, according to the Turban stages o f the disease on ad
mission and discharge, are contained in the table which follow s:
TURBAN STAGE OP DISEASE ON ADMISSION AND AT DISCHARGE OP PATIENTS
TREATED FOR TUBERCULOSIS BY GERMAN INVALIDITY INSURANCE INSTITU
TIONS DURING 1909, BY SEX.
M a le s d is c h a r g e d w ith r e s t o r e d e a r n in g c a p a c it y .
Turban stage at discharge.
Num
ber.
n.
I.
O.
Turban stage on Patients
treated.
admission.
Percent
Percent
Num
of
of
patients Number. patients ber.
treated.
treated.
in .
Per cent
Per cent
Num
of
of
patients ber. patients
treated.
treated.
I .........................
n .......................
m .....................
11,111
7,777
1,079
428
107
4
3.9
1.4
.2
10,246
2,206
148
92.2
28.4
8.8
416
5,402
484
3.7
69.5
28.8
21
62
1,043
0.2
.8
62.1
Total........
20,507
539
2.6
12,600
61.3
6,302
30.6
1,126
5.5
M a l e s d is c h a r g e d w i t h o u t r e s t o r e d e a r n in g c a p a c it y .
1.........................
n .......................
m ......................
904
1,384
1,911
18
6
2.0
.4
775
90
7
85.7
6.5
.4
71
1,108 #
107
7.9
80.1
5.6
40
180
1,797
4.4
13.0
94.0
Total........
4,199
24
.6
872
20.8
1,286
30.6
2,017
48.0
T o ta l.
1.........................
II.......................
i n ......................
12,015
9,161
3,590
446
113
4
3.7
1.2
.1
11,021
2,296
155
91.7
25.1
4.3
487
6,510
591
4.1
71.1
16.5
61
242
2,840
0.5
2.6
79.1
Total........
24,766
563
2.3
13,472
54.4
7,588
30.6
3,143
12.7
F e m a l e s d is c h a r g e d w i t h r e s t o r e d e a r n in g c a p a c it y .
I .........................
II.......................
m ......................
5,507
2,670
385
218
137
3
4.0
5.1
.8
5,119
844
65
93.0
31.6
16.9
165
1,671
77
3.0
62.6
20.0
5
18
240
0.1
.7
62.3
Total........
8,562
358
4.2
6,028
70.4
1,913
22.3
263
3.1
F e m a l e s d is c h a r g e d w i t h o u t r e s t o r e d e a r n in g c a p a c it y .
319
729
769
3
0.9
264
73
20
82.8
10.0
2.6
35
581
76
11.0
79.7
9.9
17
75
673
5.3
10.3
87.5
1,817
3
.2
357
19.6
692
38.1
765
42.1
87
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
TURBAN STAGE OF DISEASE ON ADMISSION AND AT DISCHARGE OF PATIENTS
TREATED FOR TUBERCULOSIS BY GERMAN INVALIDITY INSURANCE INSTITU
TIONS DURING 1909, BY SEX—Concluded.
Total.
Turban stage at discharge.
Num
ber.
I .........................
1.
O.
Turban stage on Patients
admission.
treated.
II.
III.
Per cent
Per cent
Per cent
Per cent
Num
of
of
Num
of
of
patients Number. patients ber. patients ber.
patients
treated.
treated.
treated.
treated.
n .................
h i ......................
5,826
3,399
1,154
221
137
3
3.8
4.0
.3
5,383
917
85
92.4
27.0
7.4
200
2,252
153
3.4
66.3
13.3
22
93
913
0.4
2.7
79.1
Total........
10,379
361
3.5
6,385
61.5
2,605
25.1
1,028
9.9
POSTDISCHARGE RESULTS OF SANATORIUM TREATMENT.
B y far the most important and conclusive fact o f the collective
investigation is the statistical evidence regarding postdischarge
results, which are observed fo r a period o f five years to determine
the extent to which earning capacity has been maintained.1 Since
the object o f the treatment is to prevent invalidity or incapacity for
work, it is obvious that the efficacy o f the treatment is determined
by the proportion o f patients recovering their earning capacity
through sanatorium treatment and maintaining the same for a rea
sonable period o f time. The facts in the case are ascertained by
careful official inquiry, which is facilitated by the permanent relation
o f the patients to the institutions and the cooperation o f Govern
ment authorities such as the police, poor-law guardians, etc. For a
certain number o f patients, however, the inform ation could not be
secured because o f the fact that they had moved away or that the
requests fo r information concerning them were not complied with.
Lim iting the follow ing considerations, therefore, only to such patients
as furnished a record o f their subsequent personal history and restored
or lost wage-earning capacity, it requires further to be observed that
readmissions for treatment were considered as new cases. The
extent o f such readmissions has been previously dealt with in detail.
F or a full understanding o f the method by which the after results
o f sanatorium treatment are calculated it is necessary to refer to the
details in the table which follow s (p. 88), and which contains the
available facts for each o f the years 1897 to 1909. According to this
table, o f the 2,598 male patients receiving fu ll treatment and care on
account o f tuberculosis o f the lungs during 1897, the number dis
charged as having had their earning capacity sufficiently restored to
warrant the anticipation that a loss o f earning power was not prob
able within a reasonable period o f time was 1,760, or 67.7 per cent.
1 Since 1909 these observations are made a t two-year
six years, but in the case of tuberculosis o f the lungs and
http://fraser.stlouisfed.org/
of nontubercular diseases.
Federal Reserve Bank of St. Louis
intervals for a total period of
larynx only, and not in the case
88
BU LLETIN OF TH E BUREAU OF LABOR,
ECONOMIC RESULTS OF FULL TREATMENT AND CARE ON ACCOUNT OF TUBER
CULOSIS OF THE LUNGS BY GERMAN STATE INVALIDITY INSURANCE INSTITU
TIONS, BY SEX OF PATIENTS, 1897 TO 1909.
Male patients.
Year.
1897....................
1898....................
1899....................
1900....................
1901....................
1902....................
1903....................
1904....................
1905....................
1906....................
1907....................
1908....................
1909....................
Number
receiving
full treat
ment.
2,598
3,806
6,032
8,442
10,812
12,187
14,937
16,957
19,085
21,959
22,258
26,437
29,277
Female patients.
Total patients.
Discharged with
Discharged with
Discharged with
restored earning
restored earning
restored earning
Number
Number
power.
power.
power.
receiving
receiving
full treat
full treatment.
ment.
Per
Per
Per
Number. cent.
Number. cent.
Number. cent.
1,760
2,812
4,476
6,117
8,272
9,437
11,763
13,341
15,516
18,001
18,070
21,468
24,337
67.7
73.9
74.2
72.5
76.5
77.4
78.8
78.7
81.3
82.0
81.2
81.2
83.1
736
1,104
1,666
2,652
3,844
4,302
5,211
6,520
7,536
9,063
9,816
12,288
12,955
497
811
1,220
1,920
2,977
3,448
4,284
5,293
6,272
7,748
8,217
10,511
10,794
67.5
73.5
73.2
72.4
77.4
80.1
82.2
81.2
83.2
85.5
83.7
85.5
83.3
3,334
4,910
7,698
11,094
14,656
16,489
20,148
23,477
26,621
31,022
32,074
38,725
42,232
2,257
3,623
5,696
8,037
11,249
12,886
16,047
18,634
21,788
25,749
26,287
31,979
35,131
67.7
73.8
74.0
72.4
76.8
78.1
79.6
79.4
81.8
83.0
82.0
82.6
83.2
NUMBER AND PER CENT OF PATIENTS RECEIVING FULL TREATMENT WHO
WERE DISCHARGED WITH RESTORED EARNING CAPACITY AND WHO RETAINED
THEIR EARNING CAPACITY AT THE END OF SPECIFIED YEARS SUBSEQUENT
TO THEIR DISCHARGE, BY SEX, 1897 TO 1909.
Number of males.l
l In calculating the percentages of those receiving full treatm ent who retained their
power to the end of the specified periods after discharge, cases lost sight of, th at
Digitized forearning
FRASER
is, uncontrolled cases, have been deducted from the numbers representing persons receiv
http://fraser.stlouisfed.org/
in g full treatment.
Federal Reserve Bank of St. Louis
89
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY,
NUMBER AND PER CENT OF PATIENTS RECEIVING FULL TREATMENT WHO
W ERE DISCHARGED WITH RESTORED EARNING CAPACITY AND WHO RETAINED
THEIR EARNING CAPACITY AT THE END OF SPECIFIED YEARS SUBSEQUENT
TO THEIR DISCHARGE, BY SEX, 1897 TO 1909—Concluded.
Number of females.
Retaining earning power at end of year.
Disch’ged
with
Year re
of
dis- stored
ch'ge. earn
ing 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906
pow
er.
1897..
1898..
1899..
1900..
1901..
1902..
1903..
1904..
1905..
1906..
1907..
1908..
1909..
497
811
1,220
1,920
2,977
3,448
4,284
5,293
6,272
7,748
8,217
10,511
10,794
465
348
751
231
464
1,082
252
225
441
409
399
801
690
636
589
1,735 1,308 1,167 1,010
848
2,645 2,173 1,822 1,546 1,245
3,184 2,537 2,121 2,048 1,894
3,892 3,171 2,854 2,629
4,692 4,072 3,654
5,581 4,749
6,980
1907
2,519
3,475
4,285
5,973
7,559
1908
1909
3,196
3,831 3,608
5,257 4,878
6,414 5,733
9,186 8,039
9,749
P er cent of females.^1897..
1898..
1899..
1900..
1901..
1902..
1903..
1904..
1905..
1906..
1907..
1908..
1909..
67.5
73.5
73.2
72.4
77.4
80.1
82.2
81.2
83.2
85.5
83.7
85.5
83.3
64
50
*69
35
49
67
36
43
51
67
32
39
43
52
72
38
40
46
60
76
37
40
51
62
77
35
45
54
64
76
39
50
57
66
78
4?
53
59
67
81
50
55
60
70
80
51
55
63
69
81
52
58
62
72
80
Total males and females.
1
858
1897.. 2,257 2,007 1,380 934 957
i
1898.. 3,623
3,280 1,952 1,796 1,566 1,442
l
1899.. 5,696
4,936 3,520 2,925 2,555 2,327
1
7,169 5,213 4,352 3,877 3,147
1900.. 8,037
1
10,035 7,649 6,413 5,312 4,314
1901.. 11,249
1
1902.. 12,885
11,758 9,138 7,668 7,238 6,559
14,699 11,567 10,250 9,184 8,671 j..........
1903.. 16,047
1904.. 18,634
16,539 13,998 12,201 11,295 10,412
1905.. 21,788
19,485 16,097 14,071 12,514 11,479
23,321 19,427 16,663 15,113
1906.. 25,749
24,208 20,268 17,366
1907.. 26,287
28,429 24,567
1908.. 31,979
32,154
1909.. 35,131
P er cent of total males and femalesA
1897..
1898..
1899..
1900..
1901..
1902..
1903..
1904..
1905..
1906..
1907..
1908..
1909..
67.7
73.8
74.0
72.4
76.8
78.1
79.6
79.4
81.8
83.0
82.0
82.6
83.2
62
44
68
30
45
67
30
38
48
66
27
33
40
49
70
31
35
41
55
73
32
37
46
58
74
i
i See footnote, p. 88.
31
40
50
60
74
34
46
53
62
77
42
48
54
64
78
45
50
56
65
78
46
50
57
66
78
46
52
57
68
80
90
BULLETIN* OF TH E BUREAU OF LABOR.
The first inquiry as to continued earning capacity was made at the
end o f 1897, and it was then found that o f the 1,760 male patients
just referred to 1,542, or 61 per cent, o f the original 2,5981 under
treatment still maintained their earning capacity within the definition
o f the law governing the treatment and care o f invalid members o f
State invalidity institutions. A t the end o f the second year (1898)
the number o f patients retaining their earning capacity was 1,032,
or 42 per cent o f the original number treated in 1897. B y the end o f
1899 this number has been further reduced to 703, or 29 per cent, with
a further reduction to 25 per cent at the end o f 1901. From an eco
nomic as well as a medical point o f view these results for the year
1897 can not be considered very satisfactory.
The next group o f cases concerns the experience o f 1898, observed
to the end o f the year 1902. Recalling that the per cent o f cases dis
charged as cured or with restored earning capacity was 67.7 fo r male
patients in 1897, it is shown that for 1898 the corresponding per
centage was 73.9 or somewhat more favorable. O f the 3,806 male
patients receiving full treatment during 1898, there were ascertained
to be in good health and with maintained earning capacity at the end
o f 1898, 2,529, or 67 per cent. By the end o f the second year the per
centage o f patients with maintained earning capacity was 44, at the
end o f the third year 37, at the end o f the fourth year 31, and at the
end o f the fifth year 28. There was, therefore, throughout a more
favorable result for each year o f subsequent experience during 1898
than during the year 1897.
O f the group o f 6,032 male patients receiving fu ll treatment during
1899, the number retaining their earning capacity at the end o f the
year was 3,854, or 67 per cent. During the second year the per
centage retaining their earning capacity was 48, during the third year
39, during the fourth year 33, and during the fifth year 30. The
results, therefore, were slightly more favorable than during 1898 and
much more favorable than during 1897.
O f the group o f male patients comprehending those discharged
with restored earning capacity in 1900, and numbering 6,117, or 72.5
per cent o f the original total, the number retaining their earning
capacity at the end o f the year was 5,434, or 66 per cent. A t the end
o f the second year the percentage retaining their earning capacity
was 48, at the end o f the third year it was 40, at the end o f the fourth
year 35, and at the end o f the fifth year it was 30. The results, there
fore, were quite similar to those o f the previous year.
During 1901, 8,272 male patients were discharged with restored
earning capacity, or 76.5 per cent o f the total number o f patients
originally under treatment. A t the end o f the first year 70 per cent
1 See footnote, p. 88.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
91
retained their earning capacity, at the end o f the second year 53 per
cent, at the end o f the third year 45 per cent, at the end o f the fourth
year 38 per cent, and at the end o f the fifth year 32 per cent. The
economic results, therefore, were much more favorable throughout
than during any one o f the previous four years.
During 1902 the number o f male patients discharged with restored
earning capacity was 9,437, or 77.4 per cent o f the original number
o f patients under treatment. O f the number receiving fu ll treatment
72 per cent retained their earning capacity at the end o f the first
year, 57 per cent at the end o f the second year, 48 per cent at the end
o f the third year, 44 per cent at the end o f the fourth year, and 40
per cent at the end o f the fifth year. The results, therefore, were
more favorable than during the previous year and much more so than
during any one o f the earlier years.
During 1903 the number o f male patients discharged with restored
earning capacity was 11,763, or 78.8 per cent o f the total number o f
patients under treatment. O f the patients receiving full treatment,
73 per cent retained their earning capacity at the end o f the first
year, 59 per cent at the end o f the second, 51 per cent at the end o f
the third, 46 per cent at the end o f the fourth, and 43 per cent at the
end o f the fifth year. The results throughout, therefore, were slightly
more favorable than during the previous year, and much more favor
able than during any one o f the earlier years.
During 1904 the number o f male patients discharged with restored
earning capacity was 13,341, or 78.7 per cent o f the total number under
treatment. O f the number o f patients receiving full treatment 73 per
cent retained their earning capacity at the end o f the first year, 61 per
cent at the end o f the second, 53 per cent at the end o f the third,
48 per cent at the end o f the fourth, and 44 per cent at the end o f
the fifth year. The results, therefore, were more favorable than
during 1903, and much more favorable than in any one o f the earlier
years o f experience.
During 1905 the number o f male patients discharged with restored
earning capacity was 15,516, or 81.3 per cent o f the total under treat
ment. O f the number treated, 76 per cent retained their earning
capacity at the end o f the first year, 63 per cent at the end o f the
second year, 54 per cent at the*end o f the third year, 48 per cent at
the end o f the fourth year, and 44 per cent at the end o f the fifth
year. The results, therefore, were slightly more favorable during the
previous year, but it is evident that the results approached a point
subsequent to which a material improvement is most difficult to be
realized.
W ith the experience o f 1905 the five-year periods come to an end,
and the number o f male patients subsequently treated have been
under observation only four years, three years, two years, and one
92
B U LLETIN OF TH E BUREAU OF LABOR.
year, respectively. Considering these briefly it appears that in 1906
the number o f patients discharged with restored earning capacity
was 18,001, or 82 per cent o f the total number under treatment. O f
the number treated and kept under observation after discharge 77 per
cent retained their earning capacity at the end o f the first year,
65 per cent at the end o f the second year, 55 per cent at the end o f
the third year, and 49 per cent at the end o f the fourth year.
During 1907 the number o f male patients discharged with restored
earning capacity was 18,070, or 81.2 per cent o f the total number
under treatment. O f the number treated and kept under observation
77 per cent retained their earning capacity during the first year,
65 per cent during the second year, and 55 per cent during the third
.year, or almost identically the same percentages as were obtained
with the patients o f the previous year.
During 1908 the number o f male patients discharged with restored
earning capacity was 21,468, or 81.2 per cent o f the total number
under treatment. O f the number treated and kept under observation
72.8 per cent retained their earning capacity at the end o f the first
year and 62.5 per cent at the end o f the second year.
During 1909 the number o f male patients discharged with restored
earning capacity was 24,337, or 83.1 per cent o f the total under
treatment. A t the end o f the first year 79 per cent retained their
earning capacity, or a larger percentage o f favorable results than had
been secured during any one year o f experience with the patients
discharged during the years 1897 to 1908.
The results o f the sanatorium treatment were even more favorable
in the case o f female patients, and the experience exhibits the same
tendency toward a material improvement from the earlier to the later
years. Commencing with 1897, there were 497 women patients dis
charged with restored earning capacity, or 67.5 per cent o f the total
number under treatment. O f the number treated and kept under
observation 64 per cent retained their earning capacity at the end o f
the first year, 50 per cent at the end o f the second year, 35 per cent
at the end o f the third year, 36 per cent at the end o f the fourth year,
and 32 per cent at the end o f the fifth year.
During 1898, 811 women patients were discharged with restored
earning capacity, or 73.5 per cent o f the total number under treat
ment. O f the number treated and kept under observation, 69 per
cent retained their earning capacity at the end o f the first year, 49
per cent at the end o f the second year, 43 per cent at the end o f the
third year, 39 per cent at the end o f the fourth year, and 38 per cent
at the end o f the fifth year.'
During 1899 there were 1,220 women patients discharged with
restored earning capacity, or 73.2 per cent o f the total number
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
93
under treatment. O f the number treated and kept under observation,
67 per cent retained their earning capacity at the end o f the first
year, 51 per cent at the end o f the second year, 43 per cent at the end
o f the third year, 40 per cent at the end o f the fourth year, and 37
per cent at the end o f the fifth year.
During 1900 there were 1,920 women patients discharged with
restored earning capacity, or 72.4 per cent o f the total number under
treatment. O f the number treated and kept under observation, 67
per cent retained their earning capacity at the end o f the first year,
52 per cent at the end o f the second year, 46 per cent at the end o f
the third year, 40 per cent at the end o f the fourth year, and 35 per
cent at the end o f the fifth year.
During 1901 there were 2,977 women patients discharged with
restored earning capacity, or 77.4 per cent o f the total number under
treatment. O f the number treated and kept under observation, 72
per cent retained their earning capacity at the end o f the first year,
60 per cent at the end o f the second year, 51 per cent at the end o f the
third year, 45 per cent at the end o f the fourth year, and 39 per cent
at the end o f the fifth year.
During 1902 there were 3,448 women patients discharged with
restored earning capacity, or 80.1 per cent o f the total number under
treatment. O f the number treated and kept under observation, 76
per cent retained their earning capacity at the end o f the first year,
62 per cent at the end o f the second year, 54 per cent at the end o f the
third year, 50 per cent*at the end o f the fourth year, and 47 per cent
at the end o f the fifth year.
During 1903 there were 4,284 women patients discharged with re
stored earning capacity, or 82.2 per cent o f the total number under
treatment. O f the number treated and kept under observation, 77
per cent retained their earning capacity at the end o f the first year,
64 per cent at the end o f the second year, 57 per cent at the end o f the
third year, 53 per cent at the end o f the fourth year, and 50 per cent
at the end o f the fifth year.
During 1904 there were 5,293 women patients discharged with re
stored earning capacity, or 81.2 per cent o f the total number under
treatment. O f the number treated and kept under observation, 76
per cent retained their earning capacity at the end o f the first year,
66 per cent at the end o f the second year, 59 per cent at the end o f
the third year, 55 per cent at the end o f the fourth year, and 51 per
cent at the end o f the fifth year.
During 1905 there were 6,272 women patients discharged with re
stored earning capacity, or 83.2 per cent o f the total number under
treatment. O f the number treated and kept under observation, 78
per cent retained their earning capacity at the end o f the first year,
94
B U LLETIN OF TH E BUBEAU OF LABOR.
67 per cent at the end o f the second year, 60 per cent at the end o f the
third year, 55 per cent at the end o f the fourth year, and 52 per cent
at the end of the fifth year.
During 1906 there were 7,748 women patients discharged with re
stored earning capacity, or 85.5 per cent o f the total number under
treatment. O f the number treated and kept under observation, 81
per cent retained their earning capacity at the end o f the first year,
70 per cent at the end o f the second year, 63 per cent at the end o f the
third year, and 58 per cent at the end o f the fourth year.
During 1907 there were 8,217 women patients discharged with re
stored earning capacity, or 83.7 per cent o f the total number under
treatment. O f the number treated and kept under observation, 80
per cent retained their earning capacity at the end o f the first year,
69 per cent at the end o f the second year, and 62 per cent at the end
o f the third year.
During 1908 there were 10,511 women patients discharged with re
stored earning capacity, or 85.5 per cent o f the total number under
treatment. O f the number treated and kept under observation, 81
per cent retained their earning capacity at the end o f the first year
and 72 per cent at the end o f the second year.
During 1909 there were 10,794 women patients discharged with re
stored earning capacity, or 83.3 per cent o f the total number under
treatment. O f the number treated and kept under observation, 80
per cent retained their earning capacity at the end o f the first year
after discharge.
FINANCIAL STATISTICS OF SUCCESSFUL AND UNSUCCESSFUL SANATORIUM
TREATMENT.
The economic and other results o f fu ll special treatment on account
o f tuberculosis o f the lungs during 1909 are briefly summarized as
follow s:
O f the total number o f male patients treated and cared fo r during
the year, 24,337, or 83.1 per cent, were discharged with restored wageearning capacity, in conform ity to paragraph 5, Section IY , o f
the Invalidity Insurance Law [art. 1255, par. 2, o f the Workmen’s
Insurance Code o f July 19, 1911]. The number o f days’ treatment
on account o f this group o f patients was 1,817,965, or an average
o f 75 days per patient successfully treated. The amount expended
on account o f this group was 10,456,400 marks ($2,488,623), or 88.36
per cent o f the total expenditures on account o f male patients suc
cessfully and unsuccessfully treated during the year. The average
expenditure per patient successfully treated was 429.65 marks
($102.26), and the average expenditure per day o f treatment was 5.75
marks ($1.37).
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
95
The number o f male patients unsuccessfully treated—that is, cases
in which the wage-earning capacity was not restored—was 4,940, or
16.9 per cent o f the total number o f male patients treated on account1
o f tuberculosis o f the lungs during the year. The number o f days*
treatment received by this group o f patients was 233,488. The aver
age number o f days’ treatment per male patient unsuccessfully
treated, from an economic point o f view, was 47. The total amount
expended on account o f this group was 1,378,094 marks ($327,986),
or 11.64 per cent o f the expenditures on account o f male patients suc
cessfully and unsuccessfully treated during the year. The average
expenditure per male patient unsuccessfully treated was 278.97 marks
($66.39), and the average expenditure per day o f treatment was 5.90
marks ($1.40).
O f the total number o f female patients treated and cared fo r dur
ing the year, 10,794, or 83.3 per cent, were discharged with restored
wage-earning capacity, in conform ity to paragraph 5, Section IY , o f
the Invalidity Insurance Law [art. 1255, par. 2, o f the Workmen’s
Insurance Code o f July 19, 1911]. The number o f days’ treatment
on account o f this group o f patients was 910,929, or an average o f 84
days per patient successfully treated. The amount expended was
3,911,657 marks ($930,974), or 87.53 per cent o f the total expenditures
on account o f female patients successfully and unsuccessfully treated
during the year. The average expenditure per patient successfully
treated was 362.39 marks ($86.25), and the average expenditure per
day o f treatment was 4.29 marks ($1.02).
The number o f female patients unsuccessfully treated—that is,
cases in which the wage-earning capacity was not restored—was
2,161, or 16.7 per cent o f the total number o f female patients treated
on account o f tuberculosis o f the lungs during the year. The number
o f days’ treatment received by this group o f patients was 131,416.
The average number o f days’ treatment per female patient unsuc
cessfully treated from an economic point o f view was 61. The total
amount expended on account o f this group was 557,467 marks
($132,677), or 12.47 per cent o f the expenditures on account o f female
patients successfully and unsuccessfully treated during the year.
The average expenditure per female patient unsuccessfully treated
was 257.97 marks ($61.40), and the average expenditure per day o f
treatment was 4.24 marks ($1.01).
96
BU LLETIN OF TH E BUREAU OF LABOR,
The data are presented in further detail in the table which follow s:
RESULTS OF SPECIAL TREATMENT OF MALES AND FEMALES, ON ACCOUNT OF
TUBERCULOSIS OF THE LUNGS, COMPLETED DURING THE YEARS 1905 TO 1909.
Cases wherein disability was removed or arrested: Mates.
Persons treated.
Year.
Num Per cent.
ber.
Cost of treatment.
Days of treatment.
Number.
Per
Per cent. person.
Amount.
15,516
18,001
18,070
21,468
24,337
81.3
82.0
81.2
81.2
83.1
1,228,538
1,394,445
1,386,727
1,635,793
1,817,965
88.0
88.0
87.6
87.4
88.6
79
77
77
76
75
Total.. 97,392
81.8
7,463,468
88.0
76 9,845,307.60
1905..............
1906.............
1907..............
1908..............
1909..............
Per
Per
of
Percent. person day
treat
treated. ment.
$1,529,332.20
1,791,927.02
1,815,277.88
2,220,147.30
2,488,623.20
88.53 $98.57
88.14 99.55
88.25 100.46
87.73 103.42
88.36 102.26
$1.24
1.29
1.31
1.36
1.37
88.18
101.09
1.32
Oases wherein disability was not removed: Males.
3,569
3,958
4,188
4,969
4,940
18.7
18.0
18.8
18.8
16.9
167,128
189,818
196,050
235,987
233,488
12.0
12.0
12.4
12.6
11.4
47
48
47
47
47
$198,133.85
241,144.45
241,719.70
310,488.14
327,986.37
11.47
11.86
11.75
12.27
11.64
$55.52
60.93
57.72
62.48
66.39
$1.19
1.27
1.23
1.32
1.40
Total.. 21,624
18.2
1,022,471
12.0
47 1,319,472.51
11.82
61.02
1.29
89.51 $82.24
90.18 81.46
88.87 83.48
89.96 85.00
87.53 86.25
$0.97
.96
.97
1.03
1.02
1905.............
1906..............
1907..............
1908.............
1909.............
Cases wherein disability was removed or arrested: Females.
$515,794.64
631,172.87
685,968.12
893,452.48
930,974.37
1905.............. 6,272
1906............. 7,748
1907.............. 8,217
1908.............. 10,511
1909............. 10,794
83.2
85.5
83.7
85.5
83.3
533,430
660,057
707,041
864,683
910,929
90.0
90.6
89.1
89.8
87.4
85
85
86
82
84
Total.. 43,542
84.3
3,676,140
89.2
84 3,657,362.48
89.10
84.00
.99
Cases wherein disability was not removed: Females.
1905.............
1906..............
1907.............
1908..............
1909.............
1,264
1,315
1,599
1,777
2,161
16.8
14.5
16.3
14.5
16.7
59,172
68,530
86,671
97,957
131,416
10.0
9.4
10.9
10.2
12.6
47
52
54
55
61
$60,468.54
68,717.71
85,924.19
99,763.65
132,677.15
10.49
9.82
11.13
10.04
12.47
$47.84
52.26
53.74
56.14
61.40
$1.02
1.00
.99
1.02
1.01
Total..
8,116
15.7
443,746
10.8
55
447,551.24
10.90
55.14
1.01
GENERAL CONCLUSIONS AS TO THE VALUE OF INSTITUTIONAL TREAT
MENT FOR TUBERCULOSIS.
The foregoing analysis proves conclusively that in a general way
the present results o f sanatorium treatment are o f great economic
value. Assuming, as may rightfully be done, that without such sys
tematic and effective treatment the large m ajority o f patients would
have died from the disease within two years from the date o f at
tack, it is evident that whether such treatment was provided by
insurance institutions or at public cost through direct taxation
or at the personal expense o f the patients, assuming ability to
pay, the results are decidedly gratifying and conclusive. W ith
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
97
out question an immense amount o f most valuable experience has
been gained fo r the development o f the most effective methods o f
treatment, and comparing the results secured during recent years
with those o f the earlier years the proportion o f men and women
wage earners retaining their earning capacity, after sanatorium treat
ment, for a reasonable period o f years is much larger now than fo r
merly. Taking, for the purpose o f further illustration, the year 1905,
when at the end o f the fifth year (that is, in 1909) 41.2 per cent o f
the male patients and 47.9 per cent o f the female patients were still
in possession o f their earning capacity, sufficient at least to pro
vide in part for their own support, it is self-evident that such results
are o f the greatest possible economic value to the State, even though
under present conditions the cost o f treatment may be somewhat
larger than the direct financial gain to the insurance institutions on
account o f diminished payments in the form o f disability annuities.
Recalling that during 1905 the average expense per patient was 380.31
marks ($90.51) for males and 321.29 marks ($76.47) for females, it is
clear that the after results o f the 1905 experience paid largely, if not
entirely, for the expenses incurred in behalf o f tuberculous patients
who otherwise would have died, or themselves and their dependents
would have become a charge upon the community at large. O f
course, the advantage to an invalidity insurance institution from such
treatment is much greater than would be the case in a life insurance
company or society, which, in any event, would have to pay the face
value o f the policy at death. The life insurance company would
be interested only in the deferred payment o f the amount due at
death, and the expense o f treatment, if incurred in its own behalf,
would have to be made good by additional premium receipts fo r a
number o f years sufficient to cover the expenses.
The case is quite different with invalidity insurance institutions,
which may or may not have to pay large sums, according to the
degree and duration o f the disability, and in the case o f which
preventive or curative treatment may bring about a material reduc
tion in the liability, so that the treatment and care o f patients in
special institutions may prove a sound and substantial financial in
vestment. Whether this actually has been the case with German
State invalidity insurance institutions up to the present time is still
open to question. Neither in the official reports nor in the general
literature o f the subject is there anywhere sufficient statistical or
other evidence to conclusively prove that the efforts made to bring
about restored earning capacity o f invalid members have paid a full
return on the money invested in special institutions and the annual
disbursements in behalf o f patients and their immediate dependents.
In course o f time no doubt such proof w ill be forthcom ing, and con493970— 12----- 7
98
BU LLETIN OF TH E BUREAU OF LABOR.
sidering that the entire plan o f compulsory social insurance rests,1
prim arily, not upon financial but upon general considerations o f!
public welfare, it is self-evident that the efficacy and value o f the
system can not be tested solely by reference to the annual balance
sheets o f the institutions individually considered, or even on the
basis o f their aggregate experience.
ADMINISTRATIVE CONTROL OF TUBERCULOSIS, W ITH SPECIAL REF
ERENCE TO TUBERCULOSIS DISPENSARIES, INFORMATION BUREAUS,
AND HOUSING REFORM.
LIMITATIONS OF SANATORIUM TREATMENT.
The sanatorium treatment o f tuberculosis has its inherent lim ita
tions, which, however, do not in the least detract from the farreaching usefulness o f these special institutions for the treatment o f
the disease. In the nature o f the case, only a relatively small propor
tion o f patients can be treated and cared fo r in sanatoria for the
required period o f time. F or illustration, out o f a probable number
o f from 600,000 to 800,000 cases o f tuberculosis in the German Empire
only 45,609 patients were, in 1910, provided with treatment in 99
public sanatoria1 chiefly maintained by invalidity insurance institu
tions. Since the number o f beds available for public sanatorium
treatment at the present time is only about 12,000, it is self-evident
that unless the accommodation is materially increased, or the dura
tion o f treatment substantially diminished, a very large proportion
o f tuberculous patients must be taken care o f in their homes or in
special institutions not established fo r the purpose o f systematic
treatment and care.
In sanatorium treatment the preference naturally is fo r patients
in the first and second stages o f the disease, although a fairly large
proportion are treated and cared fo r while in the third or terminal
stage. In 1910 out o f 27,857 male patients admitted to German sana
toria 18,633, or 49.8 per cent, were in the first Turban stage; 10,256,
or 37.5 per cent, were in the second; and 3,468, or 12.7 per cent, were
in the third, Out o f 13,905 female patients, 8,648, or 62.2 per cent,
were in the first Turban stage o f the disease; 4,175, or 30 per cent,
were in the second; and 1,082, or 7.8 per cent, were in the third. The
corresponding distribution o f tuberculous wage earners in the gen
eral population is not ascertainable.
A large number and proportion o f persons are at any given time
in the very earliest stage o f the disease, when accurate diagnosis and
effective treatment are o f the greatest practical importance. In due
consideration, therefore, o f the needs o f the tuberculous population
in general, and clearly differentiated from the patients in a definitely
1 There were in addition 34 private sanatoria w ith 2,078 endowed beds, 22 institutions
fo r tuberculous children, and 86 institutions for scrofulous children liable to tuberculosis.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
99
recognized stage o f the disease suitable for sanatorium treatment,
efforts have been made within recent years, and to an ever-increasing
extent, to provide inform ation bureaus aud tuberculosis dispensaries
for the rendering o f competent medical advice and material assistance
in cases o f urgent need.
GERMAN TUBERCULOSIS DISPENSARIES AND INFORMATION BUREAUS.
The establishment o f information bureaus and tuberculosis dispen
saries dates only from 1904, when the first properly equipped institu
tion o f this kind in Germany was established in the city o f Berlin.1
The chief object o f information bureaus and tuberculosis dispensaries
is to prevent the spread o f pulmonary tuberculosis, through the edu
cation o f the patients and the effective utilization o f approved
methods and means o f public or private control. The work o f the
dispensary is therefore intelligently coordinated to rational methods
o f detection or ascertainment o f all serious cases o f tuberculosis and
the dissemination o f useful information regarding the best possible
means o f providing for the needs o f tuberculous wage earners in the
different stages o f the disease. The public control o f tuberculosis, to
be really effective, requires a thoroughly coordinated administrative
organization acting intelligently in cooperation with charitable asso
ciations and medical institutions established and maintained by public
or private enterprise. The chief function o f the tuberculosis dis
pensary is to concentrate preventive and ameliorative efforts in a cen
tral station, and although methods vary in different localities and
countries, the essential principles o f the dispensary are well summed
up in the follow ing program o f the first institution o f this kind,
established by Dr. B. W . Philip, in Edinburgh, in 1887:
1. The reception and examination o f patients at the dispensary,
the keeping a record o f every case, with an account o f the patient’s
illness, history, surroundings, and present condition, the record being
added to on each subsequent visit.
2. The bacteriological examination o f expectoration and other dis
charges.
3. The instruction o f patients how to treat themselves and how to
prevent or minimize the risk o f infection to others.
4. The dispensing o f necessary medicines, sputum bottles, disin
fectants, and, where the patient’s condition seemed to warrant it,
foodstuffs, and the like.
5. The visitation o f patients at their own homes by (1) a qualified
medical man, and (2) a specially trained nurse for the double pur
pose o f treatment and o f investigation into the state o f the dwelling
and general conditions o f life and the risk o f infection to others.
6. The selection o f more likely patients fo r hospital treatment,
either o f early cases for sanatoria or o f late cases fo r incurable
homes, and the supervision, when necessary, o f patients after dis
charge from hospital.
1 There had, however, been a previous effort o f this kind at Halle.
100
BU LLETIN OF TH E BUREAU OF LABOR.
7.
The guidance, generally, o f tuberculous patients and their
friends and for inquiries from all interested persons on every ques
tion concerning tuberculosis.
The German information bureaus and tuberculosis dispensaries, on
the model o f the Berlin institution, have been developed along
somewhat different lines, and they preclude as a first and essential
consideration the medical treatment o f patients on the premises.
Such treatment to be effective, it is held, should be provided by pri
vate physicians or by the physicians employed by sick funds or,
as a last resort, through the poor-law authorities. According to a
comparatively recent imperial statute, the acceptance by tuberculous
patients o f medical treatment provided by poor-law authorities
does not involve a forfeiture o f civil rights and privileges. The
tuberculosis dispensaries are not municipal institutions, but are, as
a rule, under the control o f a local committee acting in cooperation
with the board o f health and other public authorities. Any con-,
sumptive can obtain free advice at the dispensaries, whether in an
early or advanced stage o f the disease and irrespective o f his ability
to pay for qualified advice. In the event that the applicant is found
to be tuberculous all the members o f his fam ily are required to pre
sent themselves at the dispensary for the purpose o f a thorough med
ical examination, which is also made free o f charge.
ORGANIZATION AND SCOPE OF THE TUBERCULOSIS DISPENSARY.
The organization o f the dispensary includes a bureau official, who
has general charge and who must be present during office hours to
give general information and advice. The attending physician has
more limited office hours, during which those who apply are subjected
to a medical examination, which is amplified by a bacteriological
examination o f the sputum, etc. Attached to every dispensary is
at least one visiting nurse, who, without delay, carefully examines into
the home conditions o f the patients and reports her findings. The
function o f the medical examiner is limited to the exact determina
tion o f the condition o f the lungs and the degree to which the disease
has advanced, and the results o f the examination are immediately
communicated to the patient’s own physician or to such as he may
select or as may be provided for him through the sick fund o f which
he is a member, or, i f not otherwise, through the poor-law authori
ties. In other words, the medical function o f the dispensary is
lim ited to the determination o f the applicant’s condition, and no
specific medical treatment is rendered, as is the case in French, Bel
gian, and some English dispensaries.
The first essential function o f the visiting nurse is to ascertain the
home conditions o f the applicant, and to determine what is necessary
to prevent the infection o f other members o f the fam ily. In the
CARE OP TUBERCULOUS WAGE EARNERS IN GERM ANY.
101
event that the patient is unable to provide a room for his own needs,
or even a single bed, the dispensary renders material assistance in so
far as this may be absolutely necessary. T o enable the fam ily to
rent an additional room, pecuniary aid is rendered, or, if that is
not possible, sanitary beds are lent, which are surrounded by screens
to diminish as far as practicable the risk o f infection to other mem
bers o f the fam ily. The nurse further supervises the diet o f the pa
tient and, i f necessary, supplies nutritious food at the expense o f the
dispensary. Patients to whom institutional treatment is suited are
provided fo r in so far as this is possible, particularly at forest day
and night camps, the number o f which has rapidly increased during
recent years. The aim is to provide such treatment near to the home
o f the patient and his place o f work in case the disease is not too
far advanced. It is held that the net cost o f effective treatment at
forest day and night camps need not exceed 1 mark (23.8 cents) per
day, which is in marked contrast to the generally rather high average
cost per day per patient— 4.66 marks ($1.11) in 1910— treated and
cared for at public sanatoria.
Am ong other functions o f the tuberculosis dispensary are the dis
infection o f infected premises and a general supervision o f housing
conditions in so far as they have reference to the possible prevention
or spread o f tuberculosis o f the lungs.
The work o f the dispensaries, in brief, is a combination o f public
hygiene and public nursing, and a vast amount o f good has resulted.
The dispensary aims to provide fo r every pronounced case o f tuber
culosis o f the lungs a separate room in the home o f the sufferer and
to see that the fam ily has ample protection against the danger o f
infection. The dispensary further aims to improve the economic
position o f the fam ily in order that the patient may have the care
and attention which are considered o f paramount importance in the
treatment o f the disease. Patients in the far-advanced stage are
placed in homes for incurables, but efforts in this direction have, on
the whole, been rather discouraging. The patients prefer to be
treated in their own homes and to die there rather than among
strangers in distant institutions.
TUBERCULOSIS DISPENSARIES IN GERMANY IN 1911.
The remarkable development o f tuberculosis dispensaries and infor
mation bureaus in the German Empire during recent years is best
emphasized in the statement that while in 1908 there were only 175
o f these institutions, the number by 1911 had increased to 528. In
addition thereto the number o f forest day and night camps increased
from 82 in 1908 to 98 in 1911. There had also been established 15
forest schools for tuberculous children and 2 agricultural colonies
for tuberculous wage earners. F or tuberculous patients in advanced
102
B U LLETIN OF TH E BUREAU OF LABOR.
stages of the disease adequate provision is made in a large number of
hospitals and in homes for incurables. For the treatment and care
of patients discharged from sanatoria in a condition making a con
tinuation of institutional treatment advisable 17 convalescent homes
exist, and in addition thereto there are 33 observation stations,
chiefly, however, in the principal cities of the Province of Silesia.
Finally, reference must be made to 19 polyclinics, maintained by
municipalities, for the medical treatment of cases referred to them
by medical practitioners or by tuberculosis dispensaries.
A large number of associations of all kinds have been estab
lished in recent years throughout Germany for the study and pre
vention of tuberculosis, including many which combine their activity
with general welfare work, chiefly, however, for the purpose of ren
dering effective assistance to wage earners of the lower and more or
less dependent classes. There are probably not fewer than 500 such
associations, the work of which is more or less coordinated to the
activity of the German Central Committee for the Prevention of
Tuberculosis. The tendency is to further coordinatethework of local
associations to the activities of tuberculosis dispensaries and infor
mation bureaus, which are gradually developing uniform and cen
tralized efforts for the prevention and control of the disease. The
following is a brief account of the methods and results of some of
the more important tuberculosis dispensaries and information
bureaus for the year 1910.
TUBERCULOSIS DISPENSARIES IN BERLIN.
During the four years ending with October 1, 1908, the Berlin
information bureaus and tuberculosis dispensaries medically exam
ined 82,006 persons for symptoms of tuberculosis of the lungs. The
number of homes of tuberculous wage earners examined and reported
upon, and placed in a more or less complete sanitary condition, was
45,583. The dispensary aims particularly at improved hygienic home
conditions, and what is done in this direction is practically equivalent
to a course in elementary domestic and personal hygiene. In quite a
number of cases tuberculous patients were found to occupy the same
bed with healthy members of the family, but in 835 such cases sepa
rate beds were provided through the dispensary. For the object of
providing additional rooms for sleeping accommodation, 10,720 marks
($2,551.36) was paid out as pecuniary aid, and in addition thereto
63,371 marks ($15,082.30) was advanced in particularly urgent cases,
chiefly, no doubt, for the purpose of furnishing a more substantial
diet or other aid necessary to effect an improvement or a cure. The
two items combined, amounting to 74,091 marks ($17,633.66), were
not reimbursed to the dispensary by the local poor-law authorities.
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
103
Patients in a far advanced stage of the disease and pronounced
unfit for sanitary treatment, numbering 3,048, were cared for in
hospitals, air-cure establishments, etc., and of this number 1,565
were subsequently discharged as materially improved. It is held that
but for the intervention of the dispensaries these patients would prob
ably have died, or would have become a serious economic burden
upon the immediate family or the public at large. In addition to
the foregoing, 3,231 children of tuberculous patients were provided
with accommodation in sanatoria for children, and 2,787 other
children were placed in various forest convalescing homes. The dis
pensaries also considered 1,241 applicants in a far-advanced stage
of the disease, advising immediate hospital treatment, with, however,
but a slight chance of improvement or cure.
The city of Berlin in 1910, with a population of 2,070,695, had
six tuberculosis dispensaries and information bureaus, atwhich37,415
persons received consideration, including 5,699 adult males, 10,825
females, and 20,891 children. The rapid growth of the institutions
is brought out by the fact that during 1909 the number of applicants
was only 20,396. It is explained in the annual report for 1910 that
this increase is entirely the result of public appreciation of benefits
obtained. Among the 37,415 persons considered during 1910, there
were 1,100 far-advanced cases of tuberculosis, which were effectively
isolated in their own homes for the purpose of diminishing the risk
of infection to other members of the family. By means of such isola
tion the most dangerous foci of infection are brought under public
control, and that measurable results have been obtained is made evi
dent by the actual decrease in the mortality from tuberculosis, the
rate having declined from 18.2 per 10,000 of population in 1908, to
17.9 in 1909, and to 17.6 in 1910.
The visiting nurses are provided with a brief outline of the essen
tial facts which require to be brought to the attention of tubercu
lous patients and of those persons who are exposed to the imminent
danger of infection. It is pointed out that tuberculosis can be pre
vented, and that the infection of healthy persons can be avoided upon
recognition of the infective character of the disease. The hygiene of
the home is emphasized with reference to dryness, cleanliness, sun
shine, air conditions, etc., and the number as well as the position of
the beds used for sleeping purposes. The danger of a consumptive
sharing the bed with a healthy person is explained, and in the event
that a single bed is not available, one may be provided at the ex
pense of the dispensary. Cleanliness in toilet accommodation is in
sisted upon and the duty of domestic cleanliness in every other direc
tion. Patients are warned not to kiss upon the mouth and to use
only their own toothbrush, on account of the imminent risk of
infection.
104
BU LLETIN OF TH E BUREAU OF LABOR.
Sleeping by the open windowis suggested, andinthe event that the
sputum gives positive evidence of the disease by its bacterio
logical contents a separate sleeping room is advised, and in extreme
cases is provided at the expense of the sanatorium. Members of the
patient’s family are required to report for a medical examination at
the dispensary. It is also advised that used laundry articles must
not remain in a dry condition, and all cooking utensils employed
by the patient must be cleaned immediately after use. Spitting is
prohibited, and for the sputum containers must be provided with
a soda or a lysol solution. Patients are warned not to share their
food with other members of the family, and they are further warned
against smoking, alcoholic drinks, and marriage. The premises are
required to be disinfected. The economic condition of the patient is
discussed with the visiting nurse, and if the aid rendered by the dis
pensary is inadequate the poor-law authorities are called upon.
The financial aid provided by the Berlin dispensaries during 1910
amounted to 26,746 marks ($6,365.55). From a special fund 822
persons were provided with meals for a period of six weeks each.
In addition thereto, 91,439 meals were provided for tuberculous
children at public diet kitchens. Pure milk was provided for 339
personsexclusiveof families takencare of by thepoor-lawauthorities.
The number of tuberculous persons sent to sanatoria and to homes
for incurables through the intervention or assistance of the dispen
saries was 932 adults and 1,029 children. Finally, 1,085 patients
were directed to physicians and polyclinics and 367 were taken care
of in hospitals.
The 6 dispensaries employed 17 visiting nurses, who during the
year made 37,750 visits to the homes of tuberculous patients, or an
average of from 7 to 8 visits a day.
The chief object of the tuberculosis dispensaries is to protect the
healthy, but much is done for the afflicted, particularly with regard
to the recovery of the patients’ earning capacity. As far as prac
ticable the children in tuberculous families are removed therefrom
and taken care of in children’s homes or in forest day camps. The
present effort is largely directedtoward the protection of the children
against infection, as perhaps the most promising means of ultimately
reducing the mortality from tuberculosis. It is pointed out in the
report for 1910 that one of the results of preventive effort will be to
increase the number and proportion of young men fit for military
service, which at present, in the large cities, is not more than 50 per
cent of the number examined.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
105
TUBERCULOSIS DISPENSARIES IN HAMBURG.
The city of Hamburg in 1910, with a population of 932,166, had
five tuberculosis dispensaries, two of which had been established dur
ing the previous year. The dispensaries are subsidized to the extent
of 10,000 marks ($2,380) per annum by the State of Hamburg, and
in addition 9,000 marks ($2,142) is provided by the Hanseatic In
validityInsurance Institution. The German Central Committee fur
nished 2,000 marks ($476) for the establishment of two new dis
pensaries. The various communal sick funds furnished 4,529.65
marks ($1,078.06), and a number of other sick and burial funds pro
vided 3,564.50 marks ($848.35). In addition to this income the
sum of 2,487.53 marks ($592.04) was derived from miscellaneous,
chiefly charitable, sources, making a total income of 31,581.68 marks
($7,516.45). The disbursements during the year were, in some
detail, as follows: For medical fees, 10,490 marks ($2,496.62); for
nurses, 5,900 marks ($1,404.20); for clerical assistance, 2,787.60 marks
($663.45); financial aidtopatients, 1,475 marks($351.05); for beds and
bedding, 1,571.65 marks ($374.05); for rent, 1,066.65 marks ($253.86);
for thermometers, 193.80 marks ($46.12); for printing, 670.05 marks
($176.14); and for furniture and miscellaneous expenses, 1,693.63
marks ($403.08), making a total disbursement for the year of
25,848.28 marks ($6,151.89).
The number of new patients or applicants considered during the
year was 5,004, including 1,720 men, 1,867 women, and 1,417 children.
Of the total number, 2,302 were members of sick funds and 2,391
were members of invalidity insurance institutions. Among the appli
cants were 59 disability annuitants, including 40 males and19females.
Of the 5,004 persons considered, 1,870, or 37.4 per cent, were found to
be tuberculous. The number of medical examinations made during
the year was 12,520. Of the 5,004 persons considered, 2.340 applied
at the dispensaries on their own account, 1,369 were sent to the dis
pensaries by physicians, and 169 applied at the suggestion of the in
validity insurance institution, and 61 at the suggestion of sick funds.
The dispensaries received notifications of 2,638 tuberculous persons
through the invalidity insurance institution, but of this number 1,140
had been previously considered by the tuberculosis dispensaries. The
number of persons sleeping alone was 1,841, the number sleeping
with other adults was 499, and the number sleeping with children
was 381. Only 759 had their own bedroom, but in 2,907 cases the
home was found to be clean and in a sanitary condition, in 533 cases
the condition was fairly satisfactory, and in only 40 was the condition
decidedly unsatisfactory.
The number of persons making application for sanatorium treat
ment was 678, including 238 men, 318 women, and 122 children.
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B U LLETIN OF TH E BUREAU OF LABOR.
Sanatorium treatment was provided at the expense of the invalidity
insurance institution in the case of 118 males and 93 females, and
at the expense of sick funds in the case of 45 males and 35 females,
and by public authorities in the case of 46 men, 84 women, and 97
children. In addition thereto 8 men, 19 women, and 6 children were
provided with sanatorium treatment at their own expense, and 5
persons were taken care of at the expense of others. The number
of cases declined as unsuitable for sanatorium treatment was 162.
There were 95 children of tuberculous parents provided with vaca
tions or treatment in the country, the expenses being paid for in 11
cases by the invalidity insurance institution and in the remainder
of the cases by various authorities, societies, etc.
Of the tuberculous applicants, 209 were provided with accommo
dation in hospitals, and there were 168 deaths, probably of persons
in the advanced stages of the disease. In 1,103 cases the homes of
tuberculous persons were disinfected more or less in cooperation
with the public authorities. In 34 cases beds were provided and in
239 cases financial assistance was rendered to the total amount of
615.96 marks ($146.60); in 69 cases milk was furnished; and in 39
cases additional rent was provided to the amount of 3,317.68 marks
($789.61); 55 persons were provided with clothing, and in 67 cases
financial assistance was secured through private sources. There were
95 cases in which coal was furnished, and in 107 cases the tuberculous
patients were supplied with suitable sputum cups.
A considerable proportion of the male applicants were common
laborers or small wage earners, but practically all occupations are
represented, including a fair number of persons in employments
of a higher grade, such as clerks, stenographers, etc. The total
number of new applicants at the dispensaries increased from 3,480
in 1909 to 5,004 in 1910, and the number of persons medically ex
amined increased from 7,338 in 1909 to 12,520 in 1910. The general
results are considered entirely satisfactory and a determined effort
is being made to increase the usefulness of the institutions in every
direction. The growth of the institutions is conclusive evidence of
public appreciation, and the practical results are made evident by
the fact that the tuberculosis death rate has persistently declined
from 14.9 per 10,000 in 1907 to 13.3 in 1908, to 13.1 in 1909, and to
12.6 during 1910. It may safely be assumed that the establishment
and intelligent administration of the tuberculosis dispensaries and
information bureaus throughout the city of Hamburg has materially
contributed toward this gratifying reduction in the mortality from
this disease.
TUBERCULOSIS DISPENSARY IN LEIPZIG.
In Leipzig, which in 1910 had a population of 587,635, a tuber
culosis
dispensary and information office has been established
through the Association for the Care of Sick Workmen, which has
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
107
given special and extended consideration to the problem of tuber
culosis prevention and relief. The number of new applicants during
1910 was 2,162, which compares with 1,999 during 1909, and 765
during 1908. Of the applicants considered during 1910, 809 were
males insured with invalidity insurance institutions, and 854 were
insured females. The number of children considered during 1910
was 499. The number of medical examinations was 4,118, and 4,515
visits were made to homes of persons who actually had or were
suspected of having tuberculosis. These visits were made by one
male nurse and two female nurses. The dispensary provided 15,340
liters (16,209.5 quarts) of milk and 758 marks ($180.40) in cash for
rent, etc. A considerable amount of food and medicines, as well as a
large number of sputum cups, etc., were provided, but in a general
way the methods and results conform to those of the tuberculous
dispensaries of Hamburg and of Berlin. A special effort was made in
the direction of public education in all matters relating to tubercu
losis, and among the publications distributed were the following:
A Brief Outline of the Effective Protection of the Person against
Tuberculosis; An Advisory Circular for the Tuberculous; Informa
tion as to the First Indications of Tuberculosis; Chronic LeadPoisoning as an Occupation'Disease; The Dangers of Dusty Trades;
and The Dangers of Living in Damp, Small, and Overcrowded
Dwellings.
The foregoing is only a brief outline of the activity of the tuber
culosis dispensary of Leipzig during the year 1910. Effective work
of far-reaching importance is also done by a number of charitable
and philanthropic associations, as well as through the Communal
Sick Fund, with which a large majority of the wage earners of the
city of Leipzig are insured. The tuberculosis death rate of Leipzig
has decreased within recent years from 18.6 in 1907 to 17.4 in 1908
and to 16.3 in 1909. The data for 1910 are not available.
TUBERCULOSIS DISPENSARY IN MUNICH.
Munich, with a population in 1910 of 595,053, has only one dis
pensary, opened on March 1, 1908. In 1909 (the report for 1910 not
being available) the dispensary was visited by 1,204 persons, who
made 4,210 calls during 86 hours of available medical advisory
service. The visiting nurse made 1,794 calls at the homes of the
patients, who represented all of the principal occupations and in
cluded 216 married women and widows and 403 children. The work
of the dispensary is as yet very limited, considering the large popu
lation contributory thereto. In 1909, out of 1,204 persons medically
examined, 745 were found to be tuberculous and in an advanced stage
of the disease, 362 were probably tuberculous, while only 97 were
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BU LLETIN OP TH E BUREAU OP LABOR.
entirely free from the disease or indications thereof. Most of the
persons were of the age period 21 to 50 years. Of the 1,204 persons,
229 were recommended to the dispensary by physicians, 155 by
polyclinics, and 790 otherwise. The number of persons found to have
a tubercular family history was 446, and of this number 256 were
certainly tuberculous, 156 were probably tuberculous, and 34 were
free from the disease or indications thereof. Of the 745 persons who
were certainly tuberculous, 14.7 per cent were of the age period 21
to 30 years and 17.2 per cent of the ages 31 to 40 years. The number
of persons having their own beds was 994, or 82.6 per cent of the
total. The number sharing their beds with one other person was
198, or 16.4 per cent, and the number sharing their beds with two
persons was 12, or 1 per cent.
All cases of tuberculosis as determined at the dispensary are regis
tered on cards and indicated on a map of the city, showing pre
cisely the relation of congestion of population to the occurrence of
disease.
The work of the dispensary is further emphasized in the extent to
which necessary articles were lent for temporary use, chiefly ther
mometers, beds, mattresses, bedding material, sputumcups, spittoons,
etc. The total amount of financial support on behalf of patients pro
vided with accommodation in sanatoria, forest day camps, etc., in
112 cases was 6,712.90 marks ($1,597.67). In 18 cases an addition to
the rent was paid for the purpose of providing better living quarters,
amounting to 234.25 marks ($55.75). There were 15,198 liters
(16,059.5 quarts) of milk furnished, at a cost of 2,735.68 marks
($651.09), and other expenditures for relatively small amounts were
incurred for financial assistance to patients in urgent need thereof.
The work of the dispensary is aided materially by the efforts of
the Munich Association for the Prevention of Tuberculosis, which
carries on an effective propaganda against the disease, and maintains
two day camps, one each for men and women. The day camp for
women is combined with an open-air school for children, which dur
ing 1909 was open from May 10 to September 26 and provided ac
commodation for 67 children. The day camp for women was open
from May 1 to December 26 and 829 persons were cared for5chiefly at
the expense of the communal and trade sick funds and the Invalidity
Insurance Institution of Upper Bavaria. The physical results of the
institution are made evident by the fact that for 663 patients there
was an average gain in weight of 2.7 kilograms (5.95 pounds) as the
result of an average stay of 28 days. The attendance has rapidly in
creased from an average of 30 persons per day in 1904 to 158 in 1909.
Of 236 patients for which the information is given, 107, or 45.3 per
cent, were tuberculous. Of the 236 patients under treatment and care,
80.9 per cent recovered their full earning capacity, and 7.2 recovered
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
109
partial earning capacity. The physical results in the case of children
were particularly satisfactory, the average gain in weight having
been 3.7 kilograms (8.16 pounds), and the average increase in height
4.4 centimeters (1.7 inches). Under the present limitations the use
fulness of the tuberculosis dispensary is, however, far from what the
local conditions require, for the death rate from tuberculosis in
Munich is high, having been 22.9 per 10,000 in 1909 against 17.9 for
Berlin, and 15.6 for Cologne. The tuberculosis death rate of Munich
has been practically stationary for the three years 1907 to 1909, but
there has been a decline in the occurrence of the disease when com
parison is made with earlier years.
TUBERCULOSIS DISPENSARIES IN SILESIA.
The results of dispensary treatment have been fully as encourag
ing in small communities, and even in rural districts, in which, in
some sections of Germany, the tuberculosis death rate is higher than
in the cities. What has been done in this direction in the Province
of Silesia is particularly interesting in view of the fact that 32 com
munities, in 1910, maintained information bureaus and tuberculosis
dispensaries, and that in these 4,853 persons were medically examined,
of whom 2,186, or 45 per cent, were found to be tuberculous. The
visiting nurses made 16,419 calls in behalf of 1,847 tuberculous
patients or families. In 490 cases infected homes were disinfected
by scientific methods, aside from a large amount of disinfection by
public authorities. The number of men provided with institutional
treatment was 189; of women, 208; and of children, 214. The finan
cial needs of the dispensaries were provided for in part by 25 com
munities furnishing 9^860 marks ($2,346.68). In addition thereto the
invalidity insurance institution of Silesia subsidized the dispensaries
with the sum of 9,615 marks ($2,288.37), and the German Central
Committee furnished 1,000 marks ($238). Finally, three communities
were aided to the extent of 13,000 marks ($3,094) for the establish
ment and support of forest day camps.
TUBERCULOSIS DISPENSARY IN AUGSBURG.
In the city of Augsburg, which in 1910 had a population of 102,570,
a tuberculosis dispensary was established in 1909. From the outset
the institution met with a decided response, and in 1910 97 medical
consultations were held, during which, on an average, from 15 to 20
persons were examined as to evidences of tuberculosis. The number
examined included all of the patients discharged from the sana
torium of the invalidity insurance institution, with provision for
their subsequent observation and record. The chief aim of the insti
tution is the education of the public in all that pertains to the pre
vention, treatment, and cure of tuberculosis, and included in this
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B U LLETIN OP TH E BUREAU OP LABOR.
propaganda are the members of the patients’ families. The effort is
to control, as far as possible, the housing conditions of those infected
with the disease, and the visits of the nurse are largely directed to
ward remedial measures and a moderate amount of financial support.
During the two years the dispensary has been established 680 homes
have beeninspected and as far as necessary the immediate living con
ditions have been improved as a first requisite in providing an en
vironment favorable for the cure of the disease. In many instances
very unsatisfactory housing conditions were disclosed by the inspec
tion and brought to the attention of the public authorities. A special
effort is made to control the expectorations of the patients, for the
purpose of preventing the infection of other members of the family
or the reinfection of the patient. Disinfection is practiced to a con
siderable extent, and in all cases when a tuberculous person moves
from one locality to another or in the event of death.
On January 1,1910, there were 294 persons under observation, and
during the year 359 new applicants received consideration. Of the
359 new applicants, 119 were men, 139 were women, and 101 were
children. Of the 119 men, 100, or 84 per cent, were tuberculous or
probably so; and of the 139 women, 110, or 79.1 per cent; and of the
101 children, 55, or 50.5 per cent. The number of families under ob
servation on January 1, 1911, was 179. The number of medical ex
aminations, including reexaminations, made during 1910, was 476.
The visiting nurse during the year made 1,105 visits, and in 115
cases material improvements were brought about in the home and
living conditions of the patients. The amount of financial assistance
in the case of eight families was 334 marks ($79.49). For the pre
vention of infection, 106 sputum cups and a considerable amount of
disinfecting material were provided. Disinfection of premises took
place in 150 cases, of which 135 were on account of death and 15 on
account of change of residence. The dispensary provided for 734
patients 11,055 liters (11,682 quarts) of milk and for 52 patients
1,650 noonday meals.
The death rate from tuberculosis in Augsburg is gradually de
clining. In 1900 the rate was 37.0 per 10,000 population, in 1904 it
was 30.7, in 1909 it was 22.9, and in 1910 it was 22.6. The actual
number of deaths had decreased from 328 in 1900 to 232 in 1910,
although the population had increased from 88,749 to 102,570.
TUBERCULOSIS DISPENSARIES IN WESTPHALIA.
In concluding this brief review of some of the more important
and typical tuberculosis dispensaries and information bureaus, which
within recent years have been established throughout the German
Empire, reference may be made to what has been done in this direc
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
I ll
tion in the Prussian Province of Westphalia, which in 1910 had a
population of 4,125,904. The number of dispensaries, which in 1909
had been 14, was increased by 14 during 1910. The problem is
seriously complicated by more or less unsatisfactory housing condi
tions, and the work of the dispensaries is therefore intelligently
coordinated to a well-organized system of house inspection. In the
aggregate 5,698 persons applied to the dispensaries during 1910, and
of this number 2,774 were medically examined. An examination of
the sputa was made in 1,299 cases and a positive diagnosis of tuber
culosis was made in the case of 1,839 applicants. The total number
of persons under supervision and care was 1,925, and of this num
ber 585 were provided with nourishing food, 123 with beds, 736 with
medicinal baths, 49 with financial assistance on account of rent, and
193 with sputum cups and disinfecting material, etc. In 531 cases
the premises were disinfected, including 284 on account of deaths
from tuberculosis.
AGRICULTURAL COLONY FOR TUBERCULOUS W AGE EARNERS.
One special effort should here be referred to for the purpose of
completeness, and that is the establishment of an agricultural colony
by the Invalidity Insurance Institution of Hanover chiefly for the
benefit of patients discharged from sanatoria for the treatment of
tuberculosis. The colony is located at Stubeckshom, in the Luneburg
Heath, within a reasonable distance of the city of Hanover and about
5 miles from the city of Soltau. The estate comprises 750 hectares
(1,853.3 acres) of land, of which 650 hectares (1,606.2 acres) consist
of pine woods. A simple provision*has been made for the housing
of the patients, who are employed in the open air, chiefly in
the making of roads in the woods, in the preparation of asparagus
beds, and in light field work during the harvest season. The value
of the property in 1910 was 175,587 marks ($41,789.70). The work
is done under medical supervision, but every inmate is required to
perform certain duties punctually and to the best of his ability. The
principle of compulsory labor is therefore fundamental. The mini
mum working time per day is four hours, the patients being divided
into three grades, those in the first grade working up to four hours,
those in the second grade to six hours, and those in the third grade
to eight hours, according to their strength and capacity. The stay
in the colonyis usuallylimited to two months. The patients admitted
must as a rule be tuberculous persons who, up to the time of their ad
mission, had been treated in a sanatorium, but who were relatively
free from definite symptoms of the disease on their discharge. Per
sons are also admitted who are not tuberculous, but who have had
inflammation of the lungs and who to that extent would be predis
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B U LLETIN OF TH E BUREAU OF LABOR.
posed to the disease. The two classes of patients are, however, kept
entirely separate.
The maximum duration of work is eight hours a day, the work
being paid for at the rate of 10 pfennigs (2.4 cents) an hour, which
makes possible maximum earnings of 80 pfennigs a day (19 cents),
which is credited to the patient and paid to him on his discharge, if
not before. The patients are required to be insured members of
the Invalidity Insurance Institution of Hanover.
This institution was opened on May 5, 1902. As far as the results
have been reported to date, the experiment on the whole appears to
have been satisfactory. Of the cases reportedupon in 1905,78percent
were finally discharged as fully capable of work. Of those who had
previously worked in factories 9 per cent on discharge changed their
occupations to different and more suitable employments. The aver
age gain in weight during the stay in the colony was 3.1 kilograms
(6.8 pounds). The average earnings per patient amounted to 27.15
marks ($6.46). The average hours of labor for days actually em
ployed amounted to 6.9. The average cost per patient per day dur
ing the first year of the establishment was 98 pfennigs (23 cents).1
The food served is the ordinary nutritious diet of agricultural
laborers and not the specially prepared diet of tuberculosis sanatoria.
Provision is made for a maximum of 65 patients.
A drawback to the success of this establishment has been the in
clination of the better class and more industrious married workmen
to return to their families too soon after their discharge from the
sanatorium, even though such a return was likely to be followed
by consequences injurious to health. Another drawback is that dur
ing winter months, when there is little agricultural work to be done
throughout the section, persons whocan not find any employment seek
to be admitted to the colony. The hope is held out that the colony,
in course of time, will become a most valuable connecting link in the
chain of institutions established for the common welfare of German
wage earners, primarily for the purpose of conservingthehealthand
well-being of men and women employed in industry.
CONTROL OF TUBERCULOSIS THROUGH HOUSING REFORM.
The public control of tuberculosis through housing reform re
ceived extended consideration for the first time in 1901 in an address
read before the German Central Committee.2 Earlier observers had
emphasized the intimate relation between density of population,
1 During 1910 a total of 19,087 days’ support was provided at the colony, of which
only 16 days was on account of patients other than those who, on admission, were
tuberculous or who had received treatment on account of tuberculosis of the lungs pre
vious to their admission.
2 Dr. Heydweiller, Ueber Bek&mpfung der Tuberkulose durch Wohnungsfiirsorge. Ber
lin, 1901.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
113
unsatisfactory housing conditions, and tuberculosis frequency, indi
cating that the disease is most often caused by domestic infection,
family infection, overcrowding, and bad air. It had been shown
that “ the death rate from phthisis steadily increases with the pro
portion of the total population living more than two in a room in
tenements comprising less than five rooms.”1 The average annual
phthisis rate of London was found to range from 11.1 per 10,000 of
population in districts practically free from congestion to 25.9 in
badly congested districts. Official inquiries into housing conditions
established the fact that adequate treatment and care of tuberculous
wage earners in their homes was often prevented by serious defects
in structural arrangement or bybad sanitaryconditions such as damp
ness, defects in lighting, ventilation, etc. Adequate and sanitary
housing accommodations for wage earners and their dependents were,
therefore, urged as a first step in the campaign against tuberculosis.
Much had already been done in this direction by local welfare organi
zations and building societies, particularly in the Rhine Province
and in the Grand Duchy of Hesse. Attention, however, was drawn
at about the same time to the vital interest of invalidity insurance
institutions in the reduction of the morbidity and mortality from
tuberculosis, and to the service to be rendered by these institutions in
providing the means for a nation-wide reform in housing conditions
along lines of rational sanitary requirements.
An address on the relation of housing to tuberculosis before the
German Central Committee at its fourteenth annual session in 1910,2
emphasized the view that the administrative control of tuberculosis
was la r g e ly a housing p r o b le m , not o n ly in th e c o n g e ste d sec tio n s of
large cities, but also throughout the agricultural districts. The
argument was sustained by statistical data, showing the existence of
a vast amount of overcrowding and the intimate relation thereto of
the excessive occurrence of tuberculosis. For Mannheim, for illus
tration, it was shown that in the overcrowded homes the death rate
from tuberculosis was nearly double what it had been ascertained to
be in homes with suitable accommodation. The conclusion was ad
vanced that by providing normal housing conditions the mortality
from tuberculosis would be materially reduced, but also that much
could be done by rigid house inspection along the lines developed in
the Grand Duchy of Hesse, which provides a trained building inspec
tor for every territorial division. In summarizing the conclusions it
was pointed out that (1) tuberculosis was a house disease with a
variable degree of frequency, according to overcrowding and density
of population; (2) the improvement in housing conditions and the
education of wage earners in rational methods of living would largely
1 The Prevention of Tuberculosis, by Arthur Newsholme, M. D., p. 147.
1908.
aZur Tuberkulose-Bekampfung, 1910, pp. 22, by Dr. Paul Romer.
49397°— 12------ 8
http://fraser.stlouisfed.org/
Federal Reserve Bank of St. Louis
New York,
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BU LLETIN OP TH E BUREAU OP LABOR.
affect the future reduction of the death rate; (3) the importance of
utilizing the services of trained building inspectors; (4) the noti
fication of cases of tuberculosis and the disinfection of the premises
in the event of change of residence or death; (5) the intelligent co
ordination of the investment of surplus funds of invalidity insurance
institutions in approved building projects primarily adapted to the
needs of wage earners, with a due regard to advanced sanitary and
social requirements; and (6) the general sanitary improvement of
cities, adequate drainage, and effective methods of dust prevention
and the eradication of the smoke nuisance.
In discussing the foregoing conclusions, Dr. Sarason, of Berlin,
emphasized the necessity of personal hygiene as a prerequisite for the
attainment of required results in public hygiena Dr. F. Kohler, of
Holsterhausen, sustained the argument of Building Inspector Gretzschel by an analysis of returns for 1,000 wage earners in the Rhine
Province, showing that of 636 tuberculous married men, only 24.7
per cent occupied their own beds, while 75.3 per cent shared their
beds with other members of the family, in this way exposing the
other members to additional risk of infection. Of 649 married
tuberculous wage earners, including widowers having 1,866 children,
it was found that the large majority of these children occupied beds
with tuberculous members of the family. Under conditions like
these, which are fairly typical at least for the industrial districts of
the German Empire, it is evident that the gradual eradication of
tuberculosis is largely conditioned by the problemof housing reform.
BUILDING LOANS B Y IN V A LID ITY INSURANCE INSTITUTIONS.
The intimate relation which exists between the local occurrence of
tuberculosis and the more or less unsatisfactory housing conditions
early suggested to the invalidity insurance institutions the propriety
and advantage of investing a considerable proportion of their surplus
funds in the erection of model dwellings, primarily for the use of
wage earners and their families.
In a statistical analysis published in 19051 of what had been done
by invalidity insurance institutions it was shown that 109,533,296
marks ($26,068,925) had been invested by December 31, 1903, in
building projects, or 10.8 per cent of the total funds accumulated as
reserve. The largest amount had been invested by the Invalidity
Insurance Institution of the Rhine Province, or 21,793,584 marks
($5,186,873), or 18.8 per cent of the total funds. The institution
of Hanover, however, had invested 40.4 per cent of its funds in build
ings and homes for wage earners, or a total of 16,374,215 marks
($3,897,063). By 1903, therefore, substantial results had been
1 Die Vorteile der Invalidenversicherung und ihr Einfluss auf die deutsehe Volkswirtschaft. Bearbeitet yon Gustav Vogt, Berlin-Grunewald, 1905.
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
115
achieved, and in response to a strong agitation larger investments
in this direction were made by the invalidity insurance institutions,
so that by December 31, 1910, the total amount invested in housing
accommodation for German wage earners and their families was
320,065,539 marks ($76,175,598), and of this sum 39,600,000 marks
($9,424,800) was provided by the invalidity insurance institutions
during 1910.
According to an analysis of the investments for the year 1910 in
the publications of the Imperial Insurance Office for March 15,1911,
of the 320,065,539 marks ($76,175,598), the sumof 301,280,659 marks
($71,704,797) was invested in homes for family purposes, while
18,784,880 marks ($4,470,801) was invested in lodging houses and
other means of providing for the needs of unmarried wage earners.
Of the 301,280,659 marks ($71,704,797) provided for the building of
family homes, 184,241,241 marks ($43,849,415) was lent to building
societies, stock building associations, and philanthropic building
societies, at an average rate of interest of from 2.5 per cent to 4.25
per cent. The sum of 37,571,717 marks ($8,942,069) was lent to
provinces, communities, and savings banks and other public institu
tions at rates of interest of from 2.5 per cent to 3.75 per cent.
The sumof 63,426,736 marks ($15,095,563) was lent to wage earners
insured with invalidity insurance institutions at rates of interest
of from 2 per cent to 4.5 per cent. The sum of 16,040,965 marks
($3,817,750) was lent to employers of labor at rates of interest of
from 3 per cent to 4.5 per cent.
Of the 18,784,880 marks ($4,470,801) lent for building purposes
to provide accommodation for unmarried wage earners, 15,905,180
marks ($3,785,433) was lent to building societies, stock building asso
ciations, and philanthropic building associations at rates of interest
of from 3 per cent to 4 per cent.
The sum of 2,259,950 marks ($537,868) was lent to provinces, com
munities, and savings banks and other public institutions at rates of
interest of from 3 per cent to 3.75 per cent. The sum of 619,750
marks ($147,501) was lent to employers of labor at rates of interest
of from 3.5 per cent to 4 per cent.
The Invalidity Insurance Institution of the Rhine Province pro
vided the largest amount in loans for building purposes, or 55,982,937
marks ($13,323,939). The next most important invalidity insurance
institution was that of Hanover, with 34,822,174 marks ($8,287,677);
followed by that of Westphalia, with 33,682,841 marks ($8,016,516);
the Kingdom of Saxony, with 25,451,670 marks ($6,057,497); the
Grand Duchy of Baden, with 22,580,197 marks ($5,374,087); the
Kingdom of Wurttemberg, with 17,755,224 marks ($4,225,743); the
pension fund of the Prussian-Hessian railways, with 14,681,276
marks ($3,494,144); and the Province of Hesse-Nassau, with
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BU LLETIN OF TH E BUBEAU OF LABOB.
13,680,356 marks ($3,255,925). None of the other invalidity insur
ance institutions provided a sum amounting to as much as 10,000,000
marks ($2,380,000).
TOWN PLANNING AND SANITABY PROGRESS IN GERMANY.
A very comprehensive account of building reformin German cities,1
largely for the purpose of improving the living conditions of wage
earners, was published by the Imperial Statistical Office in 1910.
The report brings out the remarkable progress which has been
achieved within recent years, not only in the direction of providing
better living quarters, but also in the more effective administrative
control by means of trained building inspectors and carefully devised
rules and regulations governing the erection of sanitary dwellings
for wage earners and others. To the extent that these aims and
plans are realized, the conditions favorable for the spread of tuber
culosis will largely be done away with, and, as has been previously
pointed out, a special effort in this direction has been made in the
Rhine Province, largely sustained by the Rhenish-Prussian Associa
tion for the Housing of the Working Classes. The report of this
association for 1909-10 contains an interesting account of what
thus far has been achieved and what will be done in the near future,
including a statement of the methods and means by which the
required funds have been provided. The model building rules of
this association, as adopted at the general meeting in 1910, are a
sure foundation for the intelligent control of future building opera
tions conditioning not only the erection of new housing quarters but
also the gradual remodeling of existing houses for their better
adaptation to the needs of wage earners, with a particular regard to
the required raising of the level of physical and material well-being.
Equally interesting in this direction has been the effort made by the
Association of Industrial Employers of Saxony, as emphasized in an
exhibit made at the International Exposition of Hygiene, at Dresden,
in 1911. The efforts of this association are not limited merely to
providing houses and gardens, but also estimates are supplied of the
cost of rational furnishings, including all thearticles required for sani
tary housekeeping and at reasonable expense. Finally, mention may
be made of what has been done by the Friederich Krupp Corporation,
of Essen. All of these efforts, local or general, are in effect a further
ance of the aims and efforts to improve the social and economic
condition of wage earners throughout the German Empire, and to
the extent that this laudable purpose is achieved within a reasonable
period of time the amount of tuberculosis due to social and eco
nomic causes must necessarily be materially diminished.
1 Wolmungsfiirsorge in deutschen St&dten.
Berlin, Carl Heymanns Verlag.
1910.
CARE OF TUBERCULOUS WAGE EABNERS IN GERMANY.
117
EXPERIENCE DATA OF REPRESENTATIVE INVALIDITY INSURANCE
INSTITUTIONS IN THE TREATMENT AND CARE OF TUBERCULOUS
WAGE EARNERS IN 1910.
BERLIN.
The territory o f the Invalidity Insurance Institution o f Berlin is
coextensive with the administrative area o f the city o f Berlin, which
includes 63 square kilometers (24.3 square m iles), and in 1910 had a
population o f 2,070,695, o f which the increase during the last decade
was 0.92 per cent per annum, against an average annual increase for
the German Empire o f 1.41 per cent. The density o f population is
32,661 per square kilometer (0.386 square m ile). The average death
rate during the 10 years ending with 1909 was 16.3 per 1,000, but the
rate decreased from 18.9 in 1900 to 14.7 in 1909. F or the purpose o f
convenient comparison it may be stated that the general death rate
o f the city o f New York during the year 1910 was 16 per 1,000.
Comparing the five years ending with 1910, the death rate o f Berlin
decreased 42 per cent when compared with the death rate prevail
ing during the period 1881 to 1885. The corresponding decline
during the same period in the general death rate for the city o f New
York was 38 per cent. The death rate o f Berlin decreased from
29.7 per 1,000 in 1880 to 20.2 in 1895 and 15.1 in 1909. The death
rate from tuberculosis decreased from 34.7 per 10,000 in 1880 to 23.4
in 1895 and to 17.9 in 1909. The average death rate from tuberculosis
o f the lungs, o f males, ages 30 to 60 years, inclusive, during the year
1908 was 35 per 10,000 o f population o f corresponding ages, and for
females 17.
In the experience o f the Invalidity Insurance Institution o f Ber
lin the proportion o f tuberculosis o f the lungs as a cause o f invalidity,
according to the investigation o f 1896 to 1899, was 25.2 per cent for
males against 15.0 for all institutions, and 14.9 per cent for females
against a general average o f 9.5 per cent. The rate o f insured per
sons treated and cared for on account o f sickness from all causes by
the Invalidity Insurance Institution o f Berlin during 1910 was 15.7
per 1,000 o f the population subject to the insurance laws, or almost
exactly twice the average rate o f 7.8 per 1,000 fo r the German Em
pire as a whole. The number o f patients under treatment and care
on account o f tuberculosis o f the lungs during the year was 3,961,
or 6.10 per 1,000 o f the insured population. The corresponding aver
age for all insurance institutions was 3.19 per 1,000. The amount ex
pended on account o f treatment and care during the year 1910 for
tuberculosis was 1,957,358 marks ($465,851), or an average expendi
ture o f 494.16 marks ($117.61) per patient per annum. The In
validity Insurance Institution o f Berlin maintains two sanatoria o f
its own and a tuberculin station, to which more extended reference is
made further on.
118
BU LLETIN OP TH E BUREAU OF LABOR.
According to the annual report for 1910 o f the Invalidity Insur
ance Institution o f Berlin, diseases o f the lungs, including tubercu
losis, accounted for the largest number o f applicants for disability
annuities. Out o f every 100 disability annuities granted during the
year at ages 20 to 24 years on account o f diseases o f the lungs, the
proportion o f males was 56 per cent and of females 62 per cent; at
ages 25 to 29 years the corresponding percentages were 54 and 42,
respectively. The details, by divisional periods o f life, are given in
the follow ing table:
PER CENT OF DISABILITY ANNUITIES GRANTED TO MALES AND TO FEMALES IN
SPECIFIED AGE GROUPS ON ACCOUNT OF TUBERCULOSIS AND OTHER DISEASES
OF THE LUNGS1 BY THE INVALIDITY INSURANCE INSTITUTION OF BERLIN, 1910.
Per cent granted
to—
Per cent granted
to—
Age groups.
Age groups.
Males.
20 to 24 years..........................
25 to 29 years. _.......................
30 to 34 years..........................
35 to 39 years.. .......................
dn tft dd yftars
45 to 49 years..........................
50 to 54 years..........................
56
54
45
33
30
30
24
Males.
Females.
62
42
39
26
15
15
13
Females.
55 to 59 years..........................
60 to 64 years..........................
65 to 69 years..........................
70 years and over...................
20
19
18
13
11
10
8
7
Total.............................
28
18
1Includes also chronic bronchial catarrh.
(See p. 32 of the report for 1910.)
It is brought out by this comparison that the relative frequency
o f lung diseases including tuberculosis was much greater among males
than among females, except at the age period 20 to 24 years. The
relative frequency diminishes with increasing age, reaching at ages
70 years and over a minimum o f 13 per cent fo r males and 7 per cent
for females.
The proportion o f disability annuities granted on account o f tuber
culosis o f the lungs has gradually decreased for males from 27.6
per cent in 1900 to 19.7 per cent in 1910; for females the rate in
creased during the corresponding period from 11.7 per cent in 1900
to 13.1 per cent in 1910. Considered by groups o f employment, the
percentage o f disability annuities granted on account o f tuberculosis
o f the lungs was highest for persons employed in the manufacture
o f metals and machinery, or 24.6 per cent, follow ed by persons em
ployed in commerce and trade, with 23.9 per cent. The lowest rate
prevailed among porters and servants, or 9.3 per cent. For females
the percentage o f disability annuities granted on account o f tuber
culosis o f the lungs was 20.7 per cent for those employed in the
clothing industry, and only 7.4 per cent for domestic servants.
During the year 1910, 3,404 persons were under treatment on
account o f tuberculosis o f the lungs at the sanatorium at Beelitz,
and o f this number 2,031 were males and 1,373 females.1 In addi
1 See p. 63 of the report for 1910.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
119
tion to the sanatorium the invalidity insurance institution aids in
the maintenance o f information bureaus and dispensaries, and on
this account during the year 1910 a subvention o f 25,000 marks
($5,950) was paid out. The accommodations at Beelitz were en
larged during the year by the erection o f a building fo r infectious
diseases, a restaurant, and a school for the children o f the employees
o f the institution. F or the support o f patients during the year 1910
the net sum o f 1,740,946 marks ($414,345) was paid out, equivalent to
an expenditure o f 4.19 marks ($1) per patient per day, against an
expenditure o f 4.16 marks (99 cents) for the previous year. In
cluding, however, interest payments on capital account, amounting
to 657,519 marks ($156,490) for the year 1910, the true expenditure
per patient per day was 5.77 marks ($1.37) for 1910, against 5.72
marks ($1.36) for 1909. The increase in expenditure is accounted
for by higher salaries and interest payments. The average duration
o f treatment fo r male patients was 70 days and fo r female patients 75
days. The available accommodation during the summer half year
is 490 beds fo r male patients and 356 beds for female patients. The
corresponding accommodation during the winter half year is 474
beds for males and 356 beds for females. The total number o f days’
treatment on account o f tuberculosis o f the lungs during the year
was 363,134, consisting o f 303,774 days’ support for patients, and
59,360 days’ support, or 16.3 per cent o f the total, on account o f
employees. The average expenditure per patient per day for board
was 1.37 marks (32.6 cents) fo r patients only, and 1.41 marks (33.6
cents) for patients and employees combined. The individual items
o f expenditure per day on account o f board are given in tabular form
below for the two years 1909 and 1910 to illustrate the comparative
expenditures for the two years:
ITEMIZED DAILY EXPENDITURES ON ACCOUNT OF BOARD FOR PATIENTS AND
EMPLOYEES AT THE BEELITZ SANATORIUM, BERLIN, 1909 AND 1910.
[From Annual Report for 1910, p. 68.]
Articles.
1910
Cheese, etc.'............................ $0.0112
.0193
.................................... Pastry
B u tter...................................
.0438
.0093
Eggs.......................................
.0112
General groceries....................
.0031
Fish........................................
Meat and sausage...................
.1495
.0012
VoorotahlAis (froaVi
.0143
Wine, beer, mineral waters,
.0214
etc.......................................
1909
$0.0119
.0205
.0443
.0102
.0117
.0024
.1442
.0017
.0126
.0236
Articles.
1910
Fowl....................................... $0.0014
Spices..................................... . .0038
Peas, beans, etc......................
.0007
Milk........................................
.0417
Flour......................................
.0019
.0014
Fruit (dried and preserved)..
Fruit (fresh)...........................
.0005
.0002
Fruit (w ild)...........................
Total.............................
.3358
1909
$0.0014
.0040
.0007
.0417
.0021
.0017
.0005
.0002
.3353
It is brought out by this table that for the three important items
o f milk, butter, and eggs, 0.398 marks (9.48 cents) per patient per
day was paid during 1910, or 28.2 per cent o f the total per capita
expenditure on account o f board. The total expenditures on account
120
BU LLETIN OF TH E BUBEAU OF LABOB.
o f food and drink, comprehended under the term “ board ” as an equiv
alent o f the term “ support,” as used in the German reports, amounted
to 547,682 marks ($130,348), but deducting 35,129 marks ($8,361)
received in payment for board and for meat, etc., sold, the net ex
penditure during the year was 512,553 marks ($121,988).
According to the annual report o f the medical director o f the In
validity Insurance Institution o f Berlin for the treatment o f tuber
culosis o f the lungs, the number o f patients on January 1, 1910, was
824, o f which 356, or 43.2 per cent, were women. The number o f
patients discharged during 1910, including 3 deaths, was 3,411, o f
which 2,031 were males and 1,380 were females. The number o f pa
tients remaining on December 31, 1910, was 817. o f which 349, or
42.7 per cent, were women.
O f the patients discharged during the year, 213 left the institution
for personal or other reasons before completing their respective
course o f treatment. There were also 37 patients who subsequent to
a definite period o f observation were discharged as apparently not
tuberculous. There remained, therefore, 3,374 patients under treat
ment for tuberculosis o f the lungs, and these were distributed accord
ing to the Turban stage o f the disease, as follow s: O f 2,018 male
patients, 1,513, or 75 per cent, were in the first stage o f the disease;
231, or 16.4 per cent, were in the second stage; and 174, or 8.6 per
cent, were in the third stage. O f the 2,018 male patients, the sputum
o f 519, or 25.7 per cent, contained the bacilli o f tuberculosis. O f the
patients in the first stage o f the disease 7.34 per cent were carriers o f
bacilli; in the second stage, 75.8 per cent; and in the third stage,
90.23 per cent. During the course o f treatment 26.8 per cent o f the
patients having bacilli in the sputum on admission were free there
from on discharge.
O f the 1,356 female patients, 1,067, or 78.7 per cent, were in the
first Turban stage o f the disease; 198, or 14.6 per cent, in the second
stage; and 91, or 6.7 per cent, in the third stage. O f the 1,356 female
patients, 309, or 22.86 per cent, were found to have the bacilli o f tuber
culosis in their sputum. O f these numbers the respective proportions
having bacilli in their sputum were 8.8 per cent for the first stage,
66.7 per cent for the second, and 91.2 per cent for the third stage o f
the disease. O f the total patients with bacilli in their expectoration,
52.4 per cent were free therefrom at the time o f their discharge.
The total number o f patients subjected to the tuberculin treatment
was 763, against 590 during the previous year. There was, therefore,
a material increase in the number o f patients treated by specific thera
peutic methods, and the results were in every respect satisfactory.
Objections on the part o f patients are stated to have practically dis
appeared, and the most o f them underwent the treatment voluntarily
and carried the same conscientiously through from beginning to end.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY,
121
The essentials o f successful treatment are stated to be a sufficient
duration, an extremely careful selection o f patients, and most pains
taking observations during the course o f treatment. It is held that
even in the second and third stages o f the disease a material im
provement can be brought about by tuberculin treatment under the
conditions stated.
A special tuberculin station is maintained at Lichtenberg, where
582 new patients received treatment during 1910. In addition to this
establishment preliminary medical examinations were made o f pa
tients intended for the institution at Beelitz, numbering in the aggre
gate 8,895 for the year. In the case o f 3,875 persons the treatment
was declined, partly on account o f the fact that a considerable pro
portion o f the patients were in too advanced a stage o f the disease to
warrant the anticipation o f favorable economic results.
A number o f tuberculosis dispensaries are maintained or substan
tially aided by the Invalidity Insurance Institution o f Berlin. The
results during 1910 were quite favorable in that many cases received
consideration in the very early stages o f the disease, including an
opportunity fo r fam ily protection much in the nature o f the work o f
visiting-nurse associations. In the case o f 127 families additions were
granted to the amount paid for rent so as to provide more wholesome
living accommodation. In 479 cases the living quarters were disin
fected on account o f having been inhabited by tuberculous patients
or because o f a death from tuberculosis. In the case o f 234 families
infected members were removed therefrom for treatment or were
otherwise adequately provided for to prevent the spread o f the dis
ease. In most o f these cases persons were affected who had made no
application for institutional treatment and who themselves were not
aware o f the fact that they were afflicted with the disease. This form
o f thorough fam ily examination in suspected cases has in practice
been decidedly effective. In other words, if reasons exist for suppos
ing one or more members o f a fam ily to be infected with the disease,
the entire fam ily is subjected to a thorough medical examination and,
if necessary, is placed under medical observation for a required
period o f time.
V isiting nurses connected with the dispensaries are, as a rule,
required to make each month at least one visit to the homes o f pa
tients who have been removed to institutions for systematic treat
ment. Such visits are utilized for purposes o f instruction and the
amelioration o f more or less adverse economic conditions at small
expense. In cases where the patients are treated at home additional
beds are provided so as to prevent the sleeping together o f tubercu
lous and nontuberculous members o f the same family. Such beds are
lent, and when no longer required they are thoroughly disinfected.
Through private philanthropy further provision is made for provid
Digitized foring
FRASER
six weeks’ medical treatment free o f cost, and the care o f the
122
BU LLETIN OF TH E BUREAU OF LABOR.
fam ily is extended to the protection o f children, who, as far as prac
ticable, are removed to wholesome surroundings. During 1910, 88
children apparently affected with tuberculosis were taken care o f in
special institutions, and in 221 cases adults were provided for in city
homes for the incurable. A record is kept o f all infected houses.
Summarizing the results o f the three dispensaries, established
almost exclusively for the benefit o f the wage-earning population o f
Berlin and vicinity, the number o f persons examined during 1910
was 6,991, and o f this number 1,428, or 20.4 per cent, were children.
The number o f persons ascertained to be tuberculous was 3,003, and
the number seriously predisposed to infection was 901. In addition
to the foregoing 1,299 tuberculous persons receiving disability annui
ties, or patients discharged from the Beelitz institution as more or
less improved, were taken care o f during the year. O f this number
564 were ascertained to be in a condition involving the risk o f infec
tion o f others. The number o f deaths follow ed by disinfection o f
the premises was 212, and the number o f visits made by nurses o f
the institution was 9,046. The total number o f patients to whom
financial aid was extended was 127, and the total amount disbursed
was 6,068 marks ($1,444).
The number o f patients discharged from the Beelitz institution for
the treatment o f tuberculosis o f the lungs during 1910 was 2,037
males and 1,367 females. O f the males 158 received less than 30 days’
treatment, and 184 more than 180 days’ treatment. Am ong the
females 108 received less than 30 days’, and 140 more than 180 days’
treatment. The average duration o f treatment during 1910 was 87.1
days fo r males and 92.9 days for females. The average duration o f
treatment has increased considerably during recent years, having
been 68.4 days for males and 74.5 days for females in 1908.
The number o f male patients receiving over three months’ treat
ment was 483, and o f this number 6 recovered their fu ll earning capac
ity, 299 recovered 75 per cent, 117 recovered 60 per cent, and 26 re
covered 50 per cent o f their previous earning capacity. Thirty-five
were discharged without having their earning capacity restored. O f
the female patients 346 were more than three months under treat
ment, and o f this number 1 was discharged with fu ll restoration o f
earning capacity, 276 with 75 per cent restored, 33 with 60 per
cent, and 18 with 50 per cent o f previous earning capacity restored.
The number o f females discharged without restored earning capacity
was 18.
O f the 2,037 male patients discharged during 1910, 484, or 23.8
per cent, were discharged as cured; 1,302, or 63.9 per cent, as im
proved; and 251, or 12.3 per cent, as unimproved. O f the 1,367
female patients, 71, or 5.2 per cent, were discharged as cured; 1,148,
or 84 per cent, as im proved; and 148, or 10.8 per cent, as unim
proved. In nearly all cases, however, a physical improvement was
123
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
obtained, as was made evident by an average increase in weight o f
from 11 to 13 pounds.
The age distribution o f patients discharged from the Beelitz insti
tution during 1910 is given in the follow ing table:
AGE DISTRIBUTION OF PATIENTS DISCHARGED FROM THE BEELITZ INSTITUTION
FOR THE TREATMENT OF TUBERCULOSIS OF THE LUNGS, 1910.
Males.
Females.
Age periods.
Number.
Per cent.
Number.
Per cent.
Under 20 years................................................................
20 to 29 years...................................................................
30 to 39 years...................................................................
40 to 49 years...................................................................
50 to 59 years.................................................................
60 to 69 y ea rs................................................................
171
961
662
214
29
8.4
47.2
32.5
10.5
1.4
188
862
258
56
2
1
13.8
63.1
18.9
4.1
.1
.1
Total.....................................................................
2,037
100.0
1,367
100.0
It is shown by this table that the actual numbers and relative pro
portions o f admissions are largest at comparatively young ages, and
that the older ages are affected to but a very limited extent. W ith
regard to occupations, it may be stated in this connection that the first
position, as measured by the number o f admissions, is held by workers
in metal, including, no doubt, a relatively large number o f polishers,
grinders, machinists, etc.
The pecuniary assistance extended to families o f patients treated
on acount o f tuberculosis o f the lungs at the Beelitz institution during
1910 was as follow s: T o 1,257 families o f males the sick funds paid,
in accordance with the provisions o f the sickness insurance law,
176,068 marks ($41,904). In addition thereto the invalidity insur
ance institution paid 55,655 marks ($13,246) in the form o f supple
mentary fam ily aid, in accordance with the discretionary powers
permitted under the invalidity insurance laws. In the case o f 1,784
fam ilies the sick funds reimbursed the invalidity insurance institu
tion to the amount o f 276,997 marks ($65,925). In 473 cases small
amounts were granted to patients fo r personal purposes. In the case
o f 232 female patients pecuniary aid was extended to the families
amounting to 19,097 marks ($4,545) and paid by the sick fund in con
form ity to the sickness insurance laws. In addition thereto the
invalidity insurance institution granted 3,206 marks ($763) o f sup
plementary aid. The sick funds reimbursed the invalidity insurance
institution on account o f 1,095 patients to the amount o f 111,099
marks ($26,442). In the case o f 677 female patients small amounts
were granted for personal use.
The number o f patients discharged with restored earning capacity
from the Beelitz institution during the period 1901 to 1910 was 13,813
males and 8,143 females. O f this number 949 males, or 6.9 per cent,
and 327 females, or 4 per cent o f the respective numbers discharged,
became
subsequently entitled to disability annuities on account o f the
BU LLETIN OF TH E BUREAU OF LABOR.
124
loss o f their earning capacity. In the case o f six males and five
females o f the number discharged during the decade, disability oc
curred but no annuities were granted. The number o f male patients
readmitted for treatment was 1,348, or 9.8 per cent o f the number
discharged, and o f female patients 500, or 6.1 per cent. The number
o f deaths during the period was 248 males, or 1.8 per cent, and 25
females, or 0.3 per cent. In a general way these results may safely
be considered as proving conclusively the economic value o f the treat
ment as measured by general welfare considerations. It is not pos
sible by means o f the available statistical data to measure accurately
the financial value o f the results; but as far as it is possible to judge,
the objects o f the treatment—that is, the prevention o f needless loss o f
earning power and the restoration o f the same—were secured in a
large number o f cases. In a considerable proportion, however, the
restored wage-earning capacity was not^ o f course, a full 100 per
cent, but it would obviously be extremely difficult to ascertain pre
cisely the results for any considerable period o f time subsequent to
discharge.
The essential facts concerning the ultimate results o f treatment
and care on account o f tuberculosis are given in the follow ing table
for the period 1901 to 1910, showing the proportion o f patients
originally treated, but who subsequently became incapacitated for
work, for each o f the years o f the period for which the information
is available:
ECONOMIC RESULTS OP TREATMENT ON ACCOUNT OP TUBERCULOSIS OF THE
LUNGS.
MALES.
Number of
Per cent of patients successfully treated, but subsequently becoming
Total
patients
incapacitated for work in number discharged
Year
with
of pa
of dis
charge. tients dis restored
charged. earning
capacity. 1901 1902 1903 1904 1905 1906
1901.
1902.
1903.
1904.
1905.
1906.
1907.
1908.
1909.
1910.
867
867
1,442
1,420
1,461
1,491
1,547
2,450
2,434
2,031
745
725
1,278
1,249
1,282
1,329
1,331
2,054
2,086
1,734
9.0
14.2
7.4
19.2
12.8
5.0
23.9
21.8
11.7
3.2
25.5
24.4
13.9
6.2
1.7
27.2
26.9
17.4
11.5
5.5
1.3
29.1
28.7
11.9
11.4
9.5
3.8
2.0
12.3
12.6
11.9
7.8
3.5
1.4
13.4
13.0
13.9
10.6
5.8
1.6
1.1
20.1
14.4
7.8
3.6
1.8
33.4
32.6
26.9
21.6
14.2
12.3
8.3
3.0
35.7
35.6
30.8
27.1
19.9
19.8
15.5
6.4
.4
15.3
14.7
17.1
14.7
10.6
7.7
5.1
1.4
16.2
17.4
19.3
17.1
14.0
12.4
10.4
2.9
37.0
33.1
29.0
23.6
24.0
21.5
9.9
3.6
2.0
FEMALES.
1901.......
1902.......
1903.......
1904.......
1905.......
1906.......
1907.......
1908.......
1909.......
1910.......
499
464
597
673
743
774
809
1,631
1,456
1,362
464
430
555
631
686
731
721
1,464
1,253
1,208
3.0
5.8
3.5
8.2
6.3
2.5
9.9
9.3
7.0
2.2
17.4
17.9
22.0
20.3
17.3
15.7
14.4
5.5
1.8
.6
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
125
According to this tabulation, which is o f unusual importance in
that the period o f observation for the patients treated in 1901 extends
over the 10 successive years, the ratio o f male patients becoming in
capacitated within 10 years was only 36.9 per cent o f the total origi
nally discharged as successfully treated from an economic point o f
view. The results throughout were much better for female patients,
and only 17.4 per cent o f the patients treated in 1901 became in
capacitated for work by the end o f 1910. As far, therefore, as it is
possible to judge, the economic results were in full conform ity to the
expectations, but whether the results justified the expense incurred
it is not possible to determine from the data at hand. It would seem
to be a safe assumption, however, that, without attempting to deter
mine the value o f the results upon the basis o f precise financial and
actuarial calculations, the object o f restoring a considerable propor
tion o f wage earners for a reasonable time to their form er full or
partial earning capacity was successfully attained.
WESTPHALIA.
The territory o f the Invalidity Insurance Institution o f West
phalia is coextensive with the Prussian Province o f Westphalia,
which has an area o f 20,214 square kilometers, and in 1910 had a
population o f 4,125,904. The increase in population during the last
decade was 2.57 per cent per annum, against an average annual in
crease for the German Empire o f 1.41. The density o f population is
204 per square "kilometer, which is considerably above the average of
120 for the German Empire as a whole. The principal cities are D ort
mund, with a population o f 214,333; Gelsenkirchen, with a popula
tion o f 169,530; Bochum, with a population o f 136,916; and Munster,
with a population o f 90,283. The average death rate for the Prov
ince during the 10 years ending with 1909 was 17.8 per 1,000, the
rate having decreased from 20.1 in 1900 to 15.7 in 1909. The average
death rate from tuberculosis o f the lungs, o f males, ages 30-60, inclu
sive, during 1908, was 25 per 10,000 o f population; and fo r females,
21. The general death rate o f Dortmund decreased from 31 per
1,000 in 1880 to 19.2 in 1895, and 16.7 in 1909. The death rate from
tuberculosis decreased from 49.5 per 10,000 in 1880 to 16.3 in 1895,
and 12 in 1909. The general death rate o f Bochum decreased from
31.4 in 1880 to 22.4 in 1895, and 19 in 1909. The death rate from
tuberculosis decreased from 35 per 10,000 in 1882 (inform ation for
earlier years not being available) to 30.7 in 1895, and to 13.4 in 1909.
In the experience o f the Invalidity Insurance Institution o f W est
phalia the p r o p o r t i^ '^ t il^ c u lp s jl *o£ tli$ lungs as a cause o f in
validity, accpird.jng^ ^ ‘investigation Of •L$8££l$#95was 18.2 per cent
126
B U LLETIN OF TH E BUREAU OF LABOR.
for males against 15 per cent for all insurance institutions; and 10.6
per cent for females against a general average o f 9.5 per cent. The
rate o f insured persons treated and cared for on account o f sickness
from all causes by the Invalidity Insurance Institution o f W est
phalia during 1910 was 9.1 per 1,000 o f the population subject to the
insurance laws, or slightly above the average o f 7.8 per 1,000 for all
insurance institutions. The number o f patients under treatment on
account o f tuberculosis o f the lungs during the year was 8,193, or
4.87 per 1,000 o f the insured population. This rate is considerably
in excess o f the general average o f 3.19 per 1,000 for all insurance
institutions, but the excess is largely due to the fact that the popula
tion o f the Province is almost exclusively engaged in mining and
other industrial pursuits. The amount expended on account o f
treatment and care during 1910 fo r tuberculosis was 838,409 marks
($199,541) or an average expenditure o f 262.58 marks ($62.49) per
case per annum.
According to the annual report o f the Invalidity Insurance Insti
tution o f Westphalia, the number o f male patients treated and cared
for on account o f tuberculosis o f the lungs was 2,144, and the num
ber o f female patients was 921.1 O f the 2,144 male patients, 2,034, or
94.9 per cent, were discharged as successfully treated from an eco
nomic point o f view. Out o f 921 female patients, 867, or 94.1 per
cent, were treated successfully during the year.
Special efforts have been made during recent years to reduce the
average duration o f treatment, and o f the patients treated at the
sanatorium at Hellersen the average duration o f treatment was 72
days in 1905, 60 days in 1909, and 59 days in 1910; and at Ambrock
the average duration was reduced from 83 days in 1905 to 55 days
in 1910. This reduction was apparently brought about by a more
careful selection o f patients, and it may be stated in this connection
that out o f 2,144 male patients treated and cared fo r during 1910,
1,135, or 52.9 per cent, were in the first Turban stage o f the disease;
771, or 36 per cent, were in the second stage; and 238, or 11.1 per
cent, were in the third stage. O f 921 female patients treated and
cared for during the same period, 582, or 63.2 per cent, were in the
first Turban stage o f the disease; 271, or 29.4 per cent, were in the
second stage; and 68, or 7.4 per cent, were in the third stage on admis
sion to institutional treatment and care.
Special efforts have also been made to increase the number and
enlarge the scope and function o f tuberculosis dispensaries through
out the Province o f Westphalia, and as elsewhere discussed in
more detail, the number
tlleSe usftfbl.**ui^titutions was doubled
during the year
ihfrhasi«g*ffom 4*tt»*28i2\^This'feffort probably
*:**.••* 1 Annual Report for 1910, p. 25.
*
2 Idem, p. 29.
:
»
•
•••
.
‘**V*
•••
.•*
•*••••
! • . • •* • (•. • • • •
•••
•.*
OAEE OF TUBERCULOUS WAGE EARNERS IN GERM ANY.
127
accounts also in part for the reduction in the average duration o f
institutional treatment.
The Invalidity Insurance Institution o f Westphalia has been par
ticularly active in the lending o f funds for building purposes, and
during the year 1910, 473 loans were made, for an aggregate amount
o f 6,968,825 marks ($1,658,580). The total amount loaned out to
the end o f 1910 fo r building purposes was 41,567,407 marks
($9,893,043). It should be understood that loans o f this character
are governed by very specific rules and regulations, aiming to provide
healthful homes for wage earners in place o f the more or less in
adequate and ill-health-producing housing conditions and accommo
dations o f an antiquated form and prim itive methods o f construction.
The importance o f tuberculosis o f the lungs as a cause o f invalidity
is emphasized by the statement that during 1910 20.1 per cent o f the
disability annuities granted were on account o f this disease.1 O f the
total number o f patients treated and cared for on account o f all dis
eases and causes, 56.1 per cent were treated on account o f tuberculosis
o f the lungs.
A t the public sanatorium at Hellersen the number o f patients
treated during the period 1898-1910 was 5,862. O f this number 12.1
per cent were discharged with their earning capacity fully restored;
75.6 per cent had their earning capacity partly restored; and 12.3 per
cent were unsuccessfully treated. O f all the patients at least five
years under observation subsequent to their discharge from the institu
tion, 33.2 per cent had retained their full earning power, 23 per cent
had retained partial earning capacity, and 43.8 per cent had either
died or become incapacitated for work and entitled to disability
annuities. The economic results show a distinct tendency toward an
improvement, and while, for illustration, o f the patients discharged
in 1898, only 28.4 per cent had retained their full earning capacity
after five years, o f the patients discharged in 1905 the corresponding
proportion was 38.6 per cent.2
A t the Sanatorium Auguste Victoria S tift, at Lippspringe, opened
in 1902, the number o f patients treated to the end o f 1910 was 3,018.
O f this number, 25.18 per cent were discharged with their earning
capacity fully restored, 63.75 per cent had their earning capacity
partly restored, and 11.07 per cent were treated unsuccessfully. O f
the patients treated at least five years, the economic results at the end
o f the period as determined by special inquiry showed that 33 per
cent o f the patients still retained their full earning capacity, 26.5
per cent retained a partial earning capacity, and 40.6 per cent had
either died or become incapacitated for work and entitled to disability
annuities.
1 Annual Report for 1910, p. 107 (843 cases of tuberculosis out of a total of 4,185).
2 Idem, p. 33.
128
B U LLETIN OF TH E BUREAU OF LABOR.
A t the Sanatorium Ambrock, opened in 1903, the total number o f
patients treated to the end o f 1910 was 4,178. O f this number, 27.33
per cent were discharged as successfully treated from an economic
point o f view, 63.43 per cent were discharged with their earning
capacity partly restored, and only 9.2 per cent o f the cases were un
successful. O f the patients at least five years under observation, 37.8
per cent had retained their full earning capacity, 30.6 per cent had
retained partial earning capacity, and 31.6 per cent had either died
or become incapacitated for work and entitled to disability annuities.
The number o f tuberculosis patients treated at the baths at L ippspringe and in private homes, or elsewhere than in a sanatorium, was
7,474 during the period 1896-4910. O f this number only 11.16 per
cent had their full earning capacity restored, but 82.70 per cent had
their earning capacity partly restored, and only 6.14 per cent were
unsuccessfully treated. O f the patients under observation at least
five years the proportion retaining their full earning capacity to the
end o f the period was 28.99 per cent, those retaining partial earning
capacity represented 29.29 per cent, and the proportion that had
died or become incapacitated for work and entitled to disability
annuities was 41.72 per cent. The results at the baths o f Lippspringe^
however, show a tendency toward an improvement, and o f the patients
discharged in 1905 the proportion retaining their full earning
capacity to the end o f 1910 was 33.33 per cent, the proportion retain
ing a partial earning capacity was 37.88 per cent, and the proportion
that died or became incapacitated fo r work was 28.79 per cent.
Combining all o f the patients treated on account o f tuberculosis o f
the lungs during the period 1905-1910, numbering 14,307, the propor
tion discharged with their earning capacity fully restored was 18.3
per cent, the proportion discharged with their earning capacity
partly restored was 73.7 per cent, and the proportion unsuccessfully
treated was 8 per cent. A fter one year, o f the number discharged
and observed by means o f subsequent inquiry, 33 per cent still re
tained their full earning capacity, 46.5 per cent retained a par
tial capacity for work, and 20.5 per cent had either died or become
incapacitated. A t the end o f the third year 35.8 per cent still re
tained their full capacity for work, 37 per cent-retained a partial
capacity, and 27.2 per cent had either died or become incapacitated
for work. A t the end o f the fifth year 36.8 per cent retained their
fu ll earning capacity, 32.2 per cent retained a partial earning
capacity, and 31.1 per cent had either died or become incapacitated
for work.
These results may safely be considered evidence o f successful treat
ment from an economic point o f view. They require to be considered,
however, with great caution to avoid erroneous inferences on account
o f the methods o f statistical analysis employed. It w ill have been
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY,
129
noted that the proportion discharged as successfully treated, with
their fu ll earning capacity restored, was only 18.3 per cent at the end
o f the treatment, but this proportion was increased to 33 per cent at
the end o f the first year, 35.8 per cent at the end o f the third year,
and 36.8 per cent at the end o f the fifth year. There was a corre
sponding reduction in the proportion retaining a partial earning
capacity from 73.7 per cent at the end o f the treatment to 46.5 per
cent at the end o f the first year, to 37 per cent at the end o f the third
year, and to 32.2 per cent at the end o f the fifth year. There was an
increase in the proportion incapacitated for work from 8 per cent at '
the end o f the treatment to 20.5 per cent at the end o f the first year,
to 27.2 per cent at the end o f the third year, and to 31.1 per cent at
the end o f the fifth year. These apparent inconsistencies are made
clear by the table below, which gives the actual numbers as well as
the resulting percentages. In other words, the foregoing percentages
are derived from each grou p 1 and not from the original number under
treatment and care.
ECONOMIC RESULTS OF SANATORIUM TREATMENT AND CARE OF TUBERCULOUS
WAGE EARNERS INSURED WITH THE INVALIDITY INSURANCE INSTITUTION OF
WESTPHALIA, 1905 TO 1910.
Number.
Per cent.
Total patients treated and cared for......................................................................
14,307
Discharged with full earning capacity restored.....................................................
Discharged with partial earning capacity restored................................................
Unsuccessfully treated...........................................................................................
2,617
10,541
1,149
18.29
73 68
8.03
N um ber retaining full earning capaeity after one year..........................................
Number retaining partial earning capacity after one year.....................................
Number incapacitated for work after one year..... ..... ..........................................
Number retaining full earning capacity after three years......................................
Number retaining partial earning capacity after three years................................
Number incapacitated for work after three years.................................................
Number retaining full earning capacity after five years.........................................
Number retaining partial earning capacity after five years...................................
Number incapacitated for work after five years.....................................................
3,667
5,178
2,282
2,090
2,162
1,591
656
574
554
32.96
46.54
20.50
35.77
37.00
27.23
36.77
32.17
31.06
According to this table the percentages as here given and as derived
from the annual report o f the Invalidity Insurance Institution o f
Westphalia for 1910 apply to each group and have no reference to
the original number o f 14,307 patients treated and cared for, with
or without economic results. The results are more precisely indi
cated, however, by the statement that o f the 14,307 patients treated
and cared for during the period 1905-1910, the number, as far as
known, retaining their full earning capacity to the end o f the fifth
year was 656, or 4.6 per cent. The number retaining a partial earn
ing capacity to the end o f the fifth year was 574, or 4 per cent, and the
number becoming incapacitated for work or dying during the fifth
year was 554, or 3.9 per cent. The number o f cases not traced or con
trolled is not shown in the report. It a^so requires to be considered
49397°—12----- 9
i Annual Report lor 1910, pp. 32-39.
130
B U LLETIN OF TH E BUREAU OF LABOR.
that quite a considerable proportion o f the patients treated and cared
for during the period 1905-1910 had not been five fu ll years under
subsequent observation. The method o f analysis is crude and not
conclusive, but it may be questioned whether the application o f
actuarial methods in conform ity to the theories o f Pearson and
Elderton would serve the purpose o f bringing the essential facts o f
successful sanatorium treatment home to the public at large. Even
the crude statistical data are fairly conclusive in showing that out o f
a total number o f 14,307 tuberculous patients treated, 1,784 survived
to a period o f five years, with a reasonable assurance o f a continued
lifetim e for a number o f years more. O f the 1,784, as has been pre
viously stated, 36.8 per cent retained their fu ll earning capacity,
32.2 per cent retained partial earning capacity, and 31.1 per cent had
either died or become entitled to disability annuities on account o f
incapacity for work. It can not be too often emphasized that tuber
culosis o f the lungs is a most important cause o f invalidity in the
experience o f invalidity insurance institutions, and it may be stated
again in this connection that out o f 3,027 disability annuities granted
to males by the Invalidity Insurance Institution o f Westphalia dur
ing 1910, 620, or 18.5 per cent, were on account o f tuberculosis o f the
lungs. Out o f 1,158 females to whom invalidity disability annuities
were granted, 223, or 19.3 per cent, were on account o f tuberculosis o f
the lungs. The relation o f tuberculosis to industry is further empha
sized by the statement that o f 2,749 disability annuities granted dur
ing 1910 to persons employed in industry and mining, 629, or 22.9
per cent, were granted on account o f tuberculosis o f the lungs. The
importance o f the disease as a cause o f disability in early life is em
phasized by the statement that out o f 274 disability annuities granted
to males at ages 20-30,145, or 52.9 per cent, were granted on account
o f tuberculosis o f the lungs. The corresponding number and pro
portion for females was 202 disability annuities granted for all
causes, o f which 115, or 56.9 per cent, were granted on account o f
tuberculosis o f the lungs.
RHENISH PRUSSIA.
The territory o f the Invalidity Insurance Institution o f Ehenish
Prussia is coextensive with the Prussian Province o f Khenish
Prussia,1 which has an area o f 26,996 square kilometers (10,423.2
square m iles), and in 1910 had a population o f 7,120,519. The in
crease in population during the last decade was 2.11 per cent per an
num, against an average annual increase for the German Empire o f
1.41. The density o f population is 264 per square kilometer (0.386
1 The territory also includes the principalities of Hohenzollern and Birkenfeld.
Hohenzollern has an area of 1,142 square kilometers (440.9 square miles), and in 1910 had a
population of 71,009. The corresponding information for Birkenfeld is not available.
CAKE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
131
square m ile), which is more than double the average o f 120 fo r the
German Empire as a whole. The principal cities are: Cologne, with a
population o f 516,167; Dusseldorf, with 357,702; Essen, with 294,629;
Duisburg, with 229,478; Elberfeld, with 170,118; and Barmen, with
169,201. The average death rate for the Province during the 10
years ending with 1909 was 18 per 1,000, but the rate decreased from
20.9 in 1900 to 15.6 in 1909. The average death rate from tubercu
losis o f the lungs o f males, ages 30 to 60 years, during the year 1908
was 26 per 10,000 o f population, and for females 19, which compare
with the corresponding averages o f 27 and 20, respectively, fo r the
male and female populations o f the German Em pire as a whole. The
general death rate o f Cologne decreased from 29.2 in 1880 to 22.8 in
1895 and 16.8 in 1909. The death rate from tuberculosis decreased
from 41.4 per 10,000 o f population in 1880 to 27.1 in 1895 and 15.6
in 1909. The general death rate o f Essen decreased from 27.3 in
1880 to 21 in 1895 and 13 in 1909. The death rate from tuberculosis
decreased from 40.9 in 1880 to 29.4 in 1895 and 10 in 1909. The
general death rate o f Dusseldorf decreased from 30 per 1,000 in
1880 to 22.6 in 1895 and 14 in 1909. The death rate from tubercu
losis decreased from 38.8 per 10,000 in 1880 to 25.4 in 1895 and to 11.9
in 1909.
In the experience o f the Invalidity Insurance Institution o f Rhenish Prussia the ratio o f tuberculosis o f the lungs as a cause o f in
validity, according to the investigation o f 1891 to 1899, was 20.8
per cent for males, against 15 fo r all insurance institutions, and 11.7
for females, against a general average o f 9.5. The rate o f insured
persons treated and cared for on account o f sickness from all causes
by the Invalidity Insurance Institution o f Rhenish Prussia during
1910 was 7.5 per 1,000 o f the population subject to the insurance laws,
or slightly below the general average o f 7.8 per 1,000 for all insur
ance institutions. The number o f patients under treatment on ac
count o f tuberculosis o f the lungs during the year was 5,393, or 3.97
per 1,000 o f the insured population. The amount expended on
account o f treatment and care during 1910 fo r tuberculosis was
1,945,974 marks ($463,142), or an average expenditure o f 360.83
marks ($85.88) per case per annum. The Invalidity Insurance In
stitution o f Rhenish Prussia has the largest population subject to
the insurance laws, or, according to the occupation census o f 1907,
1,357,952.
The Invalidity Insurance Institution o f Rhenish Prussia maintains
only one public sanatorium fo r tuberculosis o f the lungs for male
patients, at Ronsdorf, to which, during 1910, 704 new patients were
admitted, while 662 were discharged. Not all o f these patients, how
ever, were provided for at the expense o f the insurance institution,
although probably this was the case with most o f them. The sana-
132
BU LLETIN OF TH E BUREAU OF LABOR.
torium at Ronsdorf was established in 1909, and has a bed accommo
dation o f 138. The number o f days o f treatment in 1910 was 49,474,
and the average expenditure per patient per day was 4.26 marks
( $ 1 .0 1 ) .
According fco the annual report o f the Invalidity Insurance Insti
tution o f Rhenish Prussia, out o f 9,093 invalidity annuities granted
during 1910,1,865, or 20.5 per cent, were granted on account o f tuber
culosis o f the lungs. The inform ation, in detail, for the period 1900
to 1910, is given in tabular form below :
DISABILITY ANNUITIES GRANTED BY THE INVALIDITY INSURANCE INSTITUTION
OF RHENISH PRUSSIA, 1900 TO 1910.
Annuities granted each year.
Years.
For all
causes.
On account of tubercu
losis of the lungs.
Number.
Per cent.
1900....................................................................................................
1901.....................................................................................................
1902.....................................................................................................
1903...............................................................................................1 ...
1904.....................................................................................................
1905.....................................................................................................
1906.....................................................................................................
1907.....................................................................................................
1908.....................................................................................................
1909.....................................................................................................
1910.....................................................................................................
10,746
12,174
13,503
13,713
13,693
10,608
8,850
8,221
9,166
8,747
9,093
1,808
2,085
2,260
2,209
2,081
1,957
1,856
1,650
1,773
1,740
1,865
16.8
17.1
16.7
16.1
15.2
18.4
21.0
20.1
19.3
19.9
20.5
Total.........................................................................................
1900 to 1904.........................................................................................
1905 to 1910.........................................................................................
118,514
63,829
54,685
21,284
10,443
10,841
18.1
16.4
19.8
It would be unsafe, perhaps, to draw definite conclusions from the
foregoing comparison, since various important factors, aside from
the general practice o f the institution, would determine the ratio o f
disability annuities granted for all causes in general and for tuber
culosis o f the lungs in particular. As far as it is possible to judge,
however, the ratio o f disability annuities granted on account o f
tuberculosis o f the lungs to the insured population has increased
during recent years, which may be due chiefly to more careful
methods o f selection and to a more extended use o f sanatorium
methods o f treatment.1
The number o f male patients treated and cared fo r on account o f
tuberculosis o f the lungs by the Invalidity Insurance Institution o f
Rhenish Prussia during 1910 was 4,160 and o f female patients 1,356.
The total number discharged during the year was 4,260. The dura
tion o f treatment is given in detail in the table below : 2
* Annual Report for 1910, p. 29.
2 Idem, p. 45.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
133
NUMBER AND PER CENT OF PATIENTS DISCHARGED, BY DURATION OF TREAT
MENT ON ACCOUNT OF TUBERCULOSIS OF THE LUNGS, PUBLIC SANATORIA,
RHENISH PRUSSIA, 1910.
Duration of treatment.
Under 2 weeks.......................
2 to 4 weeks............................
4 to 6 weeks............................
6 to 8 weeks............................
8 to 10 weeks
10 to 12 weeks.........................
12 to 14 weeks.........................
Number. Per cent.
131
201
316
389
598
754
1,517
3.1
4.7
7.4
9.1
14.0
17.7
35.7
Duration of treatment.
14 to 16 weeks.........................
16 to 18 weeks.........................
18 to 20 weeks..................
20 weeks and over.
Total.............................
Number. Per cent.
183
123
36
12
4.3
2.9
4,260
100.0
.8
.3
The bed accommodation in the public sanatoria in Rhenish Prussia
in 1910 was 916. On an average a waiting period o f six weeks was
necessary previous to admission. In some o f the institutions the
average waiting period was as low as 2.5 weeks, and in one as
high as 10 weeks. Institutions are provided for the observation o f
more or less doubtful cases, and a considerable number o f tubercu
losis dispensaries have been established in the principal cities, and
the value o f these is enhanced by traveling tuberculosis exhibits,
which, during 1910, were open to the public on 282 days and visited
by 147,612 persons. The number o f public addresses on tuberculosis
during the year in connection with the traveling tuberculosis exhibits
was 75.1
The number o f male patients receiving full treatment and care
on account o f tuberculosis o f the lungs during 1910 was 4,129, and
the number o f days o f treatment was 262,049, or an average duration
o f treatment o f 63 days. The expenditures on account o f male
patients amounted to 1,559,595.33 marks ($371,183.69), or an average
expenditure o f 377.72 marks ($89.90). O f the disbursements on
account o f male patients, 27 per cent were reimbursed to the inva
lidity insurance institution by the communal, industrial, and other!
sick funds. The amount provided for the fam ily support o f male
patients treated on account o f tuberculosis o f the lungs was 431,614
marks ($102,724.13), or an average support per patient per case o f
104.53 marks ($24.88). O f the 4,129 male patients treated, 3,513, or
85.08 per cent, were treated successfully from an economic point o f
view ; that is, with regard to the required degree o f restored wageearning capacity.
,
The number o f female patients receiving full treatment on account
o f tuberculosis o f the lungs during the year 1910 was 1,263, and the
number o f days o f treatment was 90,519, or an average duration o f
treatment o f 72 days. The total disbursement on account o f female
patients was 386,338 marks ($91,948.44), or an average expenditure
o f 305.89 marks ($72.80). O f the expenditures incurred on account
o f female patients, 16 per cent was reimbursed to the invalidity
1 Annual Report for 1910, p. 4.
134
BU LLETIN OF TH E BUREAU OE LABOR.
insurance institution by communal, industrial, and other sick funds.
The amount o f fam ily support granted to female patients was 13,746
marks ($3,271.55), or an average support o f 10.88 marks ($2.59) per
case. O f the 1,263 female patients treated, 1,079, or 85.43 per cent,
were treated successfully from an economic point o f view or with
regard to restored wage-earning capacity.
O f the 2,777 male patients treated in 1905,928, or 39 per cent, had re
tained their earning capacity to the beginning o f the year 1911. O f 803
female patients treated during 1905, 286, or 41 per cent, had retained
their earning capacity to the commencement o f 1911.1 The results
with patients treated during subsequent years are equally favorable
and fu lly justify the conclusion that, from an economic point o f view,
the treatment and care o f tuberculous wage earners is warranted by
the facts o f extended experience. It may be stated, however, that out
o f 11,682 male wage earners successfully treated and cared fo r on
account o f tuberculosis o f the lungs during the period 1905-1910, only
595, or 5.1 per cent, became subsequently entitled to disability annui
ties. In the case o f 3,506 female patients treated and cared for suc
cessfully during the same period, 113, or 3.2 per cent, became subse
quently entitled to disability annuities. O f the male patients, 495,
or 4.2 per cent, became subsequently incapacitated for work, without,
however, becoming entitled to disability annuities, and 200 female
patients, or 5.7 per cent, became disabled or incapacitated for work
without becoming entitled to disability annuities. The number o f
deaths o f male patients during the period under observation was 370,
or 3.2 per cent o f the number treated successfully; and the number
o f deaths o f female patients was 69, or 2 per cent. The number o f
male patients who required readmission for institutional treatment
was 1,144, or 9.8 per cent; and o f female patients, 288, or 8.2 per cent.
The number o f male cases which could not be ascertained or made
subject to control was 875; and o f female cases, 362.1
The experience data o f the public sanatorium at Eonsdorf conform
to those o f similar institutions and do not require extended considera
tion. Out o f 662 patients discharged during 1910, 140 were from 12
to 13 weeks in the institution, and only a relatively small number
received treatment fo r more extended periods o f time. O f the
patients discharged during the first six weeks o f treatment, 25 were
dismissed on account o f the fact that the disease was too far advanced,
46 on account o f nostalgia, personal reasons, etc., and 13 because they
were not tuberculous.
In probably no other part o f the German Empire has the tuber
culosis campaign been more effectively organized than in Ehenish
Prussia. Throughout the entire territory tuberculosis dispensaries
1 Annual Report for 1910, pp. 56, 57.
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
135
have been established, including rural communities, and efforts are
being made to extend the campaign to all o f the rural communities.
F or illustration, at Essen and vicinity,1 tuberculosis dispensaries were
established, in 1910, in five communities, with a total population o f
245,000. The total number o f persons making application for treat
ment and advice was 1,577, o f which one-third were ascertained to be
tuberculous. That the importance o f early treatment is clearly recog
nized is made evident by the fact that o f 545 persons provided for
with treatment and care, 357, or 65.5 per cent, were in the first stage
o f the disease. The number o f nurses employed is only five, and these
during 1910 made 2,340 visits to the patients’ homes. The expendi
tures during 1909 amounted to 11,500 m arks2 ($2,737), and the num
ber o f cases considered during that year was 866, including 220
bacteriological examinations o f the sputum. The expenditures dur
ing 1910 and 1911 were larger, but fu ll information is not available.
The medical results have been much the same as in other sections o f
Rhenish Prussia, and a consideration o f details would involve need
less repetition.
Unusual attention has been given to the treatment and care o f
tuberculous invalids; that is, persons in receipt o f disability an
nuities on account o f tuberculosis, but in too advanced a stage o f
the disease to warrant treatment and care on economic grounds.3
The number o f far-advanced cases cared fo r in return for the sur
render o f the annuity has rapidly increased from 167 in 1907 to
222 in 1908, 293 in 1909, and 411 in 1910. The treatment is in hospi
tals or homes for incurables, and the social importance o f such treat
ment is made evident by the fact that during 1910 there were 67
patients who had been treated for more than two years, 75 for more
than one year, and 111 for more than six months. In 10 cases the
patients were discharged as successfully treated, with restored earn
ing capacity fo r a reasonable period o f time. Most o f the patients
undertake voluntarily the performance o f suitable duties, chiefly
domestic or farm labor. Many o f the patients have agreed to re
main permanently in the institutions providing fo r their care, which,
o f course, secures the best possible results from a sanatorium point o f
view. The 411 persons treated during 1910 received 73,652 days o f
treatment, or an average duration o f treatment per person o f 179.2
days. The total expenditure amounted to 132,805 marks ($31,607.59),
and o f this amount 34,367 marks ($8,179.35) was reimbursed by the
surrender o f disability annuities. The number o f patients under
treatment at the end o f the year increased from 44 in 1906 to 128 in
1909 and 221 in 1911. The provision is chiefly in small hospitals
1 Annual Report for 1910, p. 94.
2 Idem, p. 48.
8 Idem, p. 106.
136
BU LLETIN OF TH E BUBEAU OF LABOB.
widely distributed throughout the territory o f the Invalidity Insur
ance Institution o f Ehenish Prussia, but also in special hospitals for
tuberculosis and homes for incurables. It is held that the average
expenditure per patient per day should not exceed 2 marks (48
cents), and that provision for treatment and care should be in com
paratively small rooms, containing not more than from four to six
beds.1
The Invalidity Insurance Institution o f Ehenish Prussia has been
especially active in fostering the movement fo r housing reform
throughout the congested industrial districts o f its territory, and up
to the end o f 1910 the sum o f 54,234,795 marks ($12,907,881) had
been provided for this purpose, and o f this amount, 42,482,509 marks
($10,110,837.14) was still outstanding in the form o f loans fo r wageearners’ dwellings at the end o f 1910. O f the sum stated, 39,001,500
marks ($9,282,357) was lent out at 3 per cent, 39,588 marks ($9,422)
at 3.25 per cent, and 3,421,420 marks ($814,298) at 3.5 per cent. O f
loans made for the erection o f 8,113 dwellings, 2,728 provided for
single families, 4,233 for two families, 696 for three families, 62 for
four families, and 394 for five or more families— a total housing
provision for 16,423 families.2 I t is pointed out as especially signifi
cant that 86 per cent o f the houses erected through loans provided
by the Invalidity Insurance Institution o f Ehenish Prussia were for
one or two families. O f the loans made to the end o f 1910,15.7 per
cent provided housing accommodation in villages and towns having
up to 5,000 inhabitants, 28 per cent provided fo r cities o f from 5,000
to 20,000, 28 per cent for cities o f from 20,000 to 100,000, and 28.3
per cent for cities with over 100,000 population. O f the loans made
to the end o f 1910, amounting to 54,234,795 marks ($12,907,881),
70.8 per cent was lent to general building associations, 18.8 per cent
to cities, communities, and public savings institutions, and 10.4 per
cent to persons insured with the Invalidity Insurance Institution o f
Ehenish Prussia. A special effort has been made to utilize life-in
surance principles for the amortization o f mortgages, and at the
end o f 1910 there, were 149 policies in force, insuring 732,180 marks
($174,259), against 103 policies in force in 1909, insuring 529,292
marks ($125,972). Thus far this effort can not be said to have been
a success from a commercial point o f view.3
WURTTEMBERG.
The territory o f the Invalidity Insurance Institution o f Wurttemberg is coextensive with the Kingdom o f Wurttemberg, which has
an area o f 19,511 square kilometers (7,533.2 square m iles), and in 1910
1A list of these institutions is given on p. 109 of the report for 1910.
2 For a full discussion, see Annual Beport for 1910, p. 120 et seq.
8 Annual Beport for 1910, p. 127.
CARE OF TUBERCULOUS WAGE EARNERS I N GERM ANY.
137
had a population o f 2,435,611, o f which the increase during the last
decade was 1.16 per cent per annum, against an average annual in
crease fo r the German Empire o f 1.41 per cent. The density o f
population is 125 per square kilometer (324 per square m ile), which
is but slightly above the average o f 120 for the German Empire as
a whole. The principal cities are: Stuttgart, with a population o f
285,589, and Ulm, with a population o f 55,817. The average death
rate for the Kingdom during the 10 years ending with 1909 was
20.2 per 1,000, the rate having decreased from 23.4 in 1900 to 1S.1
in 1909. The average death rate from tuberculosis o f the lungs, o f
males, ages 30 to 60 years, inclusive, during 1908, was 25 per 10,000
o f population, and for females, 20. The general death rate o f Stutt
gart decreased from 23.5 per 1,000 o f population in 1880 to 19.2 in
1895 and to 14.7 in 1909. The death rate from tuberculosis decreased
from 23.0 per 10,000 in 1880 to 20.0 in 1895 and 16.8 in 1909. The
corresponding information for Ulm is not available.
In the experience o f the Invalidity Insurance Institution o f W urttemberg the ratio o f tuberculosis o f the lungs as a cause o f in
validity, according to the investigation o f 1896 to 1899, was 15.1
per cent for males, or practically the same as the general average
o f 15 per cent for all insurance institutions, and 10.1 per cent fo r
females, against a general average o f 9.5 per cent. The rate o f in
sured patients under treatment and care on account o f sickness from
all causes by the Invalidity Insurance Institution o f Wurttemberg
during 1910 was 12.2 per 1,000 o f the population subject to the in
surance laws, which compares with the general average o f 7.8 per
1,000 for all insurance institutions. The number o f patients under
treatment on account o f tuberculosis o f the lungs during the year
was 1,759, or 3.75 per 1,000 o f the insured population. The general
average admission rate for all institutions was 3.19 per 1,000. The
amount expended on account o f treatment and care o f tuberculous
patients during 1910 was 676,341 marks ($160,969.16), or an aver
age expenditure o f 384.50 marks ($91.51) per case per annum. The
Invalidity Insurance Institution o f Wurttemberg maintains two
sanatoria, one at Wilhelmsheim, for male patients, with a bed accom
modation o f 177, established in 1904, and one at Uberruh, for female
patients, with a bed accommodation o f 195, established in 1908.
The importance o f tuberculosis o f the lungs as a cause o f death in
the Kingdom o f Wurttemberg is precisely shown in the follow ing
table exhibiting the proportionate mortality, by divisional periods
o f life, for the year 1908.
138
BU LLETIN OP TH E BUREAU OP LABOR.
PROPORTIONATE MORTALITY FROM TUBERCULOSIS OF THE LUNGS IN THE
KINGDOM OF WURTTEMBERG, 1908 (EXCLUSIVE OF DEATHS NOT MEDICALLY
CERTIFIED TO AS TO THEIR CAUSES).
Males.
Females.
Tuberculosis of
lungs.
Ages.
All
causes.
All
causes.
Tuberculosis of
lungs.
Number. Per cent.
Number. Percent.
15 to 24 years..............................................
25 to 34 years..............................................
35 to 49 years..............................................
50 to 59 years..............................................
60 years and over........................................
689
805
1,559
1,600
5,356
274
335
459
235
194
39.8
41.6
29.4
14.7
3.6
800
1,087
1,520
1,491
5,836
446
519
345
123
162
55.8
47.7
22.7
8.2
2.8
Total................................................
15,142
1,630
10.8
15,282
1,798
11.8
According to the occupation census o f 1907, the number o f persons
subject to the insurance laws in the Kingdom o f Wurttemberg was
469,594, and o f this number the proportion o f males was 66.5 per
cent, and o f females 33.5 per cent. The insured population repre
sented 20.4 per cent o f the total population o f the Kingdom o f W urt
temberg, estimated at 2,302,179. The distribution o f insured per
sons, by divisional periods o f life, is given in the follow ing table,
which is self-explanatory, and requires no extended comment.
AGE DISTRIBUTION OF THE INSURED POPULATION OF THE KINGDOM OF WURT
TEMBERG, 1907.
Males.
Ages.
Females.
---------------r
Number.
Per cent.
Number.
Percent.
16 to 17 years...................................................................
18 to 19 years...................................................................
20 to 24 years... ...............................................................
25 to 29 years...................................................................
30 to 39 years...................................................................
40 to 49 years...................................................................
50 to 59 years...................................................................
60 to 69 years...................................................................
70 years and over............................................................
24,889
26,419
50,334
52,975
74,377
42,238
25,289
14,275
1,871
8.0
8.4
16.1
16.9
23.8
13.5
8.1
4.6
.6
21,370
20,894
41,068
22,348
22,758
13,425
9,042
5,352
670
13.6
13.826.2
14.2
14.5
8.6
5.8
3.4
.4
Total.....................................................................
312,667
100.0
156,927
100.0
Out o f 312,667 males subject to the compulsory insurance laws,
216,497, or 69.2 per cent, were employed in industries, mines, and
building. O f the insured female population o f 156,927, the number
employed in these pursuits was 63,580, or 40.5 per cent.
According to the annual report o f the Invalidity Insurance Insti
tution o f Wurttemberg, the amounts expended for treatment and
care on account o f sickness from all causes have rapidly increased
from 133,226 marks ($31,707.79) in 1898 to 655,162 marks ($155,928.56) in 1904 and 1,197,829 marks ($285,083.30) in 1910. The
amount o f labor involved in the proper handling o f the applicants
treatment and care is made evident by the fact that 15 persons
Digitized forfor
FRASER
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
139
I
were employed for this purpose during the year. O f the total in
come o f the Invalidity Insurance Institution o f Wurttemberg during
1910,13.6 per cent was expended in the treatment and care o f patients
on account o f sickness from all causes, including tuberculosis o f the
lungs, which is the most important cause o f disability in the experi
ence o f the institution.1 The tendency during the earlier years was
for tuberculosis o f the lungs to increase proportionately to the total
number o f cases under treatment, but during the last few years the
ratio declined. The facts are emphasized in the follow ing table for
the period 1897 to 1910:
TUBERCULOSIS OF THE LUNGS AS A CAUSE OF DISABILITY IN THE EXPERIENCE
OF THE INVALIDITY INSURANCE INSTITUTION OF WURTTEMBERG, 1910.
Cases of tuberculosis of
lungs treated.
Years.
Number.
1897-1901..........................
1902..................................
1903..................................
1004................................
1905..................................
1,864
826
1,122
1,163
1,114
Per cent of
total cases
treated.
31.60
38.42
40.98
44.83
44.99
Cases of tuberculosis of
lungs treated.
Years.
1906..................................
1907..................................
1908..................................
1909..................................
1910..................................
Number.
Per cent of
total cases
treated.
1,318
l,o77
1,646
1,621
1,759
48.39
48.73
47.54
44.04
42.59
This table shows that, commencing with the period 1897 to 1901,
the number o f cases o f tuberculosis was 31.60 per cent o f the total
number o f cases o f sickness from all causes treated and cared for at
the expense o f the insurance institution for the purpose o f restoring
the wage-earning capacity for a reasonable period o f time. This
proportion increased to the maximum o f 48.73 per cent in 1907, but
subsequently to this year the proportion declined to a minimum o f
42.59 per cent in 1910. It may be stated in this connection that the
next most important causes o f sickness among wage earners, in the
experience o f the Invalidity Insurance Institution o f Wurttemberg,
were rheumatism (9.3 per cent), anemia (8 per cent), neurasthenia
(7.8 per cent), and general debility (7.7 per cent).
A significant fact disclosed by the experience o f the Invalidity
Insurance Institution o f W urttemberg is the large proportion o f
tuberculous women patients, and it is emphasized in the report for
1910 that tuberculosis o f the lungs is o f exceptional frequency among
domestic servants, saleswomen, and female clerks.2
By an arrangement with the m ilitary authorities, the invalidity
insurance institution is notified o f the rejection o f recruits for tuber
culosis o f the lungs or other diseases liable to bring about permanent
wage-earning incapacity. W hile much had been anticipated from
1 Annual Report for 1910, p. 41.
2 Idem, p. 43.
140
B U LLETIN OF TH E BUBEAU OF LABOB.
this arrangement, in actual practice the number o f notifications has
been small and the tendency has been toward a decrease in the number
reported. In 1907 the institution was notified o f 152 cases, but this
number decreased to 53 cases during each o f the years 1908 and 1909,
and finally to only 36 cases during 1910.
The number o f applications for treatment on account o f tubercu
losis o f the lungs, which, during 1910, received favorable considera
tion, was 1,759, and o f this number 876 were males and 883 were
females. The number o f applications for treatment and care on
account o f tuberculosis o f the lungs which were declined was 596, and
o f this number 354 were males and 242 were females.1 O f the 1,759
cases o f tuberculosis treated and cared for during 1910, 1,142, or 64.9
per cent, were discharged as materially improved, with a reasonable
expectation o f restored earning capacity, and 617 were discharged as
unsuccessfully treated, but o f this number 407 improved during the
course o f treatment, though not sufficiently so to warrant the antici
pation o f restored wage-earning capacity for a reasonable period o f
time.
The number o f male patients treated on account o f tuberculosis
o f the lungs during 1910 was 876, and the number o f days o f treat
ment was 62,953, or an average duration o f treatment o f 72 days.
The expenditure incurred was 330,975 marks ($78,772), or an aver
age expenditure o f 377.83 marks ($89.93) per patient per case, or o f
5.26 marks ($1.25) per patient per day. On account o f dependent
members o f male patients’ families, 41,095 marks ($9,781) was dis
bursed, and in addition thereto 6,810 marks ($1,621) was paid in
cash as pecuniary assistance to single persons in financial need.
There were 883 female patients treated on account o f tuberculosis o f
the lungs during the year 1910, receiving 77,031 days o f treatment,
or an average duration o f treatment o f 87 days. The expenditures
amounted to 345,365 marks ($82,197), or 391.13 marks ($93.09) per
person per case, or 4.48 marks ($1.07) per patient per day. The
pecuniary assistance to members o f male patients’ fam ilies amounted
to 3,061 marks ($729), and the pecuniary assistance to single persons
amounted to 5,824 marks ($1,386). In the case o f male patients the
insurance institution was reimbursed to the extent o f 97,358 marks
($23,171), and on account o f female patients to the extent o f 47,752
marks ($11,365), by communal, industrial, and other sick funds liable
to the insurance institution in conform ity to the compulsory-insur
ance laws. The total number o f persons treated during the year on
account o f tuberculosis was, therefore, 1,759, receiving 139,984 days
o f treatment, or an average duration o f treatment o f 80 days.
O f 839 male patients treated during the year, fo r which the in for
mation was available, 338, or 40.3 per cent, were in the first Turban
1 Annual Report for 1910, p. 55.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
141
stage o f the disease; 231, or 27.5 per cent, were in the second; and
270, or 32.2 per cent, were in the third. O f 877 female patients
treated during the same period, 431, or 49.1 per cent, were in the first
Turban stage o f the disease; 366, or 41.7 per cent, were in the second;
and 80, or 9.1 per cent, were in the third stage. It is therefore shown
that the proportion o f male patients received in the third Turban
stage o f the disease, when the prognosis is decidedly less favorable
than during the earlier stages, was much larger than in the case
o f females.
O f 876 male patients treated and cared for on account o f tuber
culosis o f the lungs during the year 1910, 410, or 46.8 per cent, were
o f the age period 21 to 30. O f 883 female patients, 481, or 54.5 per
cent, were o f this period o f life when the prevention o f wage-earning
incapacity and the conservation o f life are o f the highest economic
importance. The economic results o f sanatorium treatment are
shown by the experience o f 1905 observed to the end o f 1910.1 O f
691 patients, including both sexes, only 60 became subsequently
entitled to disability annuities during this period o f time, but 51
became incapacitated for work though not entitled to annuities in
conform ity to the insurance laws. Only 36, or 5.2 per cent, died
during the period o f observation, and 55, or 8 per cent, required
readmission for institutional treatment. In 23 cases, or 3.3 per cent,
the inform ation was not available. Out o f the original 691 patients,
therefore, 466, or 67.4 per cent, remained at the end o f the period
o f 6 years in a more or less satisfactory condition o f health, and
with a sufficient degree o f restored earning capacity so as not to
require the payment o f disability annuities in conform ity to the
compulsory insurance laws. The data, therefore, seem to prove that,
from an economic point o f view, the expenditures incurred in the
systematic treatment and care o f tuberculous wage earners other
wise likely to become a serious charge upon the funds o f the inval
idity insurance institution, were apparently justified by the results.
O f course, these figures have no reference to the number o f persons
unsuccessfully treated, with regard to which it only needs to be said
that there were 423 such cases in 1905, o f which 122, or 28.8 per cent,
were still alive and not a charge upon the funds o f the invalidity
insurance institution at the end o f 1910.
The sanatorium at Wilhelmsheim was originally established by
the Wurttemberg Association for Public Sanatoria, in the summer o f
1900, with a bed accommodation o f 100. On October 1, 1904, the
same was purchased by the Invalidity Insurance Institution o f W urt
temberg for 496,000 marks ($118,048). B y additions made during
1904 to 1906 the bed accommodation was increased to 177 in 59 rooms.
There are now 10 rooms with 1 bed each, 20 with 2 beds each,
1 Annual Report for 1910, p. 66.
142
B U LLETIN OF TH E BUREAU OF LABOR.
18 with 4 beds, and 11 with 5 beds. The total cost o f the insti
tution to December 81, 1910, was 1,244,109 marks ($296,098). The
cost o f installation per bed amounted to 7,000 marks ($1,666). The
staff o f the sanatorium consists o f 1 medical director in chief, 2 to 3
medical assistants, 1 bookkeeper, 1 sister superior, 4 nurses, and 35
other employees. The number o f patients has increased from 128
in 1904 to a maximum o f 1,075 in 1908. During 1909 the number o f
patients was 1,064, and during 1910 it was 1,010. This is partly
explained by the unwillingness o f the patients to undergo treatment
during the winter months. A n important experiment has been tried
at this institution to diminish the use o f alcoholic drinks. The rule
is that fo r dinner each patient is entitled to one-fourth o f a liter o f
wine, and at supper to one-half o f a liter o f beer. W hile there is
quite a number o f patients who, upon their own volition, abstain
from the use o f alcoholic drinks and prefer mineral waters, which
are provided in place thereof, it is suggestive that only 11.3 per cent
o f the total number o f patients were abstainers from wine during
1910, and 13.5 per cent were abstainers from beer.1
The sanatorium at XJberruh was established during the period
1905 to 1908 at an expenditure o f over 2,000,000 marks ($476,000).
The institution is for female patients only, and the number o f beds
is 195, in 61 rooms. There is only 1 room with one bed, 28 with two
beds, 2 with three beds, 26 with four beds, 2 with six beds, and 2
with eight beds. The average expenditure per bed amounted to
11,000 marks ($2,618). The administration, consists o f a medical
director in chief, 3 assistant physicians, 2 clerks, 1 sister superior,
8 nurses, and 32 domestic servants and other persons. The number
o f patients has increased from 336 in 1908 to 869 in 1909 and 904
in 1910. A lcoholic drinks are not provided in this institution, except
upon medical request.2
Much has been done by the Invalidity Insurance Institution o f
Wurttemberg to render material assistance to the cause o f housing
reform , but what has been done in this respect does not materially
differ from corresponding efforts by other invalidity insurance insti
tutions. It may be stated, however, that a special effort has been
made to utilize life insurance principles for the purpose o f amortiza
tion o f building loans, but while the economic value o f this effort
is realized, the results as yet have not been very encouraging.2 It is
pointed out in the report for 1910 that in view o f the fact that all
loans are supposed to be repaid within a period o f 35 years, the best
security for complete amortization is provided by life insurance, and
the advantage o f this method is made clear by numerous illustrations
within the understanding o f anyone with average intelligence. As
1 Annual Report for 1910, p. 68.
a Idem, p. 81.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
143
previously pointed out, however, the effort to combine life insurance
with building loans has not as yet in actual experience been very
successful, although every borrower is furnished with printed in
structions pointing out the advantages o f the plan.
In conclusion, it may be said that o f 4,573 disability annuities
granted during 1910, the number granted on account o f tuberculosis
o f the lungs was 659, or 14.4 per cent. The number granted to males
was 2,774 fo r all causes, and 398, or 14.3 per cent, for tuberculosis o f
the lungs, and to females 1,799 for all causes, o f which 261, or 14.5
per cent, were on account o f tuberculosis o f the lungs. The im por
tance o f tuberculosis as a cause o f disability, therefore, is clearly
established by the experience o f the institution, extending over many
years.
BADEN.
The territory o f the Invalidity Insurance Institution o f Baden is
coextensive with the Grand Duchy o f Baden, which has an area o f
15,067 square kilometers (5,817.4 square m iles), and which in 1910
had a population o f 2,141,832. The rate o f increase during the last
decade was 1.37 per cent per annum, against an average annual in
crease fo r the German Empire o f 1.41 per cent. The density o f
population is 142 per square kilometer (368 per square m ile), which
is greater than the average o f 120 for the German Empire as
a whole. The principal cities are Mannheim, with a population o f
193,379, and Karlsruhe, with a population o f 134,161. The average
death rate o f the Grand Duchy o f Baden for the 10 years ending
with 1909 was 19.7 per 1,000, the rate having decreased from 22.4 in
1900 to 17.7 in 1909. The average death rate from tuberculosis o f
the lungs o f males aged 30 to 60, inclusive, during 1908, was 30 per
10,000 o f population, and for females, 24. The general death rate
o f Mannheim decreased from 23.8 per 1,000 in 1880 to 20.9 in 1895
and 15.1 in 1909. The death rate from tuberculosis decreased from
37.7 per 10,000 in 1880 to 28.6 in 1895 and to 16.9 in 1909. The gen
eral death rate o f Karlsruhe decreased from 21.1 per 1,000 in 1885
(earlier data not being available) to 17.6 in 1895 and 15.3 in 1900.
The death rate from tuberculosis decreased from 44.7 per 10,000 in
1885 to 26.6 in 1895, and to 15.8 in 1909.
In the experience o f the Invalidity Insurance Institution o f Baden
the ratio o f tuberculosis o f the lungs as a cause o f invalidity, accord
ing to the investigation o f 1896-1899, was 23.1 per cent for males,
against the general average o f 15 per cent for all insurance insti
tutions; and 21.4 per cent fo r females, against a general average o f
9.5 per cent. The rate o f insured persons treated and cared fo r by
the Invalidity Insurance Institution o f Baden on account o f sickness
from all causes during 1910 was 16.8 per 1,000 o f the population
144
BU LLETIN OF TH E BUREAU OF LABOR.
subject to the insurance laws, or very considerably above the aver
age o f 7.8 per 1,000 for all insurance institutions. The number o f
patients under treatment on account o f tuberculosis o f the lungs
during the year was 2,948, or 6.71 per 1,000 o f the insured popula
tion. This rate is considerably in excess o f the general average
o f 3.19 for all insurance institutions, and the rate conforms to the
excessive death rates from tuberculosis in the general population and
to the high ratio o f tuberculosis as a cause o f disability in the
experience o f the Invalidity Insurance Institution o f Baden during
the period 1896 to 1899. The amount expended by the Invalidity
Insurance Institution o f Baden on account o f treatment and care
o f tuberculous patients during 1910 was 1,131,011 marks ($269,181),
or an average o f 383.65 marks ($91.31) per case per annum. The
only invalidity insurance institutions expending larger amounts
on account o f systematic treatment and care o f tuberculous wage
earners during 1910 were those o f Berlin, Rhenish Prussia, and the
Kingdom o f Saxony, with, however, much larger populations subject
to the administration o f the compulsory insurance laws.
The actual importance o f tuberculosis in the Grand Duchy o f
Baden as a cause o f death in the general population is emphasized in
the statement that during the year 1909 there were 3,598 deaths
from tuberculosis o f the lungs, 942 deaths from tuberculosis o f other
organs, and 104 deaths from m iliary tuberculosis, a total tubercu
losis m ortality o f 4,644 during the year. On the basis o f the enumer
ated population o f 2,141,832 in 1910, this would be equivalent to a
tuberculosis death rate o f 2.2 per 1,000 o f population; and consider
ing tuberculosis o f the lungs only, o f 1.7. It is gratifying to find
that during the last five years there has been a persistent reduction
o f the actual mortality from tuberculosis in the Grand Duchy o f
Baden of, respectively, from 4,066 deaths in 1905 to 3,725 in 1907 and
to 3,598 in 1909. O f 3,740 deaths from tuberculosis o f the lungs in
1909, there occurred at ages under 1, 57, or 1.5 per cent; at ages 1 to
14, inclusive, 275, o f 7.4 per cent; at ages 15 to 29, inclusive, 1,255,
or 33.6 per cent; at ages 30 to 59, inclusive, 1,818, or 48.6 per cent;
and at ages 60 and over, 335, or 9 per cent o f the m ortality from
tuberculosis at all ages. It is evident, therefore, that the mortality
from this disease, although on the decrease in the Grand Duchy o f
Baden, is a question o f unusual social and economic importance.
The Invalidity Insurance Institution o f Baden maintains three sana
toria— one at Friedrichsheim, established in 1899, fo r male patients,
with a bed accommodation o f 234; one at Luisenheim, established in
1905, for female patients, with 199 beds; and one at NordrachKolonie, established in 1908, for male patients, with 110 beds.
According to the annual report o f the Grand Duchy o f Baden, the
expenditures on account o f treatment and care for all causes, includ-
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
145
ing fam ily support, have increased from 155,411 marks ($36,988) in
1897 to 605,463 marks ($144,100) in 1903, and 1,117,157 marks
($265,883) in 1910. It is stated in the report that, according to
the occupation census o f 1907, there were then enumerated 458,146
persons making contributions to invalidity insurance institutions,
and o f this number 66.8 per cent were males and 33.2 per cent were
females. The foregoing numbers are exclusive o f the persons in
sured with the railway pension funds and salt works, numbering
18,087 and including 170 females. O f the insured male population,
69 per cent were employed in industries and trades, and o f the
females, 43.5 per cent. O f the total population o f the Grand Duchy
o f Baden for the year 1910, it is estimated that 22.3 per cent were
insured with the invalidity insurance institution; or, respectively,
30 per cent o f the male population and 14.7 per cent o f the female
population.
In the year 1910, 4,736 new disability annuities were granted, and
o f these 18 per cent were on account o f tuberculosis o f the lungs and
3 per cent on account o f tuberculosis o f other organs.1 In addition
thereto the proportion o f disability annuities granted on account o f
nontubercular diseases o f the respiratory organs was 10.5 per cent.
Next to tuberculosis the most important causes o f disability were
anemia and general debility, accounting for 13.6 per cent; rheuma
tism, 7.5 per cent; and diseases o f the heart and circulatory organs,
8.9 per cent. Reviewing the experience for the 19-year period ending
with 1910, and including 63,483 disability annuitants, the number o f
annuities granted on account o f tuberculosis o f the lungs was 12,647,
or 19.9 per cent o f the disability annuities granted for all causes.
The results for 1910, therefore, were below the average for the
experience as a whole, indicating a tendency toward a decrease in the
occurrence o f tuberculosis o f the lungs as a cause o f disability among
the insured population o f the Grand Duchy o f Baden.
O f the 854 disability annuities granted in 1910 on account o f
tuberculosis o f the lungs, 520, or 60.9 per cent, were to males, and 334,
or 39.1 per cent, were to females. O f the number referred to, 74.6 per
cent were persons employed in industries and trades and 8.4 per
cent were employed in agriculture and forestry. O f the 854 dis
ability annuities granted on account o f tuberculosis o f the lungs, 289,
or 33.9 per cent o f the total, were granted at ages 30 to 39. Con
sidering only the earlier periods o f life, it is stated that 18.7 per cent
o f the total number were granted at ages 25 to 29, and 11.2 per cent
at ages 20 to 24. It is shown, therefore, that o f the total number o f
disability annuities granted during 1910 on account o f tuberculosis
o f the lungs, 63.8 per cent were granted to persons under 40 years o f
age.
49397°—12----- 10
1 Annual Report for 1910, p. 24.
146
BU LLETIN OF TH E BUREAU OF LABOR.
The treatment and care o f tuberculous wage earners insured with
the Invalidity Insurance Institution o f Baden proceeds upon very
liberal conditions, but it is required that at least 50 weekly con
tributions must have been paid, and in the case o f persons having
their permanent domicile outside o f the German Empire a minimum
requirement o f 200 contributions is insisted upon. Exceptions are
occasionally made in the case o f very young persons who, on account
o f their age or by reason o f their employment, have not' paid the
minimum o f 50 contributions.1
It is pointed out in the annual report fo r 1910 that the number o f
persons treated and cared for on account o f sickness from all causes,
and tuberculosis o f the lungs in particular, shows a constant tend
ency to increase. The number o f tuberculosis cases treated in 1901
was 1,710, against 3,171 in 1910* This is exclusive o f tuberculous
patients under observation only, the number o f which increased from
43 in 1905 to 416 in 1910. Most o f the patients treated are from
the large cities, particularly Mannheim, Karlsruhe, Pforzheim , and
Freiburg.
During 1910 the number o f days o f treatment provided for tuber
culosis patients was 219,641, or an average duration o f treatment o f
65.8 days, against 68 days during 1909. The comparatively short
duration o f treatment is accounted for by the method adopted to
place suspected cases under preliminary observation, and to provide
dispensary treatment through the 536 tuberculosis associations o f the
Grand Duchy o f Baden, thoroughly organized and intelligently co
ordinated to one another as perhaps the most effective aid in the
state-wide campaign against tuberculosis.
Inform ation is available with regard to the duration o f treatment
in detail o f 2,720 patients during 1910, it being shown that 9.5 per
cent were treated from 1 to 14 days, 4.8 per cent from 15 to 35 days,
39.4 per cent from 36 to 91 days, and 46.3 per cent were treated for
92 days or longer, including a very small number who remained in
the institution for 176 days or more.
The economic results o f treatment have not been as satisfactory as
the average for the German Empire as a whole, but the tendency is
toward an improvement in the persistency o f post-discharge results.
It is claimed that the less favorable results fo r Baden are due in part
to differences in methods o f diagnosis, and partly because the aver
age duration o f treatment is higher fo r all the invalidity insurance
institutions combined than fo r the Invalidity Insurance Institution
o f Baden considered alone. Considering, fo r illustration, the cases
treated during 1904 and observed to the end o f 1908, the percentage
o f patients retaining their earning capacity was only 37 per cent for
Baden against 46 per cent fo r the Em pire as a w hole; and for the
1 Annual Report for 1910, p. 32.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
147
four-year period ending with 1909 the percentage of successful cases
for Baden was 31, against 46 for the German Empire. It is selfevident that unless these percentages are corrected for possible im
portant variations in the age, sex, and occupation distributions of the
patients, and with a due regard to the average duration of treat
ment and condition on admission, the comparison can not be en
tirely conclusive.
The number of patients treated and cared for on account of
tuberculosis of the lungs has increased from 1,710 in 1901 to 2,265
in 1907, and 3,171 in 1910. The proportion of cases admitted in the
first stage of the disease varies widely for the different sanatoria,
having been highest for Nordrach village, for female patients, or
61 per cent, and lowest for Nordrach colony, for male patients, or 27
per cent. At Friedrichsheim, for male patients, the proportion ad
mitted in the first stage of the disease was 36 per cent, against 41 per
cent for female patients at Luisenheim. It is admitted that no satis
factory explanation can be given for these variations in conditions,
which, in part, of course, are due to differential diagnosis.1
During the year 1910 the treatment and care, on account of tuber
culosis of the lungs, was completed in the case of 2,968 patients, and
of these 58.06 per cent were treated with entire success, 29.54 per cent
with partial success, 0.99 per cent unsuccessfully, 11.26 per cent left
the institution previous to completing the regular course of treat
ment, and 0.15 per cent died.
Of the patients treated in the first Turban stage of the disease,
90.05 per cent were successfully treated from an economic point of
view; of those treated in the second stage, 91.93 per cent; and
of those in the third stage, 72.60 per cent. The general results for
the women patients were more satisfactory than for the men.
The accommodation in public sanatoria is inadequate, and as a
rule a waiting period of from three to four weeks is required. The
waiting period during the winter months, however, is much shorter
than during the summer months; for illustration, the average wait
ing period for male patients during January was 20 days and during
July 28 days. For female patients the minimum waiting period was
30 days in April and 83 days, respectively, in September and October.
These waiting periods have been somewhat reduced during the first
half of 1911.2
The details of administration and the medical as well as economic
results of the several sanatoria conform in their essentials to those
obtained in other institutions, making it unnecessary to enlarge upon
the facts given in full detail in the report for 1910. It may be
pointed out, however, that the medical reports are exceptionally
1 Annual Report for 1910, p. 38.
2 Idem, p. 41.
148
BULLETIN OF THE BUREAU OF LABOR.
complete, with ample statistical data and other information, proving
the value of the treatment and the economic justification of the
expense incurred.
The total number of disability annuities granted during 1910 was
4,376, and of this number 802, or 18.3 per cent, were granted on
account of tuberculosis of the lungs; and 116, or 2.7 per cent, on
account of tuberculosis of other organs. The number of disability
annuities granted to males was 2,707, and of this number 489, or 18.1
per cent, were on account of tuberculosis of the lungs, and 66, or
1.5 per cent, on account of tuberculosis of other organs. The num
ber of disability annuities granted to females was 1,669, and of this
number 313, or 18.8 per cent, were on account of tuberculosis of the
lungs, and 50, or 3 per cent, on account of tuberculosis of other
organs. At the age period 20 to 24 the number of disability annuities
granted for all causes was 144, and of this number 93, or 64.6 per
cent, were on account of tuberculosis of the lungs; at ages 25 to 29
the total number of disability annuities granted for all causes was
246, and of this number 151, or 61.4 per cent, were granted on ac
count of tuberculosis of the lungs; at ages 30 to 39 the total number
of disability annuities granted was 543, and of this number 267,
or 49.2 per cent, were on account of tuberculosis of the lungs; at
ages 40 to 49 the total number of disability annuities granted was
561, and of this number 145, or 25.8 per cent, were on account of
tuberculosis of the lungs. Subsequent to this period of life the
number of disability annuities granted on account of tuberculosis
of the lungs is of less economic importance and therefore does not
require extended consideration.
The number of disability annuities granted to persons employed
in agriculture and forestry was 961, and of this number 67, or 7
per cent, were granted on account of tuberculosis of the lungs. The
number of disability annuities granted to persons employed in in
dustry, mining, and building was 2,510, and of this number 603, or
24 per cent, were granted on account of tuberculosis of the lungs.
The number of disability annuities granted to persons employed
in commerce, trade, and transportation was 248, and of this number
55, or 22.2 per cent, were granted on account of tuberculosis of the
lungs. The number of disability annuities granted on account of
domestic service and casual labor was 183, and of this number 20,
or 10.9 per cent, were granted on account of tuberculosis of the lungs.
Other occupations are of less economic importance, and the actual
numbers are too small for definite conclusions.1
Of 3,587 persons treated and cared for on account of tuberculosis
of the lungs during the year 1910, excluding persons under observa
1 Annual Repart for 1910, p. 88.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
149
tion, 1,470, or 49.5 per cent, were treated with full success from an
economic point of view; 748, of 25.2 per cent, with partial success;
and 25, or 0.8 per cent, were unsuccessful; while 4 died.1 The total
expenditures amounted to 1,152,813 marks ($274,369), incurred on
account of 219,641 days of treatment.
Of the 3,587 tuberculous wage earners treated and cared for dur
ing 1910, 1,205 males were provided for with treatment in the sana
torium at Friedrichsheim, 1,049 females in the sanatorium at
Luisenheim, and 551 males in Nordrach colony, also 69 females in
Nordrach village, the remainder being distributed in a number of
institutions which do not require discussion in detail. The average
expenditure per patient per case in all institutions was 309.28 marks
($73.61), and per patient per day, 5.20 marks ($1.24). The average
duration of treatment during 1909 was 83 days for patients of both
sexes, or, respectively, 79 days for males and 90 days for females.
TH E H AN SE T O W N S.
The territory of the Invalidity Insurance Institution of the Hanse
Towns includes the three free cities of Bremen, Hamburg, and Liibeck. The area of Bremen is 256 square kilometers (98.8 square
miles); that of Hamburg, 414 (159.8 square miles); and that of
Liibeck, 298 (115.1 square miles). In 1910 the population of Bremen
was 298,736; that of Hamburg, 1,015,707; and that of Liibeck,
116,533. The domicile of the insurance institution is at Liibeck. The
rate of annual increase in population during the last decade has been
2.82 per cent for Bremen, 2.77 per cent for Hamburg, and 1.85 per
cent for Liibeck, against an average annual increase for the German
Empire of 1.41 per cent The density of population is 1,165 per
square kilometer (3,017 per square mile) for Bremen, 2,454 (6,356
per square mile) for Hamburg, and 391 (1,013 per square mile) for
Liibeck. The free city of Bremen includes the port of Bremerhaven,
which, in 1910, had a population of 24,140, the population of the
city of Bremen proper being 246,827.
The average death rate of Bremen during the 10 years ending with
1909 was 16.5 per 1,000, the rate having decreased from 18.1 in 1900
to 14.4 in 1909. The average death rate for the city of Hamburg
during the same period was 15.8 per 1,000, the rate having decreased
from 17.4 in 1900 to 14.8 in 1909. The average death rate of the city
of Liibeck during the same period was 16.2 per 1,000, the rate having
decreased from 18.2 in 1900 to 14.7 in 1909. The average death rate
from tuberculosis, of males, ages 30 to 60, inclusive, during the year
1908, was 24 per 10,000 for the city of Bremen, 25 for the city of
1 For 721 patients, or 24.3 per cent, the treatment was prematurely discontinued.
(See p. 96 o f the Annual Report for 1910.)
150
BULLETIN* OF THE BUREAU OF LABOR.
Hamburg, and 18 for the city of Liibeck. The corresponding tuber
culosis death rates for females were, respectively, 19 per 10,000 for
the city of Bremen, 15 for the city of Hamburg, and 13 for the city
of Liibeck. The tuberculosis death rate for the total population
has decreased in the city of Bremen from 39.7 per 10,000 in 1880 to
15.1 in 1909, and in the city of Hamburg from 26.4 per 10,000 in
1890 (earlier data not being available) to 13.1 in 1909. For Liibeck
the information is not available.
The actual mortality from tuberculosis of the lungs in the city of
Hamburg has decreased from 1,314 in 1901 to 1,152 in 1910. The
importance of the disease from an economic point of view is em
phasized by the statement that in the decade ending with 1910 there
were 12,294 deaths from tuberculosis. In the year 1910 the tuber
culosis death rate was 12.5 per 10,000 for the city proper, and 9.2
for the rural portions included within the territory of the Hanse
Towns. The death rates, by divisional periods of life, with distinc
tion of sex, in the urban and rural portions, are given in the table
following:
DEATH RATES FROM TUBERCULOSIS OF THE LUNGS IN THE CITY OF HAMBURG,
GERMANY, IN 1910, BY AGE PERIODS AND SEX.
[From the Annual Sanitary Report of the Medical Council of the City of Hamburg for 1910, p. 48.1
Death rates per 10,000 living persons.
Age period.
Urban territory.
Males.
Under 1 year..............................................
I to 14 years................................................
15 to 29 years..............................................
30 to 59 years...............................................
60 to 69 years..............................................
70 years and over........................................
12.9
2.3
13.0
22.3
22.3
19.2
Total.................................................
13.9
Females.
7.1
4.0
14.9
12.9
Rural territory.
City of Hamburg.
Males.
Males.
10.0
20.1
3.2
9.9
13.3
24.4
11.2
9.5
9.8
#
Females.
10.5
4.1
12.6
11.3
4.9
15.6
21.6
8.8
11.1
Females.
2.4
12.7
7.4
4.0
14.6
22.5
19.2
18.8
10.3
13.5
11.0
12.8
According to this table the mortality of males was higher than
the mortality of females in both the urban and rural territories, but
the mortality of females was in excess of the corresponding mor
tality of males at ages 1 to 29, inclusive. At ages 30 to 59, inclusive,
the mortality of males from tuberculosis of the lungs was decidedly
in excess of the corresponding mortality of females.
Of the total mortality from tuberculosis, 32.8 per cent occurred at
ages 15 to 29, inclusive, and 16.4 per cent at ages 30 to 59. An
analysis by districts disclosed wide variations in the incidence of
tuberculosis, the death rate having been as high as 2.3 per 1,000 in one
district and as low as 0.51 in another in 1910. Of the 1,151 deaths
from tuberculosis of the lungs in the city of Hamburg 151 were
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
151
persons who were common laborers. The evidence is quite conclu
sive that the relative death rate from tuberculosis was highest among
the poor, as measured by the income-tax returns. The details for the
year 1910 are given in tabular form below:
DEATH RATES FROM TUBERCULOSIS OF THE LUNGS IN THE CITY OF HAMBURG,
ACCORDING TO TAXABLE INCOMES, FOR THE YEAR 1910.
Deaths from tubercu
losis.
Taxable income.
Population.
Number.
$214 to $286..........................................................................................
$286 to $476..........................................................................................
$476 to $833..........................................................................................
$833 to $1,190.......................................................................................
$1,190 to $2,380....................................................................................
$2,380 to $5,950....................................................................................
$5,950 to $11,900...................................................................................
Over $11,900........................................................................................
47,371
91,449
32,598
11,044
9,565
5,382
1,806
1,335
241
389
74
23
Total.........................................................................................
200,550
744
12
4
1
Rate per
10,000.
50.9
42.5
22.7
20.8
12.6
7.4
5.5
37.1
Granting the limitations of the method of determining the rela
tion of tuberculosis to poverty on the basis of the income-tax returns,
which, of course, exclude the large proportion of the population not
paying taxes of this kind, the table confirms the widely accepted con
clusion that the mortality from tuberculosis of the lungs varies pro
portionately to the material well-being of the population.
During 1910 the number of tuberculous patients treated in general
hospitals in the city of Hamburg was 3,330, and of this number 635,
or 19.1 per cent, died. The number of homes disinfected on account
of tuberculosis during the year was 3,101.
In the experience of the Invalidity Insurance Institution of the
Hanse Towns the ratio of tuberculosis of the lungs as a cause of in
validity, according to the investigation of 1896 to 1899, was 24.4
per cent for males, against 15 per cent for all insurance institutions,
and 8.3 for females, against a general average of 9.5 per cent. The
rate of insured persons treated and cared for on account of sickness
from all causes by the Invalidity Insurance Institution of the Hanse
Towns during 1910 was 8.8 per 1,000 of the population subject to the
insurance laws, against 7.8 for the German Empire as a whole. The
number of patients under treatment on account of tuberculosis of the
lungs during the year was 1,731, or 4.6 per 1,000 of the insured popu
lation. This, however, is only the number of cases for which the
treatment was commenced and completed during) the year. The
amount expended on account of treatment and care during the year
1910 for tuberculosis was 696,660 marks ($165,805), or an average
expenditure of 402.46 marks ($95.79) per case per annum.
152
BULLETIN OF THE BUBEAU OF LABOB.
. The Invalidity InsuranceInstitution of the Hanse Towns maintains
three sanatoria for the treatment and care of its members—1 for
males, established in 1897 at Oderberg, in the Harz Mountains, with
180 beds; 1 for females, established in 1901 at Gliickauf, also in the
Harz Mountains, with 100 beds; and a convalescing home at GrossHansdorf, in Holstein, with an accommodation of 87 beds for male
patients.
The Invalidity Insurance Institution of the Hanse Towns was one
of the first to actively interest itself in the systematic institutional
treatment and care of tuberculous wage earners. Under the direc
tion of the managing director and privy councilor, Dr. Bielefeldt,
numerous reports have been prepared which afford a means for a
thorough study of the methods by which the best obtainable
economic results have been secured. In addition to the annual
report for 1910, which contains a wealth of statistical information,
a special souvenir volume for the 20-year period 1891 to 1911 was
published for the purpose of presenting the results obtained, together
with a descriptive account of the sanatoria owned and maintained
by the institution. According to the annual report for 1910 the
institution granted 25,957 disability annuities, in conformity to
paragraph15 of the invalidity insurance law. Of this number, 3,790,
or 14.6 per cent, were granted on account of tuberculosis of the lungs
and 165 onaccount of tuberculosis of other organs, including scrofula.
The number of applications for institutional treatment and care, in
cluding all causes, increased during 1910 to the extent of 13 per cent
over the number of cases considered during the previous year. The
total number of applications during 1910 was 6,218, of which 3,396
were approved. Of the 3,396 approved applications, 1,693, or 49.9
per cent, were on account of tuberculosis of the lungs, including 964
males and 729 females. The number of tuberculous military recruits
brought to the attention of the institution during the year was 26.
In addition to the treatment and care of tuberculous members in
special institutions, the Invalidity Insurance Institution of the Hanse
Towns extends pecuniary aid to the five tuberculosis dispensaries, the
amount provided for the city of Hamburg being 9,000marks ($2,142);
for Bremen, 2,000 marks ($476); and for Lubeck, 1,500 marks ($357).
According to an investigation made in 1910, with a due regard to
the results of the occupation census of 1907, the number of insured
persons in the Hanse Towns was estimated at 420,000, or 29.3 per cent
of the total population. The number of contributions per insured
member was 49.40 weekly payments, amounting to 14.63 marks
($3.48) per annum.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
153
In appreciation of the intimate relation betweenhousing conditions
and the local incidence of tuberculosis, the Invalidity Insurance In
stitution of the Hanse Towns, with the approval of the imperial in
surance office, provided 1,000,000 marks ($238,000) for building pur
poses for the year 1911.1
The number of disability annuities for all causes granted each year
subsequent to 1891 is given in tabular form below:
DISABILITY ANNUITIES GRANTED BY THE INVALIDITY INSURANCE INSTITUTION
OF THE HANSE TOWNS, 1892 TO 1910.
Year.
1892................
1893................
1894................
1895................
1896................
Number.
104
220
418
623
637
Year.
1897................
1898................
1899................
1900................
1901................
Number.
904
1,209
1,408
1,587
1,852
Year.
Number.
1902................
1903................
1904................
1905................
1906................
2,222
2,283
2,225
1,813
1,475
Year.
1907.............
1908...............
1909...............
1910...............
Number.
1,555
1,763
1,874
1,785
Since 1891 a total of 25,957 disability annuities have been granted,
the maximum having been attained in 1903, when the number was
2,283. Considering the increase in the insurable population, the de
crease during recent years in the total number of disability annuities
granted would seem to sustain the conclusion that this result is, in
part at least, due to the thoroughgoing methods of treatment and care
of invalid members, including a relatively large proportion of tuber
culous wage earners. The ratio of annuities granted for all causes in
proportion to the number of applications made has varied consider
ably, having beenhighest during the year 1892, when32 per centwere
declined, and lowest in the year 1900, when only 7.9 per cent were
declined. The average for the period 1892 to 1910 was 17 per cent;
or, accurately, out of 36,687 applications for disability annuities, 6,250
were declined.2
Of 16,301 disability annuities granted to males by the Invalidity
Insurance Institution of the Hanse Towns up to December 31, 1910,
3,002, or 18.4 per cent, were on account of tuberculosis of the lungs.
The corresponding numbers and proportion for females were 9,656
disability annuities granted for all causes and 788, or 8.2 per cent, for
tuberculosis of the lungs. The numbers and proportion by divisional
periods of life, for both sexes, are given in tabular form below.3
1 Annual Report for 1910, p. 29.
2Id€m, p. 39.
8 Idem, pp. 50, 51.
154
BULLETIN OF THE BUREAU OF LABOR.
DISABILITY ANNUITIES GRANTED BY THE INVALIDITY INSURANCE INSTITUTION
OF THE HANSE TOWNS, 1892 TO 1910, ON ACCOUNT OF ALL CAUSES, AND TUBERCU
LOSIS OF THE LUNGS, BY SEX AND AGE PERIODS.
Annuities granted to—
Females.
Males.
Age period.
Total
all causes.
On account of tu
berculosis of lungs.
^Total
all causes.
Number. Percent.
20 to 24 years..............................................
25 to 29 years..............................................
30 to 34 years..............................................
35 to 39 years..............................................
40 to 44 years..............................................
45 to 49 years..............................................
50 to 54 years..............................................
55 to 59 years..............................................
60 to 64 years..............................................
65 to 69 years..............................................
70 years and over........................................
1,547
2,028
2,800
2,696
1,520
Total.................................................
16,301
427
920
978
1,009
1,156
1,220
On account of tu
berculosis of lungs.
Number. Per cent.
136
39
62.1
52.3
47.0
38.8
33.1
27.9
18.3
10.5
4.9
1.4
168
161
79
73
57
59
55
75
38
19
4
54.7
37.3
27.5
27.2
17.6
11.9
5.7
5.1
1.7
.8
307
432
287
268
324
497
958
1,485
2,233
1,752
1,113
3,002
18.4
9,656
788
8.2
265
481
460
391
383
340
283
212
12
1.1
.4
According to this most interesting and instructive comparison the
largest number of disability annuities for all causes in the case of
males was granted at ages 60 to 64, inclusive, but the largest number
granted on account of tuberculosis of the lungs was at ages 25 to 29,
or 52.3 per cent of the total number of disability annuities granted
at this period of life. For females the largest number of disa
bility annuities for all causes was granted at ages 60 to 64, in
clusive, but the largest number granted on account of tuber
culosis of the lungs was at ages 20 to 24, or 54.7 per cent
of the total number of disability annuities granted at this period
of life. The table emphasizes precisely the economic importance of
tuberculosis of the lungs as a cause of disability and the peculiar
interest which invalidity insurance institutions have in the preven
tion of the disease. It may be stated in this connection that the
average value of the disability annuities granted in 1910 was 211.92
marks ($50.44) for males and 161.85 marks ($38.52) for females.1
According to the experience data for 1892 to 1910, tuberculosis of
the lungs was the cause of invalidity in the case of 18 per cent of the
males favorably considered and 8 per cent of the females; but for
1910 only, the proportion was 15 per cent for males, remaining at
8 per cent for females. The great importance of tuberculosis of the
lungs as a cause of invalidity suggests the inclusion of the following
table, which shows the actual and relative diminutions in the number
of disability annuitants on account of this disease since 1892.
1Annual Report for 1910, p. 57.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
155
DISABILITY ANNUITIES GRANTED FOR ALL CAUSES, AND FOR TUBERCULOSIS OF
THE LUNGS BY THE INVALIDITY INSURANCE INSTITUTION OF THE HANSE,
TOWNS, 1892 TO 1910.
Year.
Number of disability annui
ties granted on account of
all causes.
Males.
1892..........
1893..........
1894..........
1895..........
1896:.........
1897..........
1898..........
1899..........
1900..........
1901..........
1902..........
1903..........
1904..........
1905..........
1906..........
1907..........
1908..........
1909..........
1910..........
Females.
74
178
320
475
470
636
794
854
915
1,135
1,346
1,435
1,351
1,108
928
910
1,091
1,199
1,082
30
42
98
148
167
268
415
554
672
717
876
848
874
705
547
645
672
675
703
Total.
104
220
418
623
637
904
1,209
1,408
1,587
1,852
2,222
2,283
2,225
1,813
1,475
1,555
1,763
1,874
1,785
Number of disability annui
ties granted on account of
tuberculosis of the lungs.
Males.
5
25
80
127
120
138
151
149
174
227
282
243
237
178
194
154
168
182
158
Females.
2
10
17
12
19
34
27
42
51
60
57
74
62
68
58
58
81
56
Total.
5
27
90
144
132
157
185
176
216
278
342
300
311
240
262
212
226
263
214
Per cent of disability annui
ties granted on account of
tuberculosis of the lungs.
Males.
6.67
14.04
25.00
26.74
25.53
21.73
19.02
17.45
19.02
20.00
20.59
16.93
17.54
16.06
20.91
16.92
15.40
15.18
14.60
Females.
4.76
10.20
11.48
7.18
7.09
8.19
4.87
6.25
7.11
6.85
6.72
8.47
8.79
12.43
8.99
8.63
12.00
7.97
Total.
4.81
12.27
21.53
23.11
20.72
17.39
15.30
12.50
13.61
15.01
15.39
13.14
13.98
13.24
17.76
13.63
12.82
14.03
11.99
Annual Report for 1910, p. 64.
According to this comparison the maximum percentage of dis
ability annuities granted on account of tuberculosis of the lungs to
males was 26.74 in 1895, and the minimum, leaving out the first year,
was 14.04 per cent in 1893. For females the maximum was 12.43 per
cent in 1906 and the minimum4.76 per cent in 1893. For both sexes
combined, leaving out of consideration the year 1892, the maximum
was 23.11 per cent in 1895, and the minimum was 11.99 per cent in
1910. The table, therefore, fully confirms the conclusion that there
has been a marked reduction in the actual number and relative pro
portion of disability annuitants on account of tuberculosis of the
lungs during recent years, although the insured population or mem
bership of the Invalidity Insurance Institution of the Hanse Towns
substantially increased in the meantime.
The memorial volume commemorative of the twentieth anniversary
of the Invalidity Insurance Institution of Hamburg contains a
large amount of information, much of which, however, is too techni
cal to permit of extended consideration. The volume, however, is a
treatise of exceptional value, and should be consulted by all who de
sire to obtain a thorough understanding of the methods and results
of German invalidity insurance institutions in their efforts to provide
adequate treatment and care for tuberculous wage earners.
During the period 1891 to 1910, 30,748 applications were received
on account of treatment and care of persons suffering from tubercu
losis of the lungs, and of this number 17,057, or 55.5 per cent, received
favorable consideration. The number of male applicants was 19,754,
and the number favorably considered in this group was 10,338, or
156
BU LLETIN OF TH E BUREAU OF LABOR.
52.3 per cent. The number of female applicants was 10,994, and the
number favorably considered was 6,719, or 61.1 per cent. The inad
equacy of the present system, however, is best emphasized in the
statement that 11,789 tuberculous applicants could not receive treat
ment for various reasons, which do not require to be considered in
detail. The number of male applicants declined for treatment and
care on account of tuberculosis of the lungs was 8,309, and the num
ber of female applicants declined was 3,480.
Special efforts have been made since 1907 to improve the diagnosis
of tuberculosis, and for this purpose a special tuberculosis station
was established at Gross-Hansdorf. It was ascertained that out of
1,968 assumed tuberculous patients, only 1,693, or 86 per cent, were
tuberculous, the remaining persons being affected with nontubercular
lung diseases. Obviously, the results of treatment depend very
largely upon the accuracy of the diagnosis, and for this reason the
establishment of a special station for the purpose of a thorough and
qualified examination is likely to prove a most valuable innovation.
Out of 1,666 patients known to be tuberculous, the evidence of the
disease was determined by means of bacteriological examinations in
23 per cent of the cases, by means of physical examination only in 19
per cent of the cases, and by means of other methods, including the
tuberculin test, in 58 per cent of the cases. The average cost of
treatment and care on account of tuberculosis of the lungs during
1910 was 402.46 marks ($95.79) per patient per annum, or 5.72
marks ($1.36) per patient per day. For males the cost of treatment
per patient per day was 7.01 marks ($1.67), and for females, 4.41
marks ($1.05).
The sanatorium for male patients at Oderberg, in the Harz Moun
tains, is an institution of considerable magnitude, providing 180 beds.
There are 14 rooms with 1 bed each, 4 rooms with 2 beds each, 7 rooms
with 3 beds each, 9 rooms with 4 beds each, 9 rooms with 5 beds each,
4 rooms with 6 beds each, and 4 rooms with 8 beds each. The per
capita cost of maintenance has slightly decreased, or from 7.42 marks
($1.77) in 1908 to 6.50 marks ($1.55) in 1909 and 6.26 marks ($1.49)
in 1910. The average duration of treatment attained a maximum of
83 days in 1898, but by means of rigid selection the average duration
has been gradually reduced to 55 days in 1910. It is explained that
this reduction in the average duration is due entirely to the fact that
about one-fourth of the patients are treated in a preliminary way for
the purpose of observation and study at the tuberculosis station at
Gross-Hansdorf.
An interesting statement is made with regard to the dismissals
on account of violations of rules, the proportion having been 5 per
cent in 1910 and as high as 10 per cent in 1906.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
157
The economic results have been very satisfactory, the proportion
successfully treated having increased from 81 per cent in 1897 to
99 per cent in 1910. The improvement in results is due in part,
however, to a more careful selection of patients on admission. Leav
ing out the year 1897 on account of small numbers, the results, as
measured by the proportion of patients still able to provide for their
own support, were 53 per cent in 1898, 55 per cent in 1899, 60 per cent
in 1900, 57 per cent in 1901, 71 per cent in 1902, 63 per cent in 1903,
68 per cent in 1904, 55 per cent in 1905, and 61 per cent in 1906. Of
857 tuberculous patients treated in 1910,11 per cent were from 1 to 30
days in the institution, 42 per cent from 31 to 60 days, and 47 per
cent from 61 to 90 days. According to ages on admission, 60 per
cent were under 31 years of age, 33 per cent from 31 to 45 years, and
only 7 per cent were of ages 46 and over.
Of the 857 tuberculous patients, only 27 per cent had rendered
full military service, 56 per cent were disqualified for military
service, and in 17 per cent of the cases the point as to military fitness
had not been determined. According to conjugal condition, 55
per cent of the patients were married, 44 per cent single, and 1 per
cent widowed or divorced.
The so-called “ Brehmer’sche” taint was ascertained for 210 of
the 857tuberculous patients, or 24.5 per cent of the total. But, also, in
the case of the nontuberculous patients 15, or 26 per cent, were ascer
tained to be last-born children, which would, therefore, according
to the report, warrant the conclusion that the importance of the
so-called “ Brehmer’sche” taint was not substantiated.
A hereditary taint was ascertained with certainty in 24 per cent
of the cases, and in 66 per cent the result was certainly in the nega
tive and in 10 per cent undecided. The hereditary taint was trace
able to the father in 13 per cent of the cases, to the mother in 9
per cent, and to both parents in 3 per cent of the cases.
The commencement of the disease was alleged to have occurred
during a period of less than 6 months in 53 per cent of the cases,
during from 7 to 12 months in 19 per cent, during 1 to 5 years in 21
per cent, during 5 to 10 years in 5 per cent, and over 10 years in 2
per cent of the cases of tuberculosis treated during 1910. The aver
age duration of illness, including 58 cases of nontuberculous patients,
previous to admission was 1.6 years.
The duration of incapacity for work previous to admission was
up to 1 month for 20 per cent of the cases, from 1 to 3 months in 42
per cent, and from 3 to 12 months in 11 per cent. The remainder, or
27 per cent of the cases, were not incapacitated for work previous to
their admission to the sanatorium.
158
BULLETIN OF THE BUREAU OF LABOR.
Classified according to the Turban stage of the disease, 64 per
cent were in the first stage on admission, 33 per cent in the second
stage, and 3 per cent in the third stage. A tuberculin reaction oc
curred in 514 out of 573 patients treated by the tuberculin method.
Of the 857 tuberculous patients 30 per cent had tubercle bacilli in
the sputum on admission, 51 per cent had no bacilli in the sputum,
and 19 per cent had no expectoration at all. On discharge 20 per cent
of the patients had tubercle bacilli in the sputum; in 34 per cent
of the cases the result was negative and in 46 per cent there was no
expectoration at all. In 35 per cent of the cases of patients having
bacilli in the expectoration on admission the bacilli disappeared dur
ing treatment.
The average gain in weight during treatment was 5.8 kilograms
(12.8 pounds). In the case of 42 per cent of the patients the gain
was from 0.1 to 5 kilograms (0.2 to 11 pounds), in the case of 43 per
cent from 5.1 to 10 kilograms (11.2 to 22 pounds), and in the case of
12 per cent of the patients from 10.1 to 20 kilograms (22.3 to 44.1
pounds). The weight was stationary in 2 per cent of the cases and
decreased in 1 per cent of the cases.
Of the 857 tuberculous patients 65 per cent were discharged in a
materially improved condition, 29 per cent in a fairly improved
condition, 5 per cent in about the same condition as when received,
and in only 1 per cent was the condition decidedly worse.
The economic results were satisfactory in 83 per cent of the
cases—that is, the earning capacity was restored for a reasonable
period of time; the results were also fairly satisfactory within the
meaning of paragraph 5 of section 4 and paragraph 15 of the
invalidity insurance laws, and in only 5 per cent of the cases were
the patients discharged with their earning capacity not at least par
tially restored.
Much the same results, medical and economic, were secured at the
other institutions maintained by the Invalidity Insurance Institution
of the Hanse Towns, and it would serve no practical purpose to en
large upon the details, which are conveniently available to anyone
who may desire to inquire further into the facts.
The aggregate results are summarized for the period 1893 to 1910
for males, and for 1894 to 1910 for females, including in the former
10,067 patients under observation at least one year, and in the latter
6,485. The results are given in tabular form below, showing re
spectively the number of patients retaining their earning capacity
for a stated period of time of from 1 to 12 years.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
159
ECONOMIC RESULTS OBTAINED BY SANATORIUM TREATMENT FOR TUBERCULOSIS
OF THE LUNGS AT INSTITUTIONS MAINTAINED BY THE INVALIDITY INSURANCE
INSTITUTION OF THE HANSE TOWNS, 1893 TO 1910.
[From Twenty Years’ Experience in the Treatment and Care of Tuberculous Wage Earners by the Invalid
ity Insurance Institution of the Hanse Towns, 1891-1911, p. 179.]
Patients successfully treated and discharged, with earning capacity restored.
Years after discharge.
Number under ob
servation.
Males.
1...............................
2...............................
3...............................
4..............................
5...............................
6...............................
7...............................
8...............................
9...............................
10...............................
11...............................
12..............................
8,353
7,556
6,726
6,069
5,333
4,105
1,450
1,077
715
481
208
32
Females.
5,554
4,923
4,320
3,916
3,432
2,626
796
579
367
204
69
6
Number still at
work.
Males.
8,060
6,196
4,718
3,792
3,065
2,193
660
446
287
175
60
5
Females.
5,461
4,313
3,391
2,859
2,379
1,755
490
339
215
124
35
3
Number not traced.
Males.
326
303
277
248
206
46
37
28
18
5
2
Females.
192
180
169
145
107
36
30
23
12
8
Per cent success
fully treated.
Males.
96
86
73
65
60
56
47
43
42
38
30
17
Females.
98
91
82
76
77
70
64
62
63
65
57
50
This table shows that of the 10,067 male patients under observation
at least one year during the period 1893 to 1910, 8,353 were discharged
as successfully treated with the anticipation of a continuance of
earning capacity for a reasonable period of time. Of the 8^353
patients 8,060 were still at work at the end of the first year, or 96
per cent of the number of successful cases under observation, or 80
per cent of the total number treated and cared for.
The number of male patients under observation for two years was
7,556, and the number still at work at the end of this period was
6,196, excluding 326 for whom the information was not obtainable.
The percentage of male patients retaining their earning capacity for
two years, therefore, was 86 per cent of those successfully treated and
69 per cent of the total number of cases, including those unsuccess
fully treated. In a similar manner the results are traceable through
out the entire experience of 12 years, the percentages becoming grad
ually reduced to 73 for the third year cases, 65 for the fourth year,
60 for the fifth year, 56 for the sixth year, 47 for the seventh year,
43 for the eighth year, 42 for the ninth year, 38 for the tenth year,
30 for the eleventh year, and 17 for the twelfth year. For females
the results throughout are still better, but the facts can readily be
determined by reference to the table. The table is subject to the
correction that the number of not controlled cases requires to be de
ducted from the total number of successful cases, the percentages
being calculated on the basis of the number of cases for which the
information for each year was ascertainable.
The economic results obtained in the treatment and care of tuber
culous wage earners by the Invalidity Insurance Institution of the
H
anse Towns are a sufficient inducement to believe in the accuracy
160
BU LLETIN OP THE BUREAU OP LABOR.
of the theory that, in the long run, substantial financial gains must
result from adequate and effective methods of prevention and cure.
It is, in any event, suggestive to find that of the male patients treated
during the period 1893 to 1910, the proportion treated successfully
at the outset was 83 per cent, and for the females 86 per cent. These
results for tuberculosis of the lungs compare with some other im
portant diseases, as follows: For anemia cases the proportion success
fully treated at the outset was 90 per cent for males and 91 per cent
for females; for nervous diseases, 83 per cent and 83 per cent, re
spectively; for rheumatism, 80 per cent and 73 per cent; and for
other diseases, 79 per cent and 83 per cent.
Considering the permanent results as measured by a six-year
period, the comparison shows that for male patients the wage
earning capacity was retained in tuberculosis of the lungs in 43 per
cent of the cases; in anemia, in 48 per cent; in nervous diseases, in 46
per cent; in rheumatism, in 45 per cent; in sciatica, in 38 per cent;
and in other diseases, in 42 per cent. For females the respective
percentages as regards economic results to the end of the sixth year
were for tuberculosis of the lungs, 56; for anemia, 70; for nervous
diseases, 54; for rheumatism, 41; for sciatica, 47; and for other
diseases, 51.
A very important analysis of the results, extending over a period
of from 6 to 15 years, has been made by Dr. F. Reiche in behalf of the
Invalidity Insurance Institution of the Hanse Towns by means of a
medical reexamination of patients discharged from the sanatoria
during the period under observation. Of the male patients dis
charged in 1895,36 percent still retainedtheirwage-earning capacity
to the end of 1910, but 8 per cent had undergone a subsequent treat
ment in the meantime. Of the female patients discharged in 1895,
the proportion retaining their wage-earning capacity to the end of
1910 was 67 per cent, but 11 per cent had undergone a subsequent
treatment. Combining the results for patients discharged in 1895,
1896, and 1897, it was ascertained that out of 245 males observed and
reexamined from time to time to the end of 1910, 52 per cent had
retained their full earning capacity and 4 per cent additional had
retained a limited wage-earning capacity. For females, the respec
tive percentages were 63 for full earning capacity and 18 for limited
earning capacity. Of these proportions, however, 20 per cent of the
males and 24 per cent of the females who had retained their full or
limited earning capacity had undergone a subsequent treatment.
Of the patients under observation from 1895 to 1904, excluding,
however, all patients less than four weeks in the institutions, the
results, according to ages on admission, were as follows: Of the male
patients admitted at ages 15 to 24, the proportion retaining their full
CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
161
earning capacity to the end of 1910 was 63 per cent, and a limited
earning capacity was retained in 7 per cent of the cases. The re
spective percentages for females were 69 and 14. For male patients
at ages 25 to 49 on admission, a full earning capacity was retained
to the end of 1910 in 52 per cent of the cases and a limited earning
capacity in 9 per cent of the cases. For females, the respective per
centages were 57 and 18. The numbers at ages over 50 are very small,
but of the males 19 per cent had retained their full earning capacity,
and of the females 5 per cent. It is shown, therefore, that the
economic results are most favorable in the case of men and women
admitted for treatment at ages under 25.
Considering the results by duration of disease previous to admis
sion, it is shown by the investigation referred to that of the male pa
tients from 1 to 6 months under treatment 62 per cent retained their
full wage-earning capacity to the end of 1910; with a stay of from
6 to 24 months the percentage was 56; with a stay of from 2 to 6
years it was 44; from 6 to 12 years it was 49; and over 12 years it
was 44 per cent. For females the economic results were as follows:
For a duration of the disease of from 1 to 6 months the percentage
was 73; from 6 to 12 months it was 62; from 2 to 6 years it was 64;
from 6 to 12 years it was 65; and for over 12 years it was 49 per
cent. It is therefore shown that the economic results were most sat
isfactory in the case of patients with a comparatively short duration
of the disease previous to admission.
The economic results did not vary materially for patients with or
without a family taint of tuberculosis, having been 54 per cent
for male patients having a family history of tuberculosis, and 57
per cent for those not having a family history of the disease. For
female patients the respective percentages were 63 and 66.
Finally, it may be stated that the Invalidity Insurance Institution
of the Hanse Towns loaned 8,075,400 marks ($1,921,945) in the form
of building loans for wage earners’ homes, and it may also be stated
that in appreciation of the social service rendered by the institution
a dock laborer by the name of Gustav Kiissner, who had since June
3, 1897, been in receipt of a disability annuity, left at the time of his
death, on March 26, 1904, the sum of 3,700 marks ($881) as a legacy
to the institution for welfare purposes to be used at its discretion. It
is clearly shown by the admirable analysis of the results, statistical or
otherwise, that the aim and efforts to advance in the most important
directions the well-being of wage earners insured with the Inva
lidity Insurance Institution of the Hanse Towns have been realized.
49397°— 12----- 11
162
BU LLETIN OP TH E BUREAU OF LABOR.
APPENDIX I.— TREATMENT OF TUBERCULOUS WAGE
PUBLIC INSTITUTIONS, 1902 TO 1904.1
EARNERS IN
During the present year the Im perial Board o f Health has pub
lished a supplementary report on the results o f sanatorium treatment
for the period 1902 to 1904, which confirms in all essentials the ex
perience data for 1896 to 1901. The results o f this supplementary
investigation are briefly summarized, as follow s:
1. The statistical investigation includes 34,071 male and 12,632
female patients treated and cared for on account o f tuberculosis o f
the lungs, with an average duration o f treatment fo r males o f 86.6
days and for females o f 95.8 days.
2. The cost o f treatment was provided for by social insurance insti
tutions in the case o f male patients to the extent o f 85.4 per cent and
o f female patients to the extent o f 75.7 per cent.
3. O f the male patients 44.3 per cent and o f the female patients
59.3 per cent were o f the age period 20 to 29 years, and o f the male
patients 31.8 per cent and o f the female patients 18.8 per cent were
o f the age period 30 to 39 years.
4. A parental history o f tuberculosis was ascertained in the case o f
25.2 per cent o f the male patients and o f 36.7 per cent o f the female
patients. Tuberculosis among brothers and sisters was ascertained
in the case o f 19.6 per cent o f the male patients and o f 24.4 per cent
o f the female patients. In addition thereto, in the case o f 2.6 per cent
o f the male patients and o f 2.9 per cent o f the female patients,
respectively, the w ife or the husband was ascertained to be tubercu
lous. The proportion o f families with tuberculous children was only
0.5 per cent in the case o f male patients and only 0.4 per cent in the
case o f female patients.
5. About two-thirds o f the patients, or 61.9 per cent fo r males and
64.7 per cent for females, entered the sanatorium during the year in
which the disease first became apparent. In the case o f 16.9 per cent
o f the male patients and o f 12.3 per cent o f the female patients
receiving institutional treatment, a previous treatment had been had
in sanatoria, in hospitals, or in air-cure establishments.
6. The nutrition o f the patients on admission for institutional
treatment was ascertained to be good in the case Of 19.1 per cent o f
the male patients and o f 18.9 per cent o f the females. For 51.2 per
cent o f the males and for 50.5 per cent o f the females the condition
as regards nutrition was considered average, and in 29.7 per cent o f
the male patients and in 30.6 per cent o f the female patients the
condition as regards nutrition was bad. An improvement in the
bodily condition took place in the case o f 95.9 per cent o f the male
patients and o f 94.1 per cent o f the female patients during treatment,
1 Tuberkulose-Arbeiten aus dem Kaiserlichen Gesundheitsamte. Deutsche Heilstatten
fiir Lungenkranke. Verlag yon J. Springer, Berlin, 1912. 13. hft.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
163
and the average gain in weight was 6.6 kilograms (14.6 pounds) for
males and 5.8 kilograms (12.8 pounds) for females.
7. The general condition o f patients on admission was apparently
good in the case o f 23.1 per cent o f the males and o f 20.7 per cent o f
the females. The condition was average in the case o f 49.5 per cent o f
the males and o f 42.6 per cent o f the females, and the condition was
bad in the case o f 27.4 per cent o f the males and o f 36.8 per cent o f the
females. An improvement in the general condition during the period
o f institutional treatment took place in the case o f 64.2 per cent o f
the males and o f 66.1 per cent o f the female patients.
8. On admission the proportion o f patients with cough and expec
toration was 92 per cent for males and 65.9 per cent for females. The
proportion o f dry cough was 3.3 per cent for males and 17.6 per cent
for females. O f the patients with cough and expectoration 26.3 per
cent o f the males and 32.7 per cent o f the females were relieved there
from entirely, and a partial result was obtained in the case o f 14.3
per cent o f the males and o f 7.7 per cent o f the females. O f the male
patients 69.9 per cent were relieved from dry cough as the result o f
institutional treatment and o f the female patients 66.1 per cent.
9. The bacilli o f tuberculosis was bacteriologically ascertained to be
present in the case o f 35.1 per cent o f the male patients and o f 21.8
per cent o f the female patients. As the result o f treatment 33.4
per cent o f the male patients and 29.4 per cent o f the female patients
were free from bacillary evidences on discharge.
10. Fever was present on admission in the case o f 14.5 per cent o f
the males and o f 14.9 per cent o f the females. On discharge 71.9 per
cent o f the male patients and 57.3 per cent o f the female patients were
free from fever.
11. Night sweats on admission were present in the case o f 25.4 per
cent o f the male patients and o f 18.3 per cent o f the female patients.
O f the males 91.7 per cent were free from night sweats on discharge
and o f the females 85.8 per cent.
12. O f the male patients on admission 37.3 per cent were in the
first Turban stage o f the disease, 46.2 per cent in the second, and 16.5
per cent in the third. O f the female patients 51 per cent were in
the first Turban stage, 37.4 per cent in the second, and 11.6 per cent
in the third. In the case o f 23.3 per cent o f the male patients and o f
25.8 per cent o f the female patients only one lung was affected with
the disease on admission. The right lung only was affected in the
case o f 67.5 per cent o f the male patients and o f 65.7 per cent o f the
female patients.
13. A complete cure was obtained on discharge in the case o f 4.5
per cent o f the male patients and o f 6.7 per cent o f the female patients.
An improvement in the condition o f the lungs was secured in the case
o f 86.7 per cent o f the male patients and o f 81.7 per cent o f the female
Digitized forpatients,
FRASER and o f these, in the case o f 27 per cent and 23.1 per cent.
164
B U LLETIN OF TH E BUBEAU OF LABOR,
respectively, the improvement was so decided that there was a change
to a more favorable Turban stage o f the disease. In only 6.3 per
cent o f the male patients and in only 8.8 per cent o f the female pa
tients was there no change in the condition o f the lungs during treat
ment. The proportion o f deaths during treatment was only 0.3 per
cent for male patients and only 0.2 per cent fo r female patients.
14.
A complete economic result—that is, restored wage-earning
capacity—was obtained in the case o f 53.9 per cent o f the male
patients and o f 60 per cent o f the female patients. But, in addition
thereto, in the case o f 28.6 per cent and o f 24.2 per cent, respectively,
a fairly satisfactory economic result was secured—that is, restored
wage-earning capacity o f lim ited extent for a reasonable period o f
time.
The comparative statistical facts for the investigations o f 1896 to
1901 and 1902 to 1904 are conveniently summarized below :
COMPARATIVE RESULTS OF TREATMENT FOR TUBERCULOSIS IN GERMAN PUBLIC
SANATORIA.1
1896 to 1901
Males.
NmnhAr of nationts.....................................................................
Average duration of treatment.................................
Ages on admission:
Under 20 years...................................................
20 to 29 years......................................................
30 to 39 years.......................................................
40 years and over................................................
Tuberculous parents.................................................
Tuberculous brothers and sisters..............................
Previous duration of disease less than 1 year...........
Previous sanatorium treatment of at least 6 weeks...........do___
Good nutrition on admission.................................... ........ do___
Average nutrition on admission................................
Poor nutrition on admission.....................................
Gain in weight..........................................................
Average increase in weight......................................
Physical condition on admission:
Good...................................................................
Average.............................................................. ........d o....
Poor............................................................................do___
Physical condition during treatment:
Improved.................................................................... d o....
Unchanged........................................................ ......... d o ....
Worse................................................................ .
Cough and expectoration on admission.....................
Cough only.............................................................. ......... do___
No cough and expectoration on discharge.............. ......... d o....
Bacillary diagnosis positive on admission......................... do___
Bacillary diagnosis negative on discharge......................... d o ....
Fever on admission........................................................... do___
No fever on discharge.............................................. ......... d o....
Night sweats on admission...................................... .
No night sweats on discharge................................... ........d o ....
Turban stage on admission:
First...................................................................
Second................................................................
Third..................................................................
One lung affected..................................................... ......... do___
Condition of lungs on discharge:
Improved.................................................................... d o....
Stationary.......................................................... ........ do___
Worse................................................................ .
Deaths................................................................__ ..do___
Females.
Males.
Females.
15,869
89.2
4,008
94.4
34,071
86.6
12,632
95.8
10.5
44.0
30.1
15.4
26.4
16.5
54.4
9.8
17.9
48.9
33.2
93.6
13.0
20.4
57.8
17.6
4.4
36.7
21.2
54.6
8.2
* 18.0
44.6
37.5
92.3
11.5
8.5
44.3
31.8
15.4
25.2
19.6
61.9
16.9
19.1
51.2
29.7
95.9
14.6
16.6
59.3
18.8
5.3
36.7
24.4
64.7
12.3
18.9
50.5
30.6
94.1
12.8
32.9
36.8
30.2
28.2
31.7
40.1
23.1
49.5
27.4
20.7
42. 6
36.8
57.5
40.1
2.4
91.1
4.5
122.8
45.3
234.4
13.8
8 68.6
29.8
<90.7
59.0
38.4
2.6
65.7
18.5
126.2
30.0
225.0
19.4
863.3
27.3
<85.2
64.2
34.0
1.8
92.0
3.3
126.3
35.1
233.4
14.5
8 71.9
25.4
<91.7
66.1
32.4
1.5
65.9
17.6
132.7
21.8
229.4
14.9
8 57.3
18.3
<85.8
31.3
52.9
15.8
25.0
28.4
58.4
13.2
19.7
37.3
46.2
16.5
23.3
51.0
37.4
11.6
25.8
84.2
10.3
5.1
0.4
75.7
17.0
7.1
0.2
91.2
6.3
2.2
0.3
88.4
8.8
2.6
0.2
1 Of those having cough and expectoration on admission.
* Of those showing positive bacillary diagnosis on admission.
* Of those having fever on admission.
<Of those having night sweats on admission.
1902 to 1904
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
165
APPENDIX II.—MEMORANDUM ON TUBERCULOSIS.
[Compiled and published in English by German Imperial Board of Health at Berlin.]
A. WHAT IS TUBERCULOSIS?
Tuberculosis is the most destructive of all infectious diseases. It attacks
various parts of the body, chiefly, however, the lungs; it spares no nation, no
age, no vocation, no class of people. More than 100,000 persons die each year
in Germany from the effects of it, the number of patients afflicted by it being
estimated as 10 times as numerous. Every third person who dies between the
ages of 15 and 60 years succumbs to tuberculosis.
Tuberculosis is caused by the tubercle bacillus discovered by Robert Koch.
This is a minute creature of the lowest scale, visible only when very highly
magnified. It thrives best at blood temperature (about 98° F.) and multiplies in
the interior of the body. It reaches the outer world chiefly in the sputum of
sick persons and in the milk of diseased animals.
Every person is exposed to the danger of taking up the germs of tuberculosis
into his own system, and many harbor them a long time without knowing it.1
Everyone must therefore be prepared for battle with this enemy.
The tubercle bacillus is most efficiently destroyed by burning, boiling, or
steaming. It can not long resist the action of sunlight. Other means of
disinfection, such as cresol water, a solution of carbolic acid, formaldehyde,
require a special previous knowledge for safe and effective use.
B. HOW DOES THE INFECTION TAKE PLACE?
Hereditary tuberculosis is rare.
Tubercle bacilli enter the human body mainly by the respiratory organs and
the digestive system.
Tubercle bacilli are taken up—
1. By inhaling with the air germs either from the dried sputum of tuberculous
persons in the dust, whirled by winds and drafts while sweeping out, or
carried on clothing or shoe soles; or from the minute moist drops which invalids
diffuse in their immediate vicinity by coughing or talking.
2. With the food, first through unboiled milk, also, in case of unsatisfactory
inspection of meat through the flesh of tuberculous animals, which, admitted
in trade, was not afterwards thoroughly cooked before being eaten.
3. By means of unclean hands and unclean utensils, e. g., in the case of chil
dren crawling on the floor, seizing soiled objects (clothing, handkerchiefs, and
the like) and immediately afterwards putting the fingers into the mouth
(sucking fingers, biting nails, licking fingers when turning over leaves), picking
the nose, and similar bad habits as putting into the mouth toys, drinking glasses,
eating utensils, wind instruments used by others.
Tubercle bacilli may also enter through injured or diseased places in the skin
or in the visible mucous membrane (unnoticed small sores, scratches, eruptions).
The result of the absorption of tubercle bacilli usually in the case of children
at first a disease of the glands (e. g., of the neck and abdomen) and, in con
nection therewith, of the lungs, the bones, and joints (scrofula of the bones,
tubercular excrescences, voluntary limping), the cerebral membrane, etc. In
the case of adults infection by inhalation predominates and leads to tuberculosis
of the lungs, more infrequently of the larynx (consumption). Through absorption1
1 One-fourth of the corpses o f persons who have died from other diseases show internal
traces o f tuberculosis that had been overcome.
166
BU LLETIN OF TH E BUBEAU OF LABOB.
of the tubercle bacilli into the skin there is arising tuberculosis of the skin
(e. g., lupus, corrosive herpes.)
Most usually tuberculosis progresses slowly (chronically); exception, gallop
ing consumption.
C. HOW DOES ONE PBOTECT ONESELF AGAINST TUBERCULOSIS?
Each person, even the weakest and poorest one, will highly contribute to
guarding himself against tuberculosis by merely combining judgment with selfcontrol.
I.
M easures a g a in s t c o n tra c tin g tuberculosis.
1. Let every person, whether well or sick, provide for the safe removal of the
sputum, since one can not detect from the simple appearance whether sputum
is tuberculous or not. Do not spit on the floor of closed rooms (including
street cars and railway coaches) or on frequented thoroughfares. Place in con
venient comers spittoons filled with water which, to insure safety, should be
cleansed at short intervals by disinfecting methods. Hold your hand before
your mouth when coughing. Turn away from a coughing neighbor that does
not do so. Articles of clothing should always be kept clean, the trailing of
garments should not be tolerated. The clothes, beds, linen, eating and
drinking utensils of tuberculous persons may be used by others only after
thorough disinfection. Dry sweeping should give place to moist; if need be,
scour with hot soda or a hot solution of soft soap. The raising of dust in the
dwelling room, the work place, and on the street should be avoided whenever
possible. Shun bars or refreshment rooms where spitting on the floor is ,
allowed. Children should be kept out of dusty workshops and from work that
develops dust (carpet beating).
2. Let the strictest cleanliness prevail in the preparation and preserving
(guard against flies) as well as in the eating of food, especially of that which
is eaten raw. Milk should be boiled and meat cooked thoroughly before being
eaten; the boiled milk should be covered and kept as cool as possible.
3. The hands, including the nails, the teeth, and mouth, should be cleansed
frequently and thoroughly. Putting the fingers into the mouth or nose and *
also scratching the face should be discontinued. Every sore should be protected
against impurities by suitable bandages.
4. With regard to the tuberculosis of animals it will suffice to say that in
cattle it usually affects the lungs, in pigs usually the glands of the neck or the
intestines; in the former, commonly, through inhalation, in the latter through
the food, chiefly through the unboiled refuse and skim milk of dairies. Proper
means of extirpation are—gradual sorting out of tuberculous cattle, chiefly of
those that betray visible signs of the disease (tubercular knots on the udder,
coughing, with emaciation and rough hair, and the like) from special dairies
for children’s milk and establishments for breeding; but also removal of all
other animals feverish from the injection of tuberculin; separation of calves
from tuberculous mothers; frequent exercise of the calves and young cattle, if
possible of the older animals, too, in the open air should be encouraged; the
use of boiled milk only; and boiled dairy residues for the feeding of pigs; 1
keeping the stalls clean.
1Many large dairies now heat all the milk before manufacture so that all danger Is
removed.
CABE OP TUBEBCULOUS WAGE EABNEBS IN’ GEBM ANY.
167
I I , M easures f o r s tre n g th e n in g th e body .
It will be impossible to extirpate all tubercle bacilli, therefore it is indis
pensable so -to strengthen and harden the body that the absorbed germs can not
take hold upon it. The principal means1 are:
Plain and wholesome food, which by judicious selection need not be expensive.
Dainties and intoxicating drinks should be avoided.
A dwelling accessible to the entrance of air and light; rather in the suburbs
than in the heart of the city; the best room selected as a sleeping room.
Plain, durable clothing made of material not too thickly woven, neither too
warm nor to cool; in the case of a person in repose or of a sedentary occupation
warmer than in that of someone frequently in motion; discarding the follies of
fashion that hamper the free movement of the body, e. g., the corset and belts.
Only after defraying the necessary costs of dwelling, eating, and clothing,
other expenses may be considered.
Let order and cleanliness have the first place in the whole conduct of life.
Wash the whole body daily with moderately cold water or rub it vigorously
with a rough, damp cloth, bathe in pure river or sea water, or take a shower
bath (sparing the head), keep hair and beard, teeth and mouth, also the nails
clean. Breathe through the nose keeping the mouth shut; the former is the
natural filter for impure and injurious substances. If breathing through the
nose is difficult, be examined by a physician; it is often easy to remove the
impediment.
Seek to perform your work in accordance with your health. Take advantage
of prescribed measures for protection. Avoid a bent position in intellectual
work. If you are an employer, consider how you may remove noxious substances
or prevent such from arising (dust, smoke, etc.). The time for work and rest
should be in proper proportion.
Devote the hours free from work to the strengthening of those parts of the
body that had little opportunity to be exercised during work. Take exercise
outside of your dwelling. Draw in long, deep drafts of fresh air while
holding the hands pressed against the sides. Accustom yourself also to being in
the open air in unfavorable weather. Change wet clothing and shoes. Gym
nastic exercises—especially when out of doors—suited to the conditions of the
body, together with tramps on foot, games, moderate cycling, rowing, swimming,
and the like are the best allies in the fight with tuberculosis.
Go to bed at a reasonable hour. Avoid excesses of every sort They destroy
in a few minutes what has been gained in years. As little as a glass of mod
erately cool beer, a cup of moderately strong coffee or tea, a cigar—enjoyed at
the proper time—injure the normal adult body as much as every intemperance
injures it.
Finally, shun intercourse with persons who are suffering from infectious
diseases; if duty or profession demands such intercourse, then bear constantly
in mind the prescribed measures of precaution. If you move into a house where
a tuberculous person has lived recently, have it first disinfected.
D. ADVICE TO PERSONS IN GREAT DANGER.
Every one should study the foregoing rules of health, but especially all those
persons who, from any reason whatever, have cause to fear tuberculosis more
than others; weakly persons, such as have a long and slender figure with a flat
1 Further particulars are contained in the “ Gesundheitsbiichlein,’’ compiled in the Kais.
Gesundheitsamt. 13. Ausgabe, Berlin, J. Springer, 1908.
168
B U LLETIN OF TH E BUREAU OF LABOR,
chest, particularly if they descend from tuberculous parents; again, such as
have a reason for the assumption that they have already taken up the germs
of tuberculosis through intercourse with consumptive persons (relatives, guar
dians, fellow workmen, or playmates) or in consequence of their own sickness
in childhood from scrofula and the like; also those whom their vocation en
dangers (who work indoors or in the midst of dust, etc.); finally, those recov
ering from a severe sickness, from measles, whooping cough, influenza, and gen
erally such as have suffered or are still suffering from diseases of the lungs or
chronic affections of the throat, diabetes, chlorosis, or are inclined to severe
losses of blood (nose bleeding and the like).
Let him who possesses a body little capable of offering resistance have regard
to this fact when he chooses an occupation: An occupation that leads into fresh
air and steels the body through exercise is better than a business that confines
within doors. Persons with sensitive respiratory organs have to avoid not
only dust (and consequently dusty trades) but also smoke (tobacco smoke
included) and cold, rough winds or else to take corresponding measures of pre
caution; talking in the cold air or while walking should be discontinued, and
one should guard against catching cold and excessive bodily exertion.
Not less important is the sensible observance of general measures of precau
tion in every place where people assemble in large numbers through their occu
pation or from other causes (in schools, boarding schools—corresponding con
duct of tuberculous teachers—factories, hotels, poorhouses, orphanages). Neg
lect of tuberculosis by individuals endangers the general public.
E. ADVICE TO DISEASED PEBSONS.
If symptoms appear that arouse the suspicion of a not merely transient dis
ease of the respiratory passages, repeated coughing (dry or with sputum), fre
quent pains in the throat, breast, or back, lasting depression or tendency toward
exhaustion, recurring fever, especially in the evening, with night sweats
(though the covering be light), traces of blood in the sputum or even a dis
charge of blood from the throat, then a radical examination by the physician
(also of the sputum for tubercle bacilli) should be made as soon as possible.
If the suspicion is not confirmed, yet the advice given under D should be care
fully followed. If the suspicion is confirmed, then the regulations prescribed
by the physician are first of all to be observed. No cure is of avail if the
patient himself does not contribute thereto by his general hygienic conduct and
rigid observance of the prescribed measures of precaution. The patient should
realize the double duty of taking thought for his own cure, in order to become
once more a useful, earning member of human society, and also of preserving
his family, servants, and neighbors from infection by heeding the precautionary
regulations. Incipient tuberculosis is often curable; advanced seldom. Success
depends chiefly on timely anticipation.
Especial attention should be paid to the sputum; it should neither be cast
upon the floor nor swallowed, but rather be vented into a separate, suitable
vessel, which should be regularly disinfected; better still are the saliva bottles
(something like the Dettweiler) which the patient takes with him. Should it
be necessary at times to vent the sputum into the handkerchief, the latter
should be boiled before becoming dry.
The disease can also be communicated by kissing. An evidently consump
tive person should be urgently dissuaded from marrying; let him wait until he
is cured. Tuberculous women should not suckle or nurse children.
The cure is most surely effected in a sanatorium devoted especially to the
restoration of consumptives and directed by an experienced physician. After
CAEE OF TUBERCULOUS WAGE EARNERS IN GERM ANY.
169
not too short a sojourn (not under 3 months), the obedient and attentive pa
tient often regains not only his health, but appropriates to himself also the
rules of living necessary to avoid relapses.
To poor consumptive people advice and help is given free of charge by the
information and care offices recently so often established (Auskunfts- und Fiirsorgestellen) and by dispensaries for tuberculous people.
APPENDIX m .—DEFINITION OF GERMAN TERMS RELATING TO TREAT
MENT AND CARE OF TUBERCULOUS WAGE EARNERS.
1. Heilbehandlung: This term has been interpreted as “ treatment and care.”
There is no exact equivalent of this term in the English language.
2. Heilverfahren: This term has been interpreted as “ systematic institutional
treatment and care.” There is no exact equivalent of this term in the
English language.
3. Landes-Versieherungsanstalt: This term has been interpreted as “ invalid
ity insurance institution.” In German law the term, however, is more
inclusive, since the insurance provides also for annuities on account of
old age.
4. Fursorge: This term has no exact equivalent in English, and the word
“ care ” very inadequately gives expression to the German meaning of the
word. In brief, the term comprehends the whole German paternal solici
tude of the State toward wage earners and others in all matters summed
up in the approximate English equivalent of “ welfare work.”
5. Dauererfolg: This term has been interpreted as “ permanent economic re
sults of treatment and care,” but in actual practice the observed results
are generally limited to five or six years. By results is meant the re
tained earning capacity of the patient after his or her discharge from the
sanatorium.
6. Walderholungstatte: This term has been interpreted as “ forest day and
night camps,” and on some occasions as “ forest convalescent homes.”
7. Invalidenpensionen: This term has been interpreted as “ homes for incura
bles.” The use of the term varies with different institutions, but in the
present sense applies to homes provided for tuberculous wage earners in
a stage of the disease too far advanced to warrant the anticipation of a suc
cessful recovery of health, strength, and wage-earning capacity. Insured
members provided with accommodation in homes of this kind pay for
their support by means of their invalidity or disability annuities.
8. Erwerbsfahigkeit: This term has been translated as “ wage-earning capac
ity,” which, in the strict sense of the German invalidity insurance law,
means the ability to earn at least one-third of the normal daily wages
of the employment usually followed.
9. Erwerbsunfahigkeit: This term has been translated as “ incapacity for
work,” which, in the strict sense of the invalidity insurance law, means
inability to earn one-third of the usual wages in the occupation followed.
10. Volksheilstatten: This term has been translated as “ public sanatoria,” irre
spective of whether owned and maintained by invalidity insurance insti
tutions or by States, provinces, municipalities, etc., provided the accom
modation is primarily for wage earners, whether free or on payment of
rates within the paying ability of wage earners and their dependents.
11. Privatheilanstalten: This term has been interpreted in the usual sense of
private sanatoria maintained for the accommodation of pay patients, but
in many of these wage earners are provided with accommodations at re
duced rates.
170
B U LLETIN OF TH E BUBEAU OF LABOB.
12. Kinderheilstatten: This term has been interpreted as “ sanatoria for chil
dren,” which is about the equivalent of the term “ preventorium,” since
the object is not only to treat tuberculous children, but also to treat
children of tuberculous wage earners who are scrofulous, anemic, or
otherwise impaired in health.
13. Schulsanatorien: This term is practically the equivalent of No. 12 (Kinder
heilstatten), except that the accommodation is limited to tuberculous
school children.
14. Waldschulen: This term has been interpreted as “ open-air” or “ forest”
schools. In the strict interpretation of the term the schools are open-air
schools, located in forests, and the provision is for tuberculous children
of school age, the treatment being combined with teaching methods
adapted to the situation.
15. Landliche Kolonien: This term has been interpreted as “ agricultural col
onies” which provide treatment and care for convalescing tuberculous
wage earners, together with possibilities for light outdoor work under
medical supervision.
16. Invalidenheime: This term is the equivalent of No. 7 (Invalidenpensionen).
17. Genesungsheime: This term has been interpreted as “ convalescing homes,”
but the meaning is somewhat indefinite and the accommodation may be
for tuberculous as well as nontuberculous wage earners, chiefly, however,
for convalescing patients who have received previous and systematic
treatment in sanatoria, hospitals, etc.
18. Beobachtungsstationen: This term has been translated as “ observation sta
tions ” established for the purpose of ascertaining the patients’ condition
and to safeguard against the admission of the nontuberculous to institu
tions provided for the treatment and care of tuberculous wage earners.
19. Folikliniken: This term has been translated “ tuberculosis clinics,” usually
conducted in connection with hospitals and medical schools.
20. Auskunfts- und Fursorgestellen: This term has been translated as “ infor
mation bureaus and tuberculosis dispensaries,” in clear distinction to
polyclinics and tuberculosis clinics, which provide medical treatment and
medicines, which is not the case in German tuberculosis dispensaries on
the so-called Putter plan.
21. Tuberkulose-Vereine: This term has been translated in the usual sense of
tuberculosis associations, chiefly such as are maintained by private sub
scriptions, but also such as are under official patronage and subsidized by
State and municipal contributions, or the financial aid rendered by inva
lidity insurance institutions, sick funds, etc.
22. Deutsches Zentral-Komite zur Errichtung von Heilstatten Lungenkranker:
This term has been translated, briefly, as “ The German Central Commit
tee,” which formerly had the subtitle “for the establishment of sanatoria
for tuberculous wage earners,” but which now bears the subtitle “ for
the warfare against tuberculosis.” This committee sustains the efforts
throughout Germany to increase the number of public sanatoria and to
further financially the establishment of tuberculosis dispensaries, etc.
23. Invaliden-Versicherungs-Gesetz (Juli 13, 1899) : This term has been trans
lated as the “invalidity insurance law.” The text of the law used is
the English translation published by the foreign office under date of
December, 1899, No. 518 of the miscellaneous section of diplomatic and
consular reports and reprinted in Bulletin of the Bureau of Labor, No. 91.
CARE OF TUBERCULOUS WAGE EARNERS IN GERMANY.
APPENDIX IV.— LEGAL PROVISIONS REGARDING TREATMENT
ACTUAL OR PROSPECTIVE INVALIDS.
171
OF
The special treatment o f actual or prospective invalids was pro
vided for in section 18 o f the German Invalidity and Old Age In
surance Law o f 1899,1 as follow s:
S ection 18. If an insured person is so ill that incapacity to earn a livelihood
is to be apprehended as a consequence of the illness, which would constitute a
claim to a pension, in accordance with the laws of the Empire, the insurance
institution is entitled to cause him to undergo a cure to the extent it may
think desirable in order to avert this loss.
The insurance institution can effect the cure by placing the sick person in a
hospital or in an establishment for convalescents. If the sick person is mar
ried, if he has a household of his own, or if he is a member of the household
of his people, his consent to this step is required.
If the insurance institution orders a cure to be entered upon, the obligations
of the sick fund toward the insured person pass to the institution from the
commencement of this curative course to its conclusion, in the case of such in
sured persons as come under the provision against illness, under the laws
either of the Empire or State.
The sick fund has to indemnify the insurance office to the amount of the
payment which the insured person could claim from it.
During the cure, relief has to be paid to such persons as are dependent upon
the insured person, and for whose maintenance the insured person has hitherto
provided out of his earnings, as also when the insured person does not come
under the provisions for sickness under the laws of the Empire or State. Re
lief of this nature, in so far as the insured person had to be tended under the
provisions for sickness of the laws of the Empire or State, amounts to the half
of the money he ought to receive during the legal time of the sick relief, and
otherwise to a fourth of the standard daily wages of ordinary day laborers in
the locality of his last employment or of his last abode. If the insured person
is in receipt of an infirmity pension, the same can be also reckoned for the
relief of persons dependent upon him.
The cooperation o f the invalidity insurance institution and the
sickness insurance association in connection with the special treat
ment o f invalids was provided for in section 19 o f the law, as follow s:
S ection 19. The insurance institution which causes a cure to be entered upon
is authorized to transfer the provision for the sick person to the sick fund to
which he belongs or last belonged, to the extent which the insurance institution
considers fitting. If a burden is thereby imposed on the funds which exceeds the
extent of the provision to be made by it according to law or statute, the insurance
institution has to make good the surplus costs arising. If the obligation of
provision on the part of the sick fund no longer existed, the insurance insti
tution, by awarding the services specified in section 6, paragraph 1, of the sick
ness insurance law, has to indemnify it with half of the money paid to the
sick person; and if the insured person is placed in a hospital or in an estab
lishment for convalescents, one and a half times the amount of that money, in
so far as greater expenses are not proved.
The cooperation o f industrial accident associations was provided
for in section 21 o f the law, as follow s:
S ection 21. If the illness, on account of which the cure is entered upon, is due to
an accident which entitles to compensation under the imperial laws on accident
insurance, and if the entering upon a state of incapacity to earn a livelihood is
prevented by the curative course, and, at the same time, a burden to the person
upon whom the cost of indemnification in cases of accident insurance has taken
place from the fact of the accident compensation having been withheld alto
gether or granted in part only, then the insurance institution has a claim
1 For text of this law see Bulletin of the Bureau of Labor, No. 91, p. 966 et seq.
.172
B U LLETIN OF TH E BUREAU OF LABOR.
against this person for reimbursement of the costs of the cure to the extent
provided in section 19, sentence 3. A reimbursement of the costs of the cure,
which arose before the beginning of the fourteenth week after the accident oc
curred, can not be claimed.
It was further provided by the law o f 1899, under section 22, that:
S ection 22. If the insured in consequence of the illness becomes incapable of
earning a livelihood, he can, in cases where he has declined without good
cause to follow the measures adopted by the insurance institution in accordance
with sections 18 and 19, be deprived for a time of the infirmity pension either
wholly or partially, in so far as these consequences were pointed out to him,
and if it is proved that his incapacity to earn a livelihood is the result of his
own conduct.
Under section 45 o f the law o f 1899 authority was granted to the in
validity insurance institutions to advance loans for the establishment
o f sanatoria or to erect such sanatoria on their own account. The
section follow s :
S ection 45. By unanimous decision of the directors and of the committee it
can be decided that the surpluses of the special capital of an insurance institu
tion over the permanent requirements for covering their obligations can be
applied to other services than those provided for in the law in the economic
interest of the pension recipients of insured persons, and of their dependents
provided for by the insurance institution.
Such decisions require the sanction of the Federal Council. The sanction can
be withdrawn if the special capital of the insurance institution no longer suf
fices to permanently cover their obligations.
In addition to the above provisions the follow ing articles o f the
W orkm en’s Insurance Code o f July 19, 1911, provide fo r medical
treatment for the prevention o f in validity:1
V. MEDICAL TREATMENT.
A rticle
1269.
In order to prevent impending invalidity of an insured person or of a widow
resulting from sickness, the insurance institute may inaugurate a course of
medical treatment.
A rticle 1270.
P a r a g r a ph 1. The insurance institute may in particular place the insured
person in a hospital or in an institution for convalescents.
Par. 2. If the sick person is married and lives together with his family or
has a household of his own, or is a member of the household of his family,
then his consent thereto shall be required.
Par. 3. In the case of a minor person, his consent shall be sufficient.
A rticle
1271.
The relatives of the sick person whose support he has either wholly or prin
cipally defrayed out of his earnings shall, during the course of treatment (art.
1270) receive house money even in cases where he has no claim against the
sick fund, the miners’ sick fund, or the substitute fund. It shall amount to
one-fourth of the local wage for an adult day laborer. If, however, up to the
1 For text of this law see Bulletin of the Bureau of Labor, No. 96, p. 514 et seq.
CARE OP TUBERCULOUS WAGE EARNERS IN GERM ANY.
173
assumption of the matter by the insurance institute, the sick person was subject
to the sickness insurance, the house money shall be based on the provisions of
the sickness insurance for that time also for which the obligation of the sick
fund no longer exists. An invalidity pension or widow’s pension may be either
wholly or partly refused for the duration of the course of treatment. The
house money shall not be paid, for the time and to the extent that wages or
salary are paid, on the basis of a legal claim.
A rticle
1272.
If the sick person without legal or other reasonable ground declines to receive
the medical treatment (art. 1269) and if the invalidity could probably have
been prevented through the medical treatment, then the pension may, for the
time being, be refused either wholly or partly if the sick person has been noti
fied of this consequence.
A rticle 1273.
In regard to controversies which have not been settled on the determination
of the pension, the superior insurance office shall decide finally upon the appeal.
A rticle
1274.
With the approval of the supervisory authority, the insurance institute may
expend its funds to promote or to carry out general measures for the preven
tion of premature invalidity among insured persons or improve the health con
ditions of the population subject to the insurance. Approval may also be
granted for the expenditure of lump sums.
APPENDIX V.—BIBLIOGRAPHY.
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174
B U LLETIN OF TH E BUREAU OF LABOR,
Bielefeldt, Alwin—Continued.
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Frankel, Carl: Die Lungentuberkulose, ihre Entstehung, Verhiitung und
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CAEE OP TT7BEBCULOTJS WAGE EABNEBS IN GEBMANY.
175
German Workingmen’s Insurance. A Conspectus of its Work issued on the
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Statistik der Ursachen der Erwerbsunfahigkeit (Invaliditat) nach dem
Invaliditats- und Altersversicherungsgesetz. (Amtliche Nachrichten Beiheft. Berlin, 1898.) 1 p. 1., xvi, 227 p.
Germany. Laws: Invalidenversicherungsgesetz. Vom 13. Juli, 1899. [Berlin,
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Reichsversicherungsordnung. Vom 19. Juli, 1911. [Berlin, Reichsdruckerei, 1911] pp. 509-860. (Reichsgesetzblatt, 1911, nr. 42.) Translated
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Versicherungsgesetz fiir Angestellte. Vom 20. Dezember, 1911. [Berlin,
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Translated in United States Bureau of Labor Bulletin No. 107.
Germany. Reichs-Versicherungsamt: Statistik der Heilbehandlung bei den
Versicherungsanstalten und zugelassenen Kasseneinrichtungen der Invalidenversicherung ftir die Jahre 1909-1910. (Amtliche Nachrichten,
1905-1911. Beihefte: 1905, No. 1; 1906, No. 2 ; 1907, No. 1 ; 1908, No. 1;
1909, No. 2; 1910, No. 2; 1911, No. 1. Berlin, 190&-11.) 7 v.
Statistik der Ursachen der Erwerbsunfahigkeit (Invaliditat) nach dem
Invaliditats- und Altersversicherungsgesetz fiir die Jahre 1896 bis 1899.
(Amtliche Nachrichten, 1903. 2. Beiheft. Berlin, 1904.) xxiii, [1], 231,
[1] P.
Ubersicht iiber die am 1. Januar 1910 bei den Tragem der Invalidenversicherung gemass, sec. 164, art. 3 des Invalidenversicherungegestzes zum
Zwecke der Arbeiterwohnungsfiirsorge und fiir andere, insbesondere
gemeinniitzige Zwecke verfiigbar gewesenen und von ihnen aufgewendeten Beitrage. (Amtliche Nachrichten. Nr. 3,15. Mhrz, 1911, 27. Jahrg.
pp. 337-339.)
Germany. Statistisches Amt: Bevolkerung des Deutschen Reiches am 1. Dezem
ber, 1910. (Vierteljahrshefte zur Statistik des Deutschen Reiches. 20.
Jahrg., 1911, 1. Heft Berlin, 1911.)
Bewegung der Bevolkerung im Jahre 1909. (Statistik des Deutschen
Reichs, Band 236. Berlin, 1911.)
Statistisches Jahrbuch fiir das Deutsche Reich. 32. Jahrg., 1911. Berlin,
1911.
Germany. Statistisches Amt: Abteilung fiir Arbeiterstatistik: Die Arbeiterversicherung in Europa nach dem gegenwartigen Stande der Gesetzgebung in den verschiedenen Staaten. (Sonderbeilage zum ReichsArbeitsblatt, Nr. 7, Juli, 1910.)
Wohnungsfiirsorge in deutschen Stadten. Bearbeitet im Kaiserlichen
Statistischen Amte. Abteilung fiir Arbeiterstatistik. Berlin, C. Heymanns Verlag, 1910.
Gemeinniitzige Vermogensanlage der Trhger der Invalidenversicherung.
(Reichsarbeitsblatt, 9. Jahrg., April, 1911, Nr. 4, pp. 299-300.)
Die Heilbehandlung in der Invalidenversicherung. (Reichs-Arbeitsblatt,
March, 1911, pp. 203-210.)
176
B U LLETIN OF TH E BUREAU OF LABOR.
Gocke, Theodore: Die Lungenheilstatte der Landes-Versicherungsanstalt
Brandenburg in der Cottbuser Stadtforst bei Kolkwitz, in ihrer baulichen
Anlage und Einrichtung, beschrieben von ihrem Architekten Theodore
Gocke.
Gottstein, A : Die friihzeitige Feststellung des Yorhandenseins einer Yeranlagung
zur Tuberkulose, insbesondere zur Lungentuberkulose, von Sanitatsrat
Dr. A. Gottstein. (IV. Internationaler Kongress ftir Versicherungs-Medizin du Berlin 11, bis 15. September, 1906.)
Great Britain Local Government Board: Supplement in Continuation of the
Report of the Medical Officer from 1905-1906, on Sanatoria for Con
sumption and certain other Aspects of the Tuberculosis Question. Lon
don, 1908. xii, 670 p.
Hannoverscher Provinzialverein zu Bekampfung der Tuberkulose. Verwaltungsbericht 1909 des Hannoverschen Provinzialvereins zur Bekampfung
der Tuberkulose. Hannover, 1910.
Hanseatische Yersicherungsanstalt, Liibeck. Ratschlage fiir Lungenkranke,
zusammeugestellt von der Hanseatischen Yersicherungs-Anstalt in Liibeck. Hrsg. von der Yereinigung zur Fiirsorge fiir kranke Arbeiter zu
Leipzig, 1905.
Die Heilstatte Heidehaus bei Hannover, [n. d.]
Heilstatte Albertsberg bei Auerbach i. Y. Verhaltungsmassregeln fiir Lungen
kranke bei der Entlassung aus der Heilstatte Albertsberg bei Auerbach
i. V., 1908.
Heilstatte Holsterhausen, Werden, Essen-Ruhr.
Heilstatte Nordrach-Kolonie. II. Jahresbericht der Heilstatte Nordrach-Kolonie
fiir das Jahr 1910. Landes-Versicherungsanstalt Baden.
Heydweiller-Liidenscheid: Ueber Bekampfung der Tuberkulose durch Wohnungsfursorge, von Landrat Dr. Heydweiller-Liidenscheid. Sonderabdruck aus den Yerhandlungen der Jahresversammlung des Deutschen
Zentral-Komitees, 23. Marz, 1901.
Kehl: Die Forderung des Wohnungsbaues durch die deutsche Arbeiterversicherung, von Geheimen Regierungsrat Kehl. Berlin, 1909.
Koch, Robert: Epidemiology of Tuberculosis, by Robert Koch. (In Smithso
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“ Translated from Zeitschrift fiir Hygiene, Leipzig, 1910. v. 67, pt. 1,
pp. 1-18.”
Koehler, F .: Die Lungenheilstatten im Lichte der historischen Entwicklung der
Tuberkulosebekampfung, von Chefarzt Dr. F. Koehler, Heilstatte Hol
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Krupp’sche Gussstahlfabrik, Essen-Ruhr. Fiihrer durch die Wohlfahrtseinrichtungen der Gussstahlfabrik. [n. d.]
Landes-Yersicherungsanstalt Baden. Jahresbericht der Heilstatten Friedricbi
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Landes-Versicherungsanstalt Berlin. -Die Heilstatten Beelitz und sonstige Einrichtungen der Landes-Versicherungsanstalt Berlin im Kampfe gegen die
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Heilverfahren der Landes-Yersicherungsanstalt Berlin im Jahr. 1909. Ber
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Landes-Versicherungsanstalt Brandenburg. Auszug aus dem Verwaltungsberieht des Yorstandes der Landes-Yersicherunganstalt Brandenburg fiir
das Geschaftsjahr 1910 betreffend die Lungenheilstatte Cottbus bei
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CARE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
177
Landes-Versicherungsanstalt Hannover. Bericht des Vorstandes der LandesVersicherungsanstalt Hannover iiber die Verwaltungdersecbs Genesungsh&user in den Jahren 1904-07, nebst drei Bericbten iiber die Krankenfiirsorge in den Badern Oynhausen, Nenndorf und Rehburg sowie in St.
Andreasberg. Hannover, Buchdruckerei Friedrich Culemann (M. Leonhardt), 1908.
Forderung des Baues von Arbeiterwohnungen bis 1. Jan., 1906. Sonderbericht der Landes-Versicherungsanstalt Hannover. Hannover, 1907.
Landes-Versicherungsanstalt der Hansastadte. Ergebnisse des von der LandesYersicherungsanstalt der Hansastadte eingeleiteten Heilverfahrens bei
Lungenkranken Versicherten bis Ende 1903. Hamburg, Luetcke & Wulff,
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Die Beteiligung der Landes-Yersicherungsanstalt der Hansastadte an der
Bekampfung der Tuberkulose. Liibeck, 1904.
Heilbehandlung von Versicherten und Fiirsorge fiir Invalide bei der LandesYersicherungsanstalt der Hansastadte, 1909. Liibeck, 1910.
Landes - Versicherungsanstalt Sachsen - Anhalt: Lungen - Heilstatte Schielo.
Landes-Versicherungsanstalt Sachsen-Anhalt.
Landes-Versicherungsanstalt Schlesien. Arzt und Invalidenversicherung, bearbeitet im Auftrage des Vorstandes der Landes-Versicherungsanstalt Schle
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Landes-Versicherungsanstalt zu Weimar.
Das Invalidenheim der Thiiringischen Landes-Versicherungs-Anstalt zu Weimar. 1911.
Libawski [Richard]: Eine Answeisung fiir Krankenpflegesehwestem, [von Dr.
Med. R. Libawski. Breslau.]
Die Tuberkulose als Volkskrankheit und ihre Bekampfung, von Dr. Richard
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Magdeburger Verein zur Bekampfung der Lungenschwindsucht. Verwaltungsbericht des Magdeburger Vereins zur Bekampfung der Lungenschwind
sucht, fiir die Zeit vom 1. April-31, Marz, 1910.
Mayet: 25 Jahre Todesursachenstatistik; hierzu 4 Tafeln mit Diagrammen.
Referent: Regierungsrat Professor Dr. Mayet. (In Germany. Statistisches Amt. Vierteljahrshefte zur Statistik des Deutschen Reichs. 12.
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Meirerei O. Bolle, Berlin: Bekampfung der Tuberkulose, durch die Einrichtungen der Meierei C. Bolle, Berlin, [n. d.]
Meyer: Finanzielle und rechtliche Trager der Heilstattenunternehmungen, von
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National Association for the Study and Prevention of Tuberculosis, Committee
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Tuberculosis. Transactions of the Second Annual Meeting, Washington,
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Nietner: Die Tuberkulose als Volkskrankheit und ihre Verhiitung, von Prof.
Dr. Nietner, Generalsekretar des Deutschen Zentral-Komitees zur Be
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Nietner, and Lorentz, Fried.: Wesen der Tuberkulose als Volkskrankheit und
ihre Bekampfung durch die Schule, von Prof. Dr. Nietner, Generalsekre*
taer des Deutschen Zentral-Komitees zur Bekaempfung der Tuberkulose
und Fried. Lorentz, Lehrer. Berlin, 1909.
49397°—12-----12
178
B U LLETIN OF TH E BUREAU OF LABOR.
Flitter, Ernst: Die Bekampfung der Tuberkulose innerhalb der Stadt, ein
Beitrag zur Wohnungsfrage, von Ernst Putter. Berlin, Yerlagsbuchhandlung yon Richard Schotz, 1907.
PUtter, and Kayserling, A .: Die Errichtung und Yerwaltung yon Auskunfts- und
FUrsorgestellen fUr Tuberkulose, von PUtter und Dr. A. Kayserling.
Berlin, August Hirschwald, 1905.
PUtter, [Ernst]: German Information Bureaus and Dispensaries (Auskunftsund FUrsorgestellen) for Consumptives in Berlin.
Reiche, F .: Die Erfolge der Heilstattebehandlung Lungenschwindstichtiger, von
Dr. F. Reiche. Leipzig, Georg Thieme, 1899.
Rheinischer Verein ftir Kleinwohnungswesen. Jahresbericht des Rheinischen
Vereins ftir Kleinwohnungswesen ftir 1909 und 1910. DUsseldorf, Druck
von August Bagel, 1911.
Rosatzin, Th.: FUrsorgestelle ftir Lungenleidende in Hamburg. Jahresbericht
ftir 1910, von Dr. Th. Rosatzin, II. Schriftfuehrer.
Rumpf, E .: Beitrag zur Bewertung der Heilstattebehandlung Lungenkranker
von Direktor Dr. E. Rumpf. Separatabdruck aus der Mtinchener medizinischen Wochenschrift. [n. d.]
Sachsischer Volksheilstatteverein, Auerbach. Bericht des Sachsischen Volksheilstattevereins auf das Jahr 1910. Auerbach, 1911.
Schlesischer Provinzialverein ftir Lungenkranke. Was kann der Einzelne tun
im Kampfe gegen die Tuberkulose? [Dieser Vortag ist auf Anregung des
Schlesischen Provinzialvereins ftir Lungenkranke 1908 ftir die Zoeglinge
des Schles. Seminare geschrieben worden.]
Schlesischer Provinzialverein zur Bekaempfung der Tuberkulose. Was sollt Ihr
in der Heilstatte gelernt haben? Schlesischer Provinzialverein zur
Bekaempfung der Tuberkulose. Breslau, 1907.
Schmidt, C .: Die Aufgaben und die Tatigkeit der deutschen Invalidenversicherungsanstalten in der Arbeiterwohnungsfrage, von C. Schmidt,
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Schmidt, L. F. Karl: Die Kleinwohnungsbauten des Yerbandes Sachs. Industrieller, bearbeitet von L. F. Karl Schmidt, Oberbaurat in Dresden.
Schon, Max: Die Invalidenversicherung des Deutschen Reiches im taglichen
Leben, von Max Schon. Grunewald-Berlin, Yerlag der Arbeiter-Yersorgung, A. Troschel, 1906.
Schtirmann, Fr.: Die Bedeutung der deutschen Lungenheilstatten ftir die
Bekampfung der Tuberkulose als Volkskrankheit, von Dr. Schtir
mann, Stadtassistenzarzt in Dtisseldorf. Berlin, August Hirschwald.
Siefart, H .: Der Begriff der Erwerbsunfahigkeit auf dem Gebiete des Versicherungswesena 3d ed., Berlin, 1908.
Statistique D^mographique des Grandes Yilles du Monde pendant les Annies
1880-1909. Johannes Mueller, Amsterdam, 1911.
Thtiringische Landes-Yersicherungs-Anstalt, Weimar. Die Invalidenpflege der
Thtiringischen Landes-Versicherungs-Anstalt zu Weimar.
Tuberkulose-Merkblatt, bearbeitet im Kaiserlichen Gesundheitsamte
Tuberkulose-Merkbuch. Schlesischer Provinzialverein zur Bektimpfung der
Tuberkulose und Breslauer Yerein zur Ftirsorge ftir unbemittelte Lungen
kranke.
Ulrici, H .: Das Krankenmaterial und die Therapeutischen Leistungen der
Lungenheilanstalten, von Dr. H. Ulrici, Chefarzt der Heilstaette Muellrose. Sonderabdruck aus “ Reichs - Medizinal - Anzeiger,” Jahrg. 1910.
[Nr.] 14 & 15.
Vaterlandischer Frauenverein zu Cassel. Der Neubau (FrauenabteUung) der
Heilstatte zu Oberkaufungen, bearbeitet vom Vorstand der Sektion YII
(Heilstatte zu Oberkaufungen) des Yaterlandischen Frauenvereins zu
Cassel. Cassel, 1911.
CASE OP TUBERCULOUS WAGE EARNERS IN GERMANY.
179
Verband der Vaterlandischen Frauen-Yereine der Provinz Schlesien. Bericht
liber die siebenzebnte General-Yersammlung des Yerbandes der Vater
landischen Frauen-Yereine, der Provinz Schlesien am 3. September, 1907.
Breslau, 1907.
Yerband Rheinischer Baugenossenschaften. Die Frage der Geldbeschaffung
fiir den Kleinwohungsbau. Bericht liber die VIII. Generalversammlung
des Yerbandes Rheinischer Baugenossenschaften am 5. November 1910.
Diisseldorf, 1910.
Yerein fiir Kinderheilstatten an den deutschen Seekiisten. XXI. Jahresbericht
des Vereins fiir Kinderheilstatten an den deutschen Seekiisten. Berlin,
1911.
Verein fiir Volksheilstatten in Oberbayern. XY. Bericht des Yereins fiir
Volksheilstatten in Oberbayern, 1910. Mtinchen, 1911.
Verein zur Bekampfung der Schwindsucht in Chemnitz und Umgebung: Merkblatt zum Schutz gegen Schwindsucht. Eigentum des Yereins zur Be
kampfung der Schwindsucht in Chemnitz und Umgebung.
Verein zur Bekampfung der Schwindsucht in Chemnitz und Umgebung. Ratschiage fur die Haltung und Reinigung der Wohnungen Tuberkuloser
zur Verhiitung der Ansteckung. Eigentum des Vereins zur Bekampfung
der Schwindsucht in Chemnitz und Umgebung.
Verein zur Bekampfung der Schwindsucht in der Provinz Sachsen und dem
Herzogtum Anhalt. Die Kinderheilstatte Herzogin Marie bei Oranienbaum in Anhalt. Yerein zur Bekampfung der Schwindsucht in der Pro
vinz Sachsen und dem Herzogtum Anhalt.
Die Yereinigung der Flirsorgebestrebungen in einer Gemeinde. Verlag, Norddeutsche Verlagsgesellschaft m. b. H., Berlin.
Vereinigung zur Flirsorge fur Kranke Arbeiter, Leipzig. Belehrung liber die
ersten Anzeichen beginnender Lungenschwindsucht und Mahnung zu
deren Beachtung. Vereinigung zur Flirsorge fur kranke Arbeiter, Leipzig.
Bestimmungen fiir die Erholungsstatten Leipzig-Stotteritz der Yereinigung
zur Flirsorge fur kranke Arbeiter zu Leipzig.
Einiges liber die Walderholungsstatten fur Lungenkranke in Leipzig-Stot
teritz. Yereinigung zur Flirsorge fiir kranke Arbeiter, Leipzig.
Die Staubkrankheiten der Arbeiter und die Mittel zu ihrer Verhiitung.
Vereinigung zur Fursorge fur kranke Arbeiter. Leipzig, 1908.
Vogt, Gustav. Die Vorteile der Invalidenversicherung und ihr Einfluss auf die
deutsche Volkswirtschaft, von Gustav Vogt. Grunewald-Berlin, Verlag
der Arbeiter-Versorgung, A Troschel, 1905.
Weicker-Gobersdorf: Beitraege zur Frage der Volksheilstaetten, von Dr.
Weicker-Gobersdorf. Berlin, Medizinischer Verlag G. m. b. H., 1905.
Westphalia: Die Invaliden- und Altersversicherung in der Provinz Westfalen
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Westfaiischen Provinzial-Landtages herausgegebenen Festschrift: Die
Provinzielle Selbstverwaltung Westfalens.
Wezel: Katalog der Sondergruppe Tuberkulose der Internationalen Hygieneausstellung Dresden 1911, bearbeitet von Stabsarzt Dr. Wezel. Dresden,
Verlag der Internationalen Hygieneausstellung, 1911.
Windscheid, Franz: Innere Erkrankungen mit besonderer Beriieksichtigung der
Unfallnervenkrankenheiten, von Dr. Med. F. Windscheid. Jena, Gustav
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Band. Der Arzt als Begutaehter auf dem Gebiete der Unfall- und Inva
lidenversicherung. Erste Abteilung.)
3k
I N D E X
Page.
Administrative control of tuberculosis____________________________________________ 98-116
Agricultural colony at Stilbeckshorn for tuberculous wage earners.________ 111, 112
Building loans by invalidity insurance institutions__________________________ 114-116
Dispensaries and information bureaus_________________________________________ 99-111
Housing reform---------------------------------------------------------------------------------------------- 112-114
Sanatorium treatment, limitations of__________________________________________ 98,99
Town planning and sanitary progress--------------------------------------------------------------116
Admission to, and discharge from, sanatoria of tuberculous patients according to
Turban stage of disease, statistics of-------------------------------------------------------------------- 84-87
Agricultural colonies and forest homes for tuberculous patients----------------------------37
Agricultural colony at Stilbeckshorn for tuberculous wage earners---------------------- 111, 112
Annuities, disability, granted on account of tuberculosis by invalidity insurance
institutions:
118
Berlin__________________________________________
Hanse Towns________________________________________________________________ 153-155
Rhenish Prussia-----------------------------------------------------------------------------------------------132
Army recruits, rejection of, on account of tuberculosis, report of, to invalidity in
surance institutions required-------------------------------------------------------------------------------66
Augsburg, tuberculosis dispensary in____________________________________________ 109,110
Baaen, Invalidity Insurance Institution of, experience data of__________________ 143-149
Berlin, Invalidity Insurance Institution of, experience data of__________________ 117-125
Berlin invalidity insurance institutions, per cent of disability annuities granted by,
on account of tuberculosis, 1910________________________________________________
118
Berlin, tuberculosis dispensaries in------------------------------------------------------------------------102-104
Bibliography----------------------------------------------------------------------------------------------------------- 173-179
Board of Health, Imperial, at Berlin, memorandum on tuberculosis by__________ 165-169
Building loans made by invalidity insurance institutions to aid in control of
tuberculosis____________________________________________________________________114-116
Children, tuberculous, measures for treatment and care of, advised by German
Central Committee_______________________________________________________________
36
Cost of treatment and care of tuberculous patients:
Distribution of________________________________________________________________ * 39
Per capita_____________________________________________________________ 75, 76, 78-80
To specified territorial and employees* insurance institutions, 1910------------------25
Deaths from tuberculosis:
18
German cities and American cities compared, 1880 to 1909----------------------------Germany_______________________________________________________________________ 11-15
Hamburg-------------150,151
Kingdom of Wurttemberg-------------------------------------------------------------------------------138
United States, registration area, 1900 to 1909-------------------------------------------------- 16,17
Disability annuities granted on account of tuberculosis by invalidity insurance
institutions:
Berlin________________________________________________________________________
118
Hanse Towns________________________________________________________________ 153-155
Rhenish Prussia______________________________________________________________
132
Discharge from, and admission to, sanatoria of tuberculous patients according to
Turban stage of disease, statistics of-------------------------------------------------------------------- 84-87
Dispensaries and information bureaus, control of tuberculosis through___________ 99-111
Dispensaries and informationbureausinstituted by German Central Committee______35, 36
Dust and fumes as predisposingcauses of tuberculosis_______________________________ 41,42
Earning capacity, restoration of, through treatment___ 26-32, 55, 84-89, 96,124,129,159
Economic loss (estimated loss of earning power) from tuberculosis in United
States__________________________________________________________________________ 18,19
Economic value, estimated, of sanatorium treatment in Germany__________________ 20-22
Employment, suitable, of tuberculous patients______________________________________
78
Experience data of representative invalidity insurance institutions in treatment and
care of tuberculous wage earners,1910__________________________________________ 117-161
Baden______________________________________________________________________ 143-149
Berlin___________________________________________
117-125
Hanse Towns________________________________________________________________ 149-161
Rhenish Prussia_____________________________________________________________130-136
Westphalia__________________________________________________________________ 125-130
Wurttemberg_________________________________________________________________ 136-143
Family support, contributions to, during treatment of wage earners in public sana
toria_________________________________________________________________________________ 68,69
Forest homes and agricultural colonies for tuberculous patients___________________
37
Fumes and dust as predisposing cause of tuberculosis-----------------------------------------------41,42
181
182
INDEX.
Page.
German Central Committee for the Prevention of Tuberculosis, organization and
activities of______________________________________________________________________ 34-38
Dispensaries and information bureaus-------------------------------------------------------------- 35, 36
Forest homes and agricultural colonies------------------------------------------------------------37
Homes and institutions for advanced cases------------------------------------------------------37
Sanatoria_____________________________________________________________________ 36, 37
36
Treatment and care of tuberculous children__________________________________
Work of the organization, conclusion as to__________________________________ 37, 38
German Imperial Board of Health at Berlin, memorandum by, on tuberculosis— 165-169
German invalidity insurance institutions, in treatment and care of tuberculous
wage earners, experience data_____________________________________________________58-98
Army recruits, rejection of, on account of tuberculosis, notice of, required-----66
Cost and duration of treatment------------------------------------------------------------- 75, 76, 78-80
Employment, suitable, of tuberculous patients------------------------------------------------78
Expenditures on account of treatment and care--------------------------------------------- 61-65
Family support, provisions for. during treatment of wage earner in sanatorium. 68, 69
Financial aid given in campaign against tuberculosis-------------------------------------67
Loans by, for the erection of public sanatoria_________________________________ 77, 78
Methods of treatment and care------------------------------------------------------------------- •— 69-75
Patients treated, number of, by sex__________________________________________ 60, 61
Proportion of insured population treated in 1909_____________________________
65
Proportion of patients tieatod, by selected States___________________________
65, 66
Sanatoria owned by, financial statistics of________•____________________________76, 77
Sanatorium treatment, general conditions as to value of_____________________ 96-98
Sanatorium treatment, nostdischarge results of______________________________ 87-94
Sanatorium treatment, successful and unsuccessful, financial statistics of-------- 94-96
Treatment, effect of premature discontinuance of_____________________________
81
Treatment, statistics of readmission for_______________________________________ 81-83
Turban-Gerhardt method of classifying tuberculous patients_________________83, 84
Turban stage of disease, statistics of admission and discharge of patients ac
cording to____________________________________________________________________84-87
German terms relating to treatment of tuberculous wage earners, definition of— 169,170
Hamburg, death rate from tuberculosis in_______________________________________150,151
Hamburg, tuberculosis dispensaries in___________________________________________ 105,106
Hanse Towns, invalidity insurance institutions of, experience data of___________ 149-161
Homes and institutions for advanced cases of tuberculosis-------------------------------------37
Hospital and sanatorium treatment, comparative results of______________________ 33, 34
Housing reform, control of tuberculosis through__________________________________ 112—114
Imperial Board of Health at Berlin, memorandum on tuberculosis by-----------------165-169
41
Indoor and outdoor workers, proportion of, among tuberculous patients-------------Information bureaus and dispensaries instituted by German Central Committee------ 35, 36
Institutional and noninstitutional treatment of tuberculous patients, comparative
results of---------------------------------------------------------------------------------------------------------------- 32, 33
Institutions and homes for advanced cases of tuberculosis_________________________
37
Invalidity insurance institutions. (S e e German invalidity insurance institutions.)
Invalidity insurance institutions, treatment and care or tuberculous patients by,
legal sanction for-------------------------------------------------------------------------------------------------- 22, 23
Legal provisions regarding treatment of actual or prospective invalids__________171-173
Leipzig, tuberculous dispensaries in------------------------------------------------ ---------------------106,107
Mortality from tuberculosis:
German cities and American cities compared-------------------------------------------------18
German Empire-------------------------------------------------------------------------------------------------- 11-15
Hamburg____________________________________________________________________150,151
Hospitals and sanatoria compared_____________________________________________33, 34
United States, registration area________________________________________________ 15-17
Munich, tuberculosis dispensary in_______________________________________________ 107-109
Occupational conditions of tuberculous patients------------------------------------------------------- 42, 43
Outdoor and indoor workers, proportion of, among tuberculous patients___________
41
Patients treated for tuberculosis. ( S e e Tuberculosis, statistics of patients treated
for.)
Public institutions for treatment of tuberculous wage earners, experience data of_^8-^58.
Causes, predisposing or complicating, in tuberculosis__________________ 41, 42, 44, 45
Condition of patients, changes in, during treatment----------------------------------------49-52
Condition of patients on admission------------------------------------------------------------------ 47, 48
Cost of treatment, provisions for defraying___________________________________
39
Occupational conditions of patients-----------------------------------------------------------------42
Previous duration of disease------------------------------------------------------ 1---------------------- 45, 46
Previous sanatorium treatment________________________________________________
45
Patients with family history of tuberculosis_____________________ i____________ 43, 44
Patients treated, proportion of indoor and outdoor workers----------------------------41
Patients treated, age, sex, and conjugal condition of----------------------------------------40, 41
Sanatorium experience, 1896 to 1901, summary of------------------------------------------- 56-58
Social condition of patients___________________________________________________
43
Treatment, duration of_________________________________________________________ 52, 53
Treatment, economic results of--------------------------------------------------------------------------- 54, 55
Treatment in incipient stage of disease, importance of---- ----------------------------------55, 56
Treatment, medical results of__________________________________________________ 53, 54
Treatment of tuberculosis in relation to gain in weight of body--------------------- 48, 49
Treatment of tuberculosis in relation to stage of disease______________________ 46, 47
Prussian-Hessian railways peusion fund, average membership of, tuberculous
patients treated, cost, etc----------------------------------------------------------------------------28
Rhenish Prussia, Invalidity Insurance Institution of, experience data of____ 130-136
Sanatoria experience data:
German,invalidity insurance institutions_______________________________________ 58-98
Public institutions for treatment of tuberculous wage earners_________________38-58
INDEX,
183
Page.
Sanatorium treatment of tuberculosis, Germany:
Comparative results of, with treatment at home_______________________________32, 33
Comparative results of, with treatment in hospitals__________________________ 33, 34
Cost of, per person, in 1010___________________________________________________ 24-26
Earning capacity of wage earners, restoration of, resulting from_____________ 26-32
Economic value of---------------------------------------------------------------------------------------------- 20-22
Legal sanction for, to invalidity insurance institutions------------------------------------ 22, 23
Limitations o f ________________________________________________________________ 98, 99
Results of______________________________________________________________________ 87-98
Wage earners treated, 1910, number of----------------------------------------------------------- 23, 24
Sanitary progress and town planning, control of tuberculosis through-------------------116
Silesia, tuberculosis dispensaries in------------------------------------------------------------------------109
Tuberculosis, administrative control of------------------------------------------------------------------ 98-116
Tuberculosis, memorandum on, by German Imperial Board of Health at Berlin__ 165-169
Tuberculosis, special institutions for treatment of, owned by invalidity insurance
institutions, number, financial, and other statistics of------------------------------------------- 71-74
Tuberculosis, statistics of patients treated for, in German institutions:
Age at discharge, number and per cent of patients of each classified___________
123
Cost of treatment per day and per person--------------------------------------------------------- 80, 96
Cost of treatment, Prussian-Hessian railways pension fund------------------------------28
Cost of treatment, total and per capita amount of, by districts_______________
25
Days of treatment in each year, 1897 to 1900, number of____________________
80
Duration of disease previous to admission, patients admitted in each speci
fied year of------------------------------------------------------------- 1-------------------------------------46
Earning capacity restored, patients having_______ 28, 55, 86, 88, 89, 96,124,129,159
Expenditures on account of treatment_________________________________________ 62, 64
Expenditures per day for board and drink of patients, special institutions-----76
Expenditures per day for board of patients, itemized__________________________
119
Mortality of patients in hospitals and in sanatoria compared-------------------------33
Patients discharged as cured, number and per cent of, Dy sex and by age on
admission___________________________________________ :______________________
54
Patients treated, number of, etc_____________________________ 24, 28, 40, 60, 61, 70, 96
Readmissions for treatment after discharge, number of______________________ 82, 83
77
Sanatoria, general, financial, and other statistics of___________________________
Treatment lasting each classified number of weeks, patients discharged after
receiving________________________________________ __________________________ 52,133
Treatment, sanatorium, comparative results of, for two specified periods_____
164
Turban stages of the disease, sanatoria patients in each of the—
admitted, number of______________________________________________________
47
bacilli in sputum, number having________________________________________
51
discharged, with and without earning capacity restored, number of____ 55, 86, 87
Tuberculosis. (S e e a lso Deaths; Mortality.)
Turban-Gerhardt method of classifying tuberculous patients________________________83, 84
United States and Germany, comparative mortality from tuberculosis in___________ 15-18
United States, estimated economic loss in, from tuberculosis______________________ 18,19
Wage earners, tuberculous, treatment and care of, experience data:
German invalidity insurance institutions_______________________________________58-98
Public institutions_____________________________________________________________38-58
Westphalia, Invalidity Insurance Institution of, experience data of_____________ 125-130
Westphalia, tuberculosis dispensaries in__________________________________________ 110-111
Wurttemberg:
Invalidity Insurance Institution of, experience data of_____________________ 136-143
Mortality from tuberculosis, by age, 1908____________________________________
138
Population in each age group, per cent of, insured------------------------------------------138
Tuberculosis of lungs, disability rate from___________________________________
139
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@FedFRASER