and to 16.3 in 1909. The data for 1910 are not available.
TITBEBCTrLOSIS DISPEH8A&T IN miHICH.
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 caUs 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, 862 were probably tuberculous, while only 97 were
Digitized by VjOOQIC
108 BULLETIN OP THE BUBEAU OF LABOB.
entirely free from the disease or indications thereof. Most of the
persons were of the age period 21 to 60 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, sputum cups, 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 marics
($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 for^ chiefly 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
Digitized by VjOOQIC
CABB OP TUBBBCULOUS WAGE EABNBBS IN GBBMANY. 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 c^tLmeters (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 hi^, 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
Las beMi practically stationary for the three years 1907 to 1909, but
there has be^i a decline in the occurrence of the disease when com-
parison is made with earlier years.
TTTBEKCTTLOSIS DISPEHSABIES IK SILESIA.
The results of dispensary treatment have been fully as encourag-
ing in small ccxnmunities, and even in rural districts, in which, in
KHne sections of Grermany, 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
pubhc 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.
TUBEBCDXCSIS DISPEH8A&T IN AHQSBIJBQ.
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-
tiMium 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-
ventiim, treatment, and cure of tuberculosis, and included in this
Digitized by VjOOQ IC
110 BULLETIN OP THE BI7BEAU OF LABOB.
propaganda are the members of the patients' families. The effort ia
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 been inspected 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 60.5 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.
TUBEBCXTLOSIS DISPEKSABIES 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-
Digitized by VjOOQ IC
CABB OF TUBBECULOUS WAGB BABNBBS IN GBBMANT. Ill
ti(m 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-
b» 585 were provided with nourishing food, 123 with beds, 736 with
medicinal baths, 49 with financial assistance on account of rent, and
198 with sputum cups and disinfecting material, etc. In 531 cases
the premises were disinfected, including 284 oa account of deaths
from tuberculosis.
AeRICTTLTrnBLAL COLOHT FOB TTTBEBCTrLOire WAQB XABHBB8.
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 Stiibeckshom, in the Liineburg
Heath, within a reasonable distance of the city of Hanover and about
8 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 fimdamental. 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 colony is usually limited 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
inflanunation of the lungs and who to that extent would be predis-
Digitized by VjOOQ IC
112 BULLETIN OF THE BUBEAU OF LABOB.
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 c^its),
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 reported upon in 1905, 78 per cent
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).*
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 who can 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 conmion welfare of German
wage earners, primarily for the purpose of conserving the health and
well-being of men and women employed in industry.
COITTBOL 07 TITBEBCTrLOSIS THBOHQH HOUSINQ KE70BX.
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.* Earlier observers had
emphasized the intimate relation between density of population,
1 Daring 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-
Tlous to their admission.
*Dr. HeydweiUer, Ueber B^dUnpfung der Tuberkulose durch Wofanungsfttrsorge. B^
lin, 1901.
Digitized by
Google
CABB OP TUBEROTJLOUS WAGE EABNEBS IN GBBMANT. 113
unsatisfactory housing oonditions, and tuberculosis frequency, indi-
cating that the disease is most often caused by domestic infection,
&mily infection, overcrowding, and bad air. It had been shown
that " the death rate from phthisis steadily increases with the pro-
p<nrtion of the total population living more than two in a room in
tenements comprising less than five rooms." ^ The average annual
phthisis rate of London was foimd to range frcwn 11.1 per 10,000 of
peculation 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
m structural arrangement or by bad sanitary conditicms 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,'
emphasized the view that the administrative control of tuberculosis
was largely a housing problem, not only in the congested sections of
large cities, but also throughout the agricultural districts. The
argument was sustained by statistical data, showing the existence of
a Tast 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 sunmiarizing 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 improv^nent in housing conditions and the
education of wage earners in rational methods of living would largely
'The PreTention of Tuberculosis, by Arthur Newsholme, M. D., p. 147. New York,
1908.
"Zor TabCTkulcse-Bekftrnpfung, 1910, pp. 22, by Dr. Paul R5mer.
49307*— 12 8 Digitized by GoOglc
114 BULLETIN OF THE BUBBAU OF LABOB.
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 hygiene. Dr. F. Kohler, of
Holsterhausen, sustained the argument of Building Inspector Gretz-
schel 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 problem of housing reform.
BiriLDIirO LOANS BY IHYALIDITT nrSinBLAHCE INSTITXrnOHS.
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 1905* of what had been done
by invalidity insurance institutions it was shown tiiat 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 instituti(Mi
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
^Dle Vortelle der Inyalidenversicherung and Ihr Binfluss auf die dentsche Volkswlrt-
â– chaft. Bearbeltet von OoBtav Vogt, Berlin-Onmewald, 1905.
Digitized by VjOOQ IC
OABB OP TUBEBOULOTJS WAQE EABNBBS IK GBBMAKY. 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 Grerman 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 sum of 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 sum of 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
mterest 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 Bhine 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) ;
fdlowed by that of Westphalia, with 33,682,841 marks ($8,016,516) ;
fte Kmgdom of Saxcmy, with 25,451,670 marks ($6,057,497) ; the
Grrand Duchy of Baden, with 22,580,197 marks ($5,374,087) ; the
Kingdom of Wurttemberg, with 17,755,224 marks ($4,225,743) ; the
pensicm fund of the Prussian-Hessian railways, with 14,681,276
m^rks ($3,494,144) ; and the Province of Hesse-Nassau, with
Digitized by VjOOQ IC
116 BULLETIN OF THE BUREAU 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