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 Lubeck 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
^For 721 patients, or 24.3 per cent, the treatment was prematurely discontinued.
(See p. 96 of the Annual Report for 1910.)
Digitized by VjOOQ IC
150
BULLETIN OF THE BUREAU OF LABOB.
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 OP THE LUNGS IN THE CITY OF HAMBUBQ,
GERMANY, IN 1910, BY AGE PERIODS AND SEX.
[From the Amuial Sanitary Report of the Medkal Coondi of the City of Hambiug for 1910, p. 4a|
Death rates per 10,000 living persons.
Age period.
Urban territory.
Rural territory.
City of Hamburg.
Males.
Females.
Males.
Females.
Males.
Females.
UndflT 1 yflar .....*» . ^
12.9
2.8
13.0
22.3
22.3
19.2
7.1
4.0
14.9
12.9
20.1
0.8
10.0
8.2
9.9
18.8
24.4
10.5
4.1
11.1
11.8
4.9
16.6
12.6
2.4
12.7
2L6
22.5
19.2
7.4
ItoUyeius.
4.0
15 to 2^ years. V.'.
14.0
80 to 59 years
12.8
60 to 09 years
18.8
70 years and over.
10.8
Total
18.9
11.2
9.5
8.8
13.5
11.0
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 anoUier in 1910. Of the 1,151 deaths
from tuberculosis of the lungs in the city of Hamburg 151 were
Digitized by VjOOQ IC
GABE OF TUBEBCULOUS WAGE EABNEBS IN OEBMANY. 151
perscxis who were common laborers. The evidence is quite conclu-
siTe 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 BATES FBOM TUBEBCULOSIS OP THE LX7NGS IN THE CTTY OP HAICBTTBO,
AOCOBDINO TO TAXABLE INCOICES, FOB THE YEAB MIO.
Taxable Inoome.
Population.
D«athfl from taberoo-
losls.
Number.
Bateper
10,000.
imtot28S
47,371
91,440
82,506
11,044
6,382
1,806
i;336
241
880
74
28
12
4
1
60.0
CSS to 1176
42.6
smtosss
22 7
ISBto$L190
20.8
^no to i2jl80.
12.6
t2i3Wto$5',960.
7.4
»,950 to tlL900.
6 6
Orcrfll^
TtttaL
200,560
744
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 8,330, 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 Inmirance 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
frwn 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.
Digitized by VjOOQ IC
152 BULLETIN OF THE BUBEAXJ OF LABOB.
The Invalidity Insurance Institution 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 Gross-
Hansdorf, in Holstein, with an accommodation of 37 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
paragraph 15 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 on account 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
amoimt provided for the city of Hamburg being 9,000 marks ($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.
Digitized by VjOOQ IC
CABB OF TUBEBCXJLOUS WAGE BARNBBS IN GBBMANY. 153
In appreciation of the intimate relation between housing conditions
and the local incidence of tuberculosis, the Invalidity Insurance In-
stitution of the Hanse Towns, 'with the approval of the imperial in-
surance oflSce, provided 1,000,000 marks ($238,000) for building pur-
poses for the year 1911.^
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 INVAT,TDITY INSURANCE INSTITUTION
OF THE HANBE TOWNS, 1892 TO 1910.
Y«r.
Number.
Y«r.
Number.
Year.
Number.
Yew.
Number.
1882
104
220
418
023
637
1897
904
1,209
1,406
1,587
1,882
1902
2,222
2,283
2,226
1,813
1,476
1907
1,656
tm
isss
1908
1906 . .
1,763
1891
1890
1904
1909
1,874
UBS
1900
1906
1910
1 785
UB8
1901
1906
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 nimiber of applications made has varied consider-
ably, having been highest during the year 1892, when 32 per cent were
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.^
Of 16,301 disability annuities granted to males by the Invalidity
Insurance Institution of the Hanse Towns up to December 31, 1910,
3/K)2, 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.*
> Annual Report for 1910, p. 29.
'Idem, p. 39.
'Idem, pp. 50, 51.
Digitized by VjOOQIC
154
BULLETIN OP 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.
Age period.
Annuities granted to—
Males.
Total
aU
On account of tu-
berculosis of lungs.
Number. Percent
Females.
Total
all causes.
On account of tu-
berculosis of lungs.
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 60 years
70 years and over.
Total
427
920
978
1,009
1,156
1,220
1,547
2,028
2,800
2,096
1,520
265
481
460
391
383
340
283
212
136
39
12
62.1
52.3
47.0
38.8
33.1
27.9
18.3
10.5
4.9
L4
.8
307
432
287
268
324
4Sn
058
1,485
2,233
1,752
1,113
168
161
79
73
57
59
55
75
38
19
4
16,301
3,002
18.4
0,656
788
64.7
87.3
27.6
37.2
17.6
11.9
6.7
6.1
1.7
1.1
.4
8.2
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.^
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.
^Annual Report for 1910, p. 57.
Digitized by VjOOQ IC
GARB OF TU^mCXTLOUS WAGE EABNEBS IN GEBliANT.
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.
Yfmr.
Number of disability annui-
ties granted on aoooont of
all causes.
Number of disability annui-
ties granted on account of
tuberculosis of the lungs-
Per cent of diaabUity annui-
ties granted on account of
tuberculosis of the lungs.
ICalcs.
Fentales*
Total.
Males.
Females.
Total.
Males.
Females.
Total.
1992
74
178
320
475
470
636
794
8&4
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
646
672
675
703
104
220
418
623
637
904
1,209
1,408
1,587
1,852
2,222
2,283
2,226
1,813
1,475
1,555
1,763
1,874
1,785
5
25
80
127
120
138
151
149
174
227
282
243
237
178
194
154
168
182
158
5
27
90
144
132
157
185
176
216
278
842
300
811
240
262
212
226
263
214
6.67
14.04
25.00
26.74
25.53
21.73
19.02
17.45
19.02
20.00
20.50
16.93
17.54
16.06
20.91
16.92
15.40
15.18
14.60
4.81
vm
WM
]m
UB6
van
ms
18»
BOO
BOl
19Q3
van
WH
M05
B06
MOT
M08
M»
IflO
2
10
17
12
19
34
27
42
51
60
57
74
62
68
68
58
81
56
4.76
10.20
1L48
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
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
14.08
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 minimum 4.76 per cent in 1893. For both sexes
ccnnbined, 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 accoimt 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 imderstanding of the methods and results
of Grennan 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
<m 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
Digitized by VjOOQIC
156 BULLETIN OF THE BUBEAU OF LABOB.
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 annimi, 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 beda
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) m 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 tiie 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 cf violations of rules, the proportion having been 5 per
cent in 1910 and as high as 10 per cent in 1906.
Digitized by VjOOQ IC
CABE OF TUBEBCULOUS WAGB EABNBBS IN GEBMANY. 157
The economic results have been very satisfactory, the proportion
snccessfully 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. T^eav-
ing out the year 1897 oa account of small numbers, the results, as
measured by the proporticMi 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 div(M:ced.
The so-called " Brehmer'sche '* taint was ascertained for 210 of
the 857 tuberculous patients, or 24.5 per cent of the total. But, also, in
the case of the non tuberculous 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 C6 per cent the result was certainly in the nega-
tive and in 10 per cent imdecided. 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
Hp 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.
Digitized by VjOOQ IC
158 BULLETIN OF THE BUREAU OF LABOB.
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.