18.64
18.38
17.16
17.26
18.50
17.66
16.85
17.07
16.16
16.42
15 68
15 51
15 79
16 66
16 13
16 19
20 47
20 46
22 36
24 23
26,132
25,166
23,829
24,849
26,930
25,723
29,309
29,183
29,321
30,584
17.40
16.41
16.19
15.48
16.42
15.35
14.38
14.06
13.07
12.54
80 03
31 99
32 86
32 68
33 46
34 19
41 20
42 32
45 45
49. . 96
65,504
54,736
52,079
53,910
68,763
56,770
65,341
66,374
67,376
70,040
18.03
1901
17.42
1902
16.20
1903
16.40
1904
17.48
1905
16.53
1906
15.65
1907
15.60
1908
14.65
1909
14.01
Total...
192,239,366
329,866
17.16
183,228,148
271,026
14.79
376,467,514
600,892
16.00
1900 to 1904...
1905 to 1909...
82,354,125
109,885,241
148,085
181,781
17.98
16.54
78,493,777
104,734,371
126,906
144,120
16.17
13.76
160,847,902
214,619,612
274,991
325,901
17.10
15.19
Tuberculosis other than pulmonarf.
1900
15 35
16 48
16 07
16 02
17 33
17 00
21 frz
21 S6
23 00
25, ,73
8,558
8746
3,714
4,075
4 813
4,623
5 427
5,599
5,926
- 6,281
2.26
2.33
2.26
2.42
2.51
2.57
2.54
2.57
2.52
2.45
15 68
15 51
15 79
16 66
16 13
16 19
20 47
20 46
22 36
24 23
3,034
3,287
3,290
3,655
3,845
4,185
4,880
4,786
5,107
6,514
2.02
2.14
2.10
2.28
2.34
2.50
2.39
2.31
2.28
2.26
30 03
81 99
32 86
32 68
33 46
34 19
41 20
42 32
45 45
49 96
6,592
7,032
7,004
7,730
8 158
8,708
10,807
10,386
11,083
11,795
2.14
1901
2.24
1902
2.18
1903...
2.35
1904
2.43
1906
2.54
1906
2.47
1907
2.44
1906
2.40
1909
2.86
Total...
192,239,366
47,161
2.45
183,228,148
41,583
2.27
375,467,514
88,744
2.36
1900 to 1904...
1905 to 1909...
82,854,125
109,885,241
19,405
27,756
2.36
2.53
78,493,777
104,734,371
17,111
24,472
2.18
2.34
160,847,902
214,619,612
86,616
52,228
2.27
2.43
Digitized by VjOOQIC
CABB OF TUBEBCULOUS WAGE EABNEBS IN OEBMANY.
17
MORTALITY FROM TITBERCULOSIS OF THE LUNGS l!k THE REGISTRATION AREA
OF THE UNITED STATES, 1900 TO 1909-Concluded.
AU forms o/tubereuloii*.
Males.
Females.
TotaL
Taanand
periods
Popul&itioii.
Deaths.
Population.
Deaths.
Population.
Deaths.
Nmn-
ber.
Rate
i(SSoo.
Num-
ber.
Rate
loSSo.
Num-
ber.
Rate
i(SSo.
1900
U S5
U 18
M 07
If 02
Yi 33
Vi DO
21 73
21 86
% 09
Z 73
32,930
33,314
31,964
33,136
36,146
85,570
41,459
42,790
43,981
45,737
20.90
20.71
19.42
19.68
2L00
20.23
19.39
19.64
18.68
17.87
15 68
15 51
15 79
16 66
16 13
16 19
20 47
20 46
22 36
24 23
29,166
28,453
27,119
28,504
80,775
29,906
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
30 03
31 89
32 86
32 68
33 46
34 19
41 20
42 32
45 45
4fi 06
62,096
61 767
59,083
61,640
66,921
65,478
75,648
76,759
78,409
81,835
20.18
V»i
19.66
1902
18.38
1903
18.75
1904
19.91
1905
19.06
1906
18.11
U07
18.04
ins
17.05
m
16.37
TotaL..
102, 239, 366
377,027
19.61
183,228,148
312,609
17.06
375,467,514
689,636
18.87
1930 to 1904...
1906 to 1909...
82,354,125
100,886,241
167,490
209,537
20.34
19.07
78,403,777
104,734,371
144,017
168,592
18.35
16.10
160,847,902
214,619,612
311,507
378,129
19.37
17.62
MORTALITY IN AMERICAN CITIES FROM TUBERCULOSIS OP THE LUNGS, 1870 TO 1909.
Year.
Num-
ber
of
cities.
Pomiila-
Deaths.
Rate
per
10,000.
Year.
Nom-
ber
of
cities.
Popola-
Deaths.
Rate
1870
11
11
12
15
13
17
17
19
20
30
46
49
48
50
50
53
54
82
54
57
58
62
62
60
18
U
B2
33
78
06
45
20
67
77
41
01
S2
86
82
62
85
90
15
00
09
33
83
21
10,224
10,257
12,270
13,635
12,304
14,625
15,486
15,973
17,244
18,416
21,047
23,502
23,431
24,026
23,995
23,906
24,522
23,720
24,120
24,061
26,280
26,601
27,050
26,987
33.37
32.54
33.^
32.15
30.55
31.31
32.06
30.40
3L18
30.37
3L31
33.52
32.58
32.01
3L01
29.96
29.55
26.56
27.06
25.40
26.60
24.80
24.55
23.89
1804
61
60
02
61
60
50
58
62
60
61
61
60
62
63
63
63
11
11
11
12
12
13
13
14
14
14
U
Ifi
Ifl
16
17
17
18
2«
3«
42
53
61
72
82
19
86
08
04
38
05
50
40
17
11
64
47
44
65
91
09
66
17
62
51
25
31
82
56
25,303
25,928
25,768
25,253
25,554
27,358
26,080
28,758
27,450
29,220
31,790
30,340
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
im
1805
22.64
1872
189S
2L71
1S73
1807
20.73
1874
1806
20.55
1875
1809
20.71
1876
1900
19.86
1877
1001
20.18
UTS
1902
18.94
1879
1903
19.53
1880
1904
20.74
UBl
1006
19.47
1882
1006
19.00
^m
1007
18.94
1884
1006
18.02
1685
1000
17.20
1886
1870 to 1874
32.32
1887
1875 to 1879
3L02
1888
1880 to 1884
32.07
vm .. ..... ...
1885 to 1889
28.03
1890
1890 to 1894
24.46
UBl
1805 to 1899
2L24
iwo , .
1900 to 1904
19.86
1893
1906 to 1909
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 from tuberculosis
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 8,516,914 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
r*— 12 — 2
Digitized by VjOOQ IC
18
BULLETIN OF THE BUBEAU OF LABOB.
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 Grerman 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 LABOR
GERMAN AND AMERICAN CITIES, BY PERIODS, 1880 TO 1909.
Gbfiuan oiths.
American cities.
Poriods.
populfttloiQ.
Number of
deaths from
tubenm-
lOBiSOf
thelirngs.
Rate
1^
popomion.
Number Of
deaths from
taberoQ-
losis of
theluigs.
Rate
lO^GOO
lUaSco!
1880 to 1884.
18,423,010
21,920,582
30,661,604
34,906,728
40,606,852
46,342,006
68,709
70,838
84,087
79,909
85,195
82,961
34.6
32.3
27.4
22.9
21.0
17.9
86,167,562
42,929,751
53,690,525
61,149,231
72,171,882
82,960,556
116,003
120,329
131,320
129,881
143,307
153,426
82.1
1885 to 1889
28.0
1890 to 1894.
24.5
1895 to 1899
21.2
1900tol904.
19.9
1906 to 1909
18.6
BSTIMATBD ECONOMIC LOSS F ROM 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 86^09 deaths from
tuberculosis, of which 73,214, or 84.8 per cent, were deaths tram
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 coimtry 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 the year, the number of cases of 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 1900* 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,
^No later data are at present avaUatole.
Digitized by VjOOQ IC
CABB OF TUBBBCITLOUS WAGE BABMTBBS IN GBBMANY. 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 (mlj 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
diff^^nt stages of the disease, from the 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
dealh is, perhaps, not an exaggeration. If that ratio is accepted, the
number of cases of tuberculosis of the lungs among the wage earners
of die United States, ages 15 to 64 years, inclusive, during 1912 would
be 752,600. These estimates take no account of the mortality or
morbidity fnMn other forms of tuberculosis, which may safely be
estimated at not much less than 5 per cent additional.^
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,^ 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.
>8ee in this connectton report of the commission to Inyestlgate and report npon a
VFBton of caring for tubercnloos patients by State and local authorities made to the
Uaflsachnsetts Legislature under date of Nov, 1, 1010. (Senate No. 818» Boston, 1910.)
'According to an official statement by the Division of Vital Statistics of the United
States Census Office for 1010 the ayerage age at death was 39.4 years for males and 36
Tttrs for females and 38 years for both sexes combined.
Digitized by VjOOQ IC
20 BULLETIN OF THE BUBEAU OF LABOB.
ESTDfATED ECONOMIC VALUE OF SANATORIUM TREATMENT IN
GERMANY.
An official German estimate of the eccmomic 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.^ In that report it is argued that if of the 90,800
deaths frcMn tuberculosis of the lungs at ages 15 to 60 years occurring
annually in the German Empire only about one-seventh or one-eighth,
that is, approximately 12,000, could have received systematic and
effective treatment in sanatoria established tor 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 maintained this gain for only three years, and assum-
ing finally that the average earnings of wage earners of both sexes
are approximately 500 marks ($119), there would have been a gain
of 3X500X9,000, or 13,500,000 marks ($3,213,000). This gain would
have to be offset by the net expenses of about 400 marks ($95) for
each of the 12,000 patients, without reference to interest on the in-
vestment in institutions, or approximately 5,000,000 marks ($1,190,-
000), or, including interest, estimated at 1,000,000 marks ($238,000)
more, there would remain as the result of sanatorium treatment a
net or economic gain to the Gterman Nation of 7,500,000 marks ($1,785,-
000). This estimate does not take into acfcount 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 sanatorium treatment 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.* The term "restored earning
1 Deutsche Heilstaetten fOr Longenkranke. Geschichtliche und Btatistlsche Mitteilun-
gen. I. Berlchterstatter : Dr. Hamel, Hilfsarbeiter im Kalserliclien Gesundheitsamte.
Hit 12 Tafeln. Berlin, Verlag von Julius Springer, 1904, p. 40.
< Die bisherigen Leistungen der HeUstaetten, von Bielefeldt, May, 1907.
Digitized by VjOOQ IC
CABE OF TUBBBCULOUS WA6B BABNBBS IN GBBMANT. 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
Bormal wages. The term " disability " is one which does not permit
of exact definition, either in Grerman 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 1906 the average amount of a dis-
ability annuity was about 160 marks ($38.08) per annum. This
would in five years amount to 800 marks ($190.40), and to this
period of time most of the investigations of post-discharge results
of sanatorium treatment have been limited.^ In 1905 the aver-
age cost per case of treatment and care on account of tuberculosis of
the longs was 363 marks ($86.39). Assuming that the economic
lesolts of the treatment can be maintained on an average for at least
fire 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 two years 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
thwewas a net saving in disability annuities of 2,900 marks ($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 msurance 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-
tbly under rather than over the actual amount realized. It is stated
* Under the new regulations of the Imperial Insurance Office the period of observation
of poet-discharge results has been extended to six years.
Digitized by VjOOQ IC
22 BULLETIN OP THE BUBEAU OP 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 assimiption of an average daily wage of only 2 marks
(48 cents) (the net gain in wages earned as the residt of prolonged
lifetime plus restored partial or complete earning capacity), the
150,802 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 cooperaticwa
of invalidity insurance institutions in the treatment and care of the
tuberculous wage earners insured with them.
Digitized by VjOOQ IC
GABE OF TUBERCULOUS WAGE EABNEBS IN QEBMAKY. 28
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.^
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, and the 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
fiunily 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 Grerman Empire, and by the supjwrt 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 EARIIBRS 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 Gterman 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
invalidi^ insurance law of 1900 are given in the table which follows :
' Bidefeldt, The battle against cooBumption as a sickness of the people ; address at the
British Congreaa for Tuberculosis, London, 1011.
Digitized by VjOOQIC
24
BULLETIN OP THE BUBEAU OP LABOB.
NUMBER OP PERSONS RECEIVINO TREATMENT ON ACCOUNT OP TUBERCULOSIS
OP THE LUNGS, ACCORDING TO TERRITORIAL INSURANCE INSTITUTION, DURING
1010.
[Prom Statlstik der Heilbehandlung bei den Versichemngsanstaltcn und sugelassenen
Kossenelnrlchtungen der Inyalldenyerslcbenmg, p. 168. Published by Behrend & Co.,
Berlin, 1911.]
Territorial Invalidity Insurance institutions.
Insured popu-
lation.
Pefsons treated.
Number.
Per 1,000.
East Prussia.
West Prussia
Berlin
Brandenburg
Pomeranla
Posen.
Silesia
Saxony-Anhalt
Schleswig-Holstein
Hanover
Westphalia
Hesse Nassau.
Rhine Province.
Upper Bavaria
Lower Bavaria.
Pfel*
Upper Pfalz and Regensburg
Upper Pranoonla
Middle Pranoonla.
Lower Pranoonla and Asohaflenburg. . .
Swabia and Neuberg
Kingdom of Saxony
Wurttemberg..
Baden
Hesse (Grand Duchy)
Mecklenburg
Thuringia
Oldenburg
Brunswick