REPORT 
 
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 HD7102.U5P4 1919 
 
 Report of the Health insurance commissio 
 
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 Health Insurance Commission 
 
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 PENNSYLVANIA 
 
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 January 1919 
 
 HAIIRISBXJKG, PBNNA. : 
 J. L. ^. KUHN, PRINTER TO THE COMMONWEALTH 
 ■ 1919. 
 
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THE LIBRARY 
 
 OF THE 
 
 NEW YORK STATE SCHOOL 
 
 OF 
 
 INDUSTRIAL AND LABOR 
 
 RELATIONS 
 
 AT 
 CORNELL UNIVERSITY 
 
REPORT 
 
 OF THE 
 
 Health Insurance Commission 
 
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 01" 
 
 PENNSYLVANIA 
 
 January 1919 
 
 HARRISBURG, PENNA.: 
 J L, L KUHN, PRINTER TO THE COMMONWEALTH 
 1919. 
 
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 REPORT OF THE HEALTH INSURANCE COM- 
 MISSION TO THE GENERAL ASSEMBLY 
 OF THE COMMONWEALTH OF 
 PENNSYLVANIA. 
 
 January, 1919. 
 
 Gentlemen : 
 
 Your Commission was appointed under the Act of July 25, 1917. 
 and directed to investigate : 
 
 1 — "Sickness and accident of employees and their families, not 
 compensated under the provisions of the Workmen's Compensation 
 Act of 1915, the loss caused to individuals and to the public thereby 
 and the causes thereof: 
 
 2 — The adequacy of the present methods of treatment and care of 
 such sickness and injury ; 
 
 3 — The adequacy of the present methods of meeting the losses 
 
 caused by such sickness or injury, either by mutual or stock insur- 
 
 ^ance companies or associations, by fraternal or other mutual benefit 
 
 associations, by employers and employees jointly, by employees alone, 
 
 01 otherwise; 
 
 4 — ^The influence of working conditions on the health of employed 
 persons ; 
 
 5 — Methods for the prevention of such sickness,— ^all with a view 
 to recommending ways and means for the better protection of em- 
 ployees from sickness and accident and their effects, and the improve- 
 ment of the health of employed persons, and their families in the 
 Commonwealth.'" 
 
 We interpret these directions as imposing on us the duty of in- 
 vestigating the extent and nature of sickness among wage workers 
 and its economic and social effects, with a view toward making recom- 
 mendations for the improvement of existing conditions. 
 
 In England and in many other countries of Europe there are now 
 in force systems of health insurance under which wage workers are 
 protected against the sickness risk. T^ie development of such in- 
 
 Otaws of Pennsylvania, 1917, page 1199. 
 
siirance in the various countries has followed the growth of that 
 system of protecting workers against the economic consequences 
 of industrial accidents which this state has embodied in the Work- 
 men's Compensation Act of 1915. We realize that the principal ob- 
 ject of our appointment, as of the appointment of similar Cojnmis- 
 sions in eight other states, was to obtain a report on the advisability 
 of taking in this state this next step in social insurance, the insurance 
 of the employee against sickness; J . 
 
 The Commission was appointed on the seventeenth of October, 
 1917. The fifteen months which have since elapsed have enabled us to 
 gather inuch information relating to the extent and nature of sick- 
 ness among wage workers in Pennsylvania, its economic and social 
 effects and the adequacy of the present methods both of treatment 
 and of meeting the losses caused by such sickness. But the time 
 and money at our disposal have not been sufl&cient to enable us to 
 examine thoroughly, in the light of these facts, the sickness insurance 
 systems in force in other countries or to consider the numerous modi- 
 fications of these systems which have been proposed in this country. 
 We are therefore not in a position to embody in this report definite 
 recommendations concerning the legislative or other action which 
 s))0uld be taken to meet the problems presented by sickness among 
 the wage workers of the state. 
 
 The Commission might have assumed that the situation created 
 by sickness among employed wage workers in a great industrial state 
 like Pennsylvania is a serious one, and might have expended the 
 appropriation of |5,000 in meetings called to hear the advocates and 
 opponents of the various remedies which have been suggested- But 
 all of us were, and are, unanimously opposed to such a procedure. 
 We believe, and we submit, that the interesting and important nature 
 of the facts relating to sickness among the wage workers of the 
 state which we are now prepared to lay before you justifies the 
 belief, that a proposition of such moment and magnitude as that in- 
 volving the general insurance of all wage workers against sickness 
 can be properly passed upon only in the light of adequate knowledge 
 of existing conditions. 
 
 It is generally realized that the Workmen's Compensation Act 
 deals with a large subject of great difficulty and importance. Some 
 idea of the, extent of the problem which we have been directed to in- 
 vestigate may be obtained by contrasting the amount of disability 
 among employees due to industrial accidents with the amount due 
 to. sickness from other causes. 
 
 In 1916 there were 255,616 industrial accidents in Pennsylvania 
 and 3,025,371 working days were lost through such accidents. In 
 the same yea^ approximately 16,800,000 -tvorking days were lost on 
 account of illness not due ,tp industrial accidents. Measured by, loss 
 
of, productive capacity and earning power,, sickness from other causes 
 produces a problem 'between five and seven times as great as that 
 produced by disability resulting from industrial accidents. 
 
 For the reason just stated, almost our first action after our organ- 
 ization' was to determine to expend our appropriation in collating 
 facts already gathered by public and private agencies and as far as 
 possible in instituting and carrying out original investigations into 
 sickness conditions among wage workers in this sta^e. 
 
 The work of the investigating staff of the Commission was begun 
 in May, 1918, and has been carried on under the immediate super- 
 vision of the Committee on Plan of Work and Investigation. 
 
 The results of the investigation are set forth in detail in the Report 
 of this Committee, attached as Appendix A. An examination of this 
 .Report will show that we have not only received the active co-opera- 
 tion of Federal and State departments and ofScials, but that we 
 have also had great material assistance from a number of private or- 
 ganizations now dealing with the social and economic results of 
 poverty and sickness. It is manifest that the sum of $5,000 is wholly 
 inadequate to make extensive original sickness surveys. The report 
 of the Committee, however, contains the results of several studies 
 made at the suggestion and under the general direction of our in- 
 vestigating staff, without expense to the Commission. The cost of 
 making through our own staff such original investigations as these 
 would have amounted to many times the appropriation available. 
 
 It is unnecessary to enter here into any detailed analysis of the 
 Report of the ^Committee. We desire, however, to point out that 
 among other things the facts obtained show that in Pennsylvania: 
 
 I — In regard to the Extent of Sickness among Employees 
 
 I — More than 385,000 persons in the state are constantly 
 suffering from illness; approximately 140,000 from severe, 
 and 245,000 from slighter illnesses. 
 
 2 — The average loss of working time among employees in the 
 state is at least six days each year because of sickness. 
 
 3_Pennsylvania stood highest of any state in the Union in 
 the percentage of men rejected for physical reasons in the 
 draft of April, 1917. Of her young men between twenty-one 
 and thirty-one years of age, 46.67 per cent, were rejected. 
 The average for the country tis a whole was 29.11 per cent, 
 and one state had but 14.13 per cent, of her men rejected. 
 
 4 Death rates in Pennsylvania are higher than those for the 
 
 registration area of the country as a whole. The infant 
 death rate — "that most sensitive index to sanitary condi- 
 tions" is highly excessive in many parts of the state. It 
 
was higher in 1917 in Philadelphia than in New York, 
 Brooklyn, Boston or Chicago. Pittsburgh ranked second 
 among cities of its size, having an infant death rate of 116 
 per 1,000. The state as a whole had an infant death rate 
 in 1916 of 114 per 1,000, while that for the whole registra- 
 tion area was 101. 
 II — In regard to Losses due to Sickness of Employees 
 
 1 — The losses to employees consist of (a) loss of wages (b) 
 cost of care (c) reduced earning power and standards of 
 living. 
 
 Averages do not measure the loss to individuals, be- 
 cause of the uneven distribution of the sickness burden. 
 In one of the sickness surveys in an industrial district 
 in Philadelphia each wage earner sick in 1917 lost 30 
 days ; in another Sickness Survey each sick wage earner 
 lost 67 days; one-third of the total time lost in this 
 group was lost by nine men, and three per cent, of the 
 total illness cost in this study was borne by one-seventh 
 of the entire number of families. In a group of 500 work-- 
 ling women one-fourth of the total cost of medical aid 
 was born by ten of the women. 
 
 a — At the nominal rate of |2.00 a day the wage loss to 
 employees of this state every year because of illness 
 is at least |33,Q00,000. 
 b— The tendency to secure needed medical care has a 
 direct relation to income of the family. As the family 
 • income increases, the amount spent on medical care 
 increases. The average cost of medical care for every 
 employee's family is between |30.00 and |50.00 a year. 
 In the Visiting Nurse Study this average was |47.00. 
 Medical charity given in many instances cannot he 
 considered as in any loay an intimate solution of the ' 
 illness proMem in a country claiming democratic 
 J ideals. 
 
 c — Because most wage earners cannot afford to be ill, 
 many develop,' chronic illnesses and greatly reduce 
 their future earning capacity; this reacts on society > 
 by a direct loss of productive power, and prevents the 
 growth of a vigorous citizenship by making it impos- 
 sible to maintain family standards which permit 
 proper nourishment, care, and opportunity for the 
 children. 
 
 2 — The losses to employers consist of (a) decrease in pro- 
 duction due to the absence of sick wage earners or to the 
 lessened efiQciency of half-sick workers; (b) cost of labor- 
 turn-over. 
 
a — Employees in the state lose at least 16,800,000 day^ 
 work annually because of sickness, and large numbers 
 of actxially sick men and women are at work every 
 day. These facts, while not an exact measure of the 
 loss to industry, give an indication of the extent to 
 which production suffers. During the influenza epi- 
 demic, anthracite coal production dropped behind 
 500,000 tons in a few days. There is constant limita- 
 tion of production because of constant illness, not 
 spectacular, and therefore not seriously considered. 
 
 b — Four large industrial establishments state that it 
 costs on an average from fSO.OO to $50.00 to hire and 
 train a new workman. The greater the labor-turn- 
 over, the greater the cost of production; the greater 
 the amount of sickness, the greater the labor-tum-over. 
 Progressive employers are engaging industrial 
 physicians and nurses, opening dispensaries and es- 
 tablishing sick benefit funds for the practical reason 
 that it pays to see to it that sick workmen receive care. 
 
 3 — The losses to the community consist of (a) money loss 
 (b) social loss. 
 
 a — The state spends over |6,000,000 every year directly 
 for the treatment of sickness. In addition, |4,000,000 
 is spent for the maintenance of institutions for the 
 care, of defectives, a large part of which expenditure 
 is undoubtedly made necessary by the neglect of sick- 
 ness and its consequences. Besides the ten State 
 Hospitals- for Miners 175 other hospitals reported to 
 the State Board of Charities in 1916 that 57 per cent, 
 of their in-patients had been treated free and 40 per 
 cent, of their hospital days had been free days. 
 
 Illness is no less a burden upon private funds. 
 Aside from the multitude of dispensaries, hospitals, 
 convalescent homes, visiting nurse societies and other 
 charitable and semi-charitable agencies especially for 
 the car.e of the sick, organized relief societies invar- 
 iably report illness to be the most frequent disability 
 in the families coming to them for aid. ' 
 
 b — The loss from illness to the community is not only in 
 money and in reduced elflciency of the employees 
 themselves, but involves the citizenship of the future. 
 Growing children, forced to endure a period of under- 
 nourishment because of straightened family resources 
 when the bread-winner is ill — mothers who receive 
 
6 
 
 no parental care, working until the last minute before 
 confinement and as soon thereafter as they can "stand 
 on their feet" — babies who are not given a fair start 
 in life — all these mean not only a present problem, 
 but a serious and unjust handicap for the generations 
 to come. 
 
 There is no more important problem to-day than 
 safeguarding the health of the wage-earning woman; 
 not only for her own sake, but for the sake of her 
 children, whose task it will be to make real the ideals 
 for which our men have been laying down their lives. 
 
 Ill — In regard to Present Methods of Meeting these Losses 
 
 1 — Facilities for medical care among wage earners are not 
 satisfactory, whether considered from the standpoint of 
 extent, cost, or proportion of persons receiving care in time 
 of sickness. 
 
 Hospital accommodations in the state average little more 
 than one-half the standard minimum of five beds per 1,000 
 of the population. 
 . Even if good medical care were available and adequate, 
 
 most employees could not afford to pay for it. Fees are 
 not large, but wages have not kept pace with the soaring 
 cost of living, save in a few groups. Most employees are 
 unable to save toward emergencies. 
 
 The result is that many of them jail to receive medical care 
 of any sort, apd that many more do not receive care until 
 the illness has passed the stage when it could he quickly 
 remedied. 
 
 Approximately a fourth of those actually disabled by illness 
 never receive medical care, and a larger percentage of those 
 ill but still trying to work, are without attention. 
 The startling number of long chronic illnesses found 
 among the 12,090 people in one Philadelphia survey (53.5 
 per cent, lasting more than one year), together with the low 
 proportion of those ill who are receiving treatment, makes 
 obvious the fact that neglected sick men often become 
 chronically disabled, and that half^sick men are struggling 
 to keep at work because they cannot afford to he ill. 
 
 2 — Insurance protection against sickness is found among ap- 
 proximately 30 per cent, of employees, but seemingly least 
 often among those who need it most. Illness is a thing of 
 chance and most employees take the chance of escaping it. 
 When the sickness comes they are stranded, after savings 
 and credit have been exhausted. The lower the wage group, 
 
the less likely the insurance protection. Nor does thi; 
 existing insurance in most instances meet the real need. It 
 seldom provides good medical care and cash ienefits^ and 
 is limited by many restrictive rules. 
 
 One-half to three-fourths of existing sickness insurance is 
 carried through the sick benefit funds of the lodges or 
 fraternals. In most of these, sickness insurance is second- 
 ary to life insurance. As a rule, no medical benefits are 
 given, and the cash benefit is but $5.00 a week for thirteen 
 weeks in any single year, payable only after a man has been 
 ill more than two weeks. Trade union funds rarely afford 
 better protection. Commercial health insurance is costly 
 and subject to many restrictive rules. 
 
 Establishment funds usually afford better protection, but 
 are relatively few in number and exist only among the most 
 progressive employers where health hazards are frequently 
 reduced to the minimum. 
 
 IV — In regard to the Influence of Working Conditions on Health 
 
 1 — Industry is clearly responsible for a large proportion of 
 illness among employees. 
 
 2 — Investigations of the industries of Pennsylvania have shown 
 that "no other state has so wide a variety of those in- 
 dustrial processes which carry with them danger to the 
 workers either because of poison in the form of fumes, 
 liquids, or dusts, or because of mechanically irritating 
 dusts which injure the throat and lungs." 
 
 3 — Seventy-nine per cent, of all the deaths of persons of work- 
 ing age in 1916 were from diseases whose connection with 
 "important Pennsylvania industries has been established." 
 
 4 — Death rates among persons of working age in Pennsylvania 
 from degenerative diseases due in large measure to certain 
 kinds of occupation, are steadily increasing. 
 V — In regard to Sickness Prevention 
 
 1 — Fully one-half of existing sickness could be eliininated if 
 proper preventive measures were taken. 
 
 2 — At present from 70 to 75 per cent, of the school children 
 in Pennsylvania are physically defective and for the most 
 part the defects are correctable if treated in time. 
 
 3 — A large number of communities in the state have no active 
 health work, much less an adequate appropriation for 
 •health activities. 
 
 4 — Nothing so stimulates preventive effort as definite respon- 
 sibility for the losses entailed- Preventive measures proved 
 
inadequate to meet the problem of industrial accident until 
 stimulated by the enactment of Workmen's Compensation 
 , Laws. This form of social insurance has steadily reduced 
 the number of accidents and the appeals to charity from 
 families affected and has proved practical in administration. 
 VI — Our own and other investigations prove that 
 
 1 — The responsibility for illness rests on three groups: the 
 community, industry and the individual. At present these 
 three groups are meeting the losses from illness in wholly 
 unequal shares; the burden on the individual is often 
 disastrous and out of proportion to his individual respon- 
 sibility. 
 Some means of a just distribution of this burden should be 
 found. 
 2 — There is in Pennsylvania today urgent need for a program 
 of health measures which will (a) provide for the efl&cient. 
 care of employees and their families when actually iU, and 
 (b) provide preventive measures which will in so far as it 
 is possible, prevent illness and increase the opportunity 
 for health and vigor in the citizenship , of the State. 
 
 The problem which your honorable bodies asked us to investigate 
 was the problem, not of the man who will not work, or the man who 
 ' cannot get work, but the problem of the employed worker who for a 
 longer or shorter period becomes incapacitated through illness. Other 
 causes of disitress such as intemperance, low wages, unemployment, 
 ignorance or extravagance, serious though they are, do not concern 
 us, save as they are connected with the problem of illness. The 
 nature of that problem and the tragic results which may come when 
 it is not solved, are shown by innumerable life histories set forth 
 in the records of our charitable institutions. 
 
 The story of a family whorn we will call the Callahan family well 
 illustrates a typical course of events: John Callahan was a tailor, 
 who had worked for a prominent Philadelphia firm for several years. 
 He Aj^as the father of four small children. His wages were not large, 
 and as he was trying to add to his small savings, he felt he could not 
 afford to be sick, even when he contracted tuberculosis, due un- 
 doubtedly in part to the industrial conditions in which he worked. 
 He denied that he was sick and dosed himself continuously with a 
 patent medicine, warranted to "cure all ills." Finally, after a bad 
 hemorrhage, he gave up, and when examined he was diagnosed as 
 an advanced case of tuberculosis. Although his fraternal paid him 
 a sick benefit and in addition took up a collection for him, no ade- 
 quate help was available and the medical attention had come too 
 late. The family, up to this time always self-supporting, became 
 
dependent upon a charitable agency. The children were all young 
 and Mrs. Callahan could not leave them to go to work. Two of 
 them were found to be tubercular, and Mrs. Callahan was pronounced 
 a ftuiescent case of tuberculosis. John Callahan was only thirty- 
 eight and the family ha;d no resources for the long future that 
 loomed ahead. He was sent to Mount Alto, where little hope is 
 given for his recovery; during the past three years the family has 
 been cared for entirely by private philanthropy; at an expense of 
 many hundreds of dollars. The oldest child is now only eleven. 
 Meanwhile the state supports Mr. Callahan in a public sanitorium. 
 Has this been cheap for public or private funds, or for society at 
 large? The community has lost a self -supporting, industrious citizen ; 
 industry has lost the productive energy of a good worker; Mr. Cal- 
 lahan has lost his earning power and his home, the children have 
 suffered, the normal family unit ha,s been permanently broken up. 
 
 The Callahans are not unlike hundreds of other families. The ro^d 
 f ro'm independence to dependence is being traveled every day in this 
 state by hundreds of our fellow citizens. It is the State's respon- 
 sibility to see that the problems of sickness are reduced to a minimum. 
 Your Commission believes that the best way to close this sickness 
 high road to poverty and dependency is to make available immeMate 
 and adequate medical care for sickness-cases a/nd to prevent the finan- 
 cial iurden of sickness from jailing entirely on the person least able 
 to bear it — the sick icage worker. In some way this burden should 
 be distributed among all wage workers, or shared by industry and by 
 the community as a whole. How the distribution should be accom- 
 plished, whether by an extension of existing voluntary insurance 
 agencies, or by a system based on some modification of the English 
 or other European plans, we are not prepared to say. In the time 
 and with the money at our disposal we have, as stated, ascertained 
 the main facts pertaining to sickness among wage workers in this 
 state, the present methods of care of such sickness, and its economic 
 consequences. 
 
 In the opinion of your Commission the next step should be to take 
 the facts set forth in Appendix A. of this report, and in the light of 
 these facts and any others that may be obtained, to make a thorough 
 investigation of existing and proposed plans for sickness insurance 
 of employees, with a view to making definite recommendations at the 
 earliest practical moment compatible with the nature of the subject. 
 
 The work of examining proposed systems of sickness insurance, of 
 holding public hearings in various parts of the state, and of obtaining 
 the views of representatives of the interests especially effected, is one 
 which will require a Commission composed of persons able to give a 
 great deal of their time to the work.' Many of the systems advocated 
 directly affect not only the wage workers but also the employers and 
 
10 
 
 the medical profession, all of which groups sliould be represented in 
 the membership of the- Commission. 
 
 We therefore recommend that instead of continuing this Commis- 
 sion, your honorable bodies pass an Act providing for the appoint- 
 ment of a Commission of eleven persons to carry on and complete the 
 task of dealing with one of the most vital of the social and industrial 
 problems of our times; the Commission to consist of three members 
 from the Senate, three from the House of Eepresentatives and five 
 other members to be appointed by the Governor, at large. 
 
 We append hereto, as appendix B, a copy of a bill providing for 
 the appointment of such a Commission as we suggest. 
 
 We respectfully urge the prompt passage of this bill. We have 
 secured an investigating staff which could not be easily replaced, 
 and which we could not hope to retain should there be any consid- 
 erable delay. Moreover, constant and steady work on the part of 
 the Commission, not from a period subsequent to the final adjourn- 
 ment of your honorable bodies, but from the present time, will alone 
 in our opinion insure the completion of the task so that any recom- 
 mendations may be thoroughly digested before the meeting of the 
 legislature of 1921. 
 
 Finally, we hope that the appropriation of |25,000 which we have 
 suggested will meet with your approval. The work of the investigat- 
 ing staff should be continued, to which must be added a study of 
 constitutionality and a thorough actuarial inquiry into the cost of 
 the various insurance systems which it will be the duty of the Com- 
 mission to examine, while the Commission will have to hold a very 
 considerable number of public hearings and executive sessions. In 
 this connection we desire to point out that the Commission charged 
 with the duty of invetigating industrial accidents on whose report 
 the Workmen's Compensation Act was adopted received $19,800 for 
 its expenses. The subject of sickness insurance is, as has been in- 
 dicated, one of greater magnitude and, we believe, of greater diffi- 
 culty. 
 
 E. E. BEIDLEMAN, 
 C. W. SONES, 
 JAMES B. WEAVER. 
 WILLIAM T. RAMSEY, 
 JOHN M. FLYNN, 
 ISADORE STERN, 
 WILLIAM FLINN, 
 WM. DRAPER LEWIS, 
 J. B. McALISTER, 
 
APPENDIX A. 
 
 REPORT 
 
 OF THE 
 
 Committee on Plan o£ Work and Investigation 
 
 TO THE 
 
 HEALTH INSURANCE COMMISSION 
 Commonwealth of Pennsylvania. 
 
(12) 
 
APPENDIX A. 
 
 TABLE OF CONTENTS. 
 
 Page. 
 
 PART I Introductory Summary, 1!J 
 
 Section 1 History of the Commission, 21 
 
 Sectiqn II Ppnnsylvanifi as an Industrial State 23 
 
 Section III Work of tlio Investigating Staff 27 
 
 Section IV Conclusions and Recommendations 31 
 
 PART II The Sickness Problem 41 
 
 Section I The Nature and Extent of the Sickness Problem, 43 
 
 The Kensington Survey, 43 
 
 The Visiting Nurse Society Study, . . . ., 45 
 
 • Working Women's Records 49 
 
 Extent of Sickness as Shown by Sickness Rates, 51 
 
 Extent of Sickness as Shown by Mortality Rates, 62 
 
 Kinds of Sickness, , 67 
 
 Section II Losses Due to Sickness, 87 
 
 Losses to Employees , , 89 
 
 Wages and Standards of Living,, i 89 
 
 Loss of Time on account of Sickness,. 95 
 
 Loss of Money on Account of Sickness, 95 
 
 Cost of Medical Care, 96 
 
 Loss of Future Earning Powe-r on Account of Sickness,. . . . 100 
 
 Losses to Industry, , 100 
 
 Losses to the State, , , 104 
 
 Sickness and Poverty, 108 
 
 Section III The. Adequacy of Present Methods of Care, 139 
 
 Physicians in Pennsylvania, 4 141 
 
 Hospital Facilities in Pennsylvania, 141 
 
 Medical Care Received by Employees and Their Families, 143 
 
 Existing Health Insurance in Pennsylvania 147 
 
 Section IV Influence of Working Conditions on Health 167 
 
 Influence of Working Conditions on Health 169 
 
 Occupational Diseases in Pennsylvania, 186 
 
 Section V Sickness Prevention 197 
 
 PART III Health Insurance, 215 
 
 Section 1 Social Insurance, 217 
 
 Section II Health Insurance in Europe 219 
 
 Section III State Social Insurance Facilities in the United States 243 
 
 (13) 
 
14 
 
 MEMBERS OP THE HEALTH INSURANCE COMMISSION. 
 
 APPOINTED FBOM THE SENATE 
 HON. EDWARD E. BEIDLEMAN 
 HON. CHARLES W. SONBS 
 HON. JAMES B. WEAVER 
 
 APPOINTED FROM THE HOUSE OF REPRESENTATIVES 
 HON. WILLIAM T. RAMSEY 
 HON. JOHN M. PLYNN 
 HON. ISADORE STERN 
 
 APPOINTED BY THE GOVERNOR 
 HON. WILLIAM FLINN 
 DR. WILLIAM DRAPER LEWIS 
 DR. J. B. McALISTER 
 
 EDITH HILLES, Executive Secretary. 
 ELIZABETH McSHANE, Assistant Secretary. 
 
To the Members of the Health Insurance Commission, 
 Commonwealth of Pennsylvania: 
 
 Gentlemen: Your Committee on Plan of Work and In- 
 vestigation present herewith their report. 
 
 January — 1919. 
 
(16) 
 
17 
 
 No. 414. 
 AN ACT 
 
 To establish a commission to investigate sickness and accident, not compensated 
 under the Workmen's Compensation Act of one thousand nine hundred and 
 fifteen, of employed persons and their families, and to make an appropriation 
 for such commission. 
 
 HEALTH INSURANCE COMMISSION. 
 Section 1. Be it enacted, &c., That a commission is hereby created, 
 to be known as the Health Insurance Commission, which shall inves- 
 tigate : , 
 
 SUBJECTS OF INVESTIGATION. 
 
 1. Sickness and accidents of employees and their families, not 
 compensated under the provisions of the Workmen's Compensation 
 Act of one thousand nine hundred and fifteen, the loss caused to in- 
 dividuals and to the public thereby, and the causes thereof ; 
 
 2. The adequacy of the present methods of treatment and care 
 of ^uch sickness and injury ; 
 
 3. The adequacy of the present methods of meeting the losses 
 caused by such sickness or injury, either by mutual or stock insur- 
 ance companies or associations, by fraternal or other mutual benefit 
 associations, by employers and employees jointly, by employees alone, 
 or otherwise ; 
 
 4. The influence of working conditions on the health of employed 
 persons; and, 
 
 5. Methods for the prevention of such sickness,— all with a view 
 to recommending ways and means for -the better protection of em- 
 ployees from sickness and accident and their efi'ects, and the im- 
 provement of the health of employed persons and their families in 
 the Commonwealth. The commission shall hold public hearings in 
 different parts of the Commonwealth. The commission shall submit 
 a full final report, including such recommendations for legislation, 
 by bill or otherwise, as in its judgment may seem proper, to the 
 General Assembly of nineteen hundred and nineteen. 
 
 APPOINTMENT OF THE COMMISSION. 
 
 Section 2. Members. — The commission shall consist of three Sen- 
 ators, to be appointed by the President pro tempore of the Senate, 
 three Representatives, to be appointed by the Speaker of the House 
 of Representatives; and three other persons, not members of the 
 General Assembly, to be appointed by the Governor. 
 
 POWERS. 
 
 Section 3. Powers. — The commission shall have power to elect 
 its chairman and other officers, to examine witnesses, books, and 
 papers resi>6Cting all matters to be investigated, to issue subpoenas, 
 to compel the attendance of witnesses and the production of books 
 
 2 
 
18 
 
 and papers, to administer oaths, to employ a secretary, experts in 
 the matters to be investigated, and all necessary clerical and other 
 assistants, to purchase books and all necessary supplies, and to rent 
 halls for hearings. If the commission shall appoint from its members 
 sub-committees to make an inquiry, the sub-committees shall have 
 the same powers for the examination of persons and papers and to 
 administer oaths as are herein conferred upon the commission. 
 Salaries and other expenses of the commission shall be paid upon 
 vouchers approved by the chairman of the commission, up to the 
 amount appropriated by the General Assembly. 
 
 CO-OPERATION. 
 
 Section 4. Co-operation of other departments. — The Commissioner 
 of Health and the Commissioner of Labor and Industry are hereby 
 directed to co-operate with the commission, and to render it any such 
 proper aid and assistance as in their judgment may not interfere with 
 the proper conduct of their respective departments; and, as far as 
 possible, rooms in buildings owned or leased by the Commonwealth 
 shall be assigned to the commission for hearings or other purposes. 
 
 APPROPRIATION. 
 
 Section 5. Appropriation. — The sum of five thousand dpllars 
 ($5,000), or so much thereof as may be necessary, is hereby specifi- 
 cally appropriated for the actual and necessary expenses of the com- 
 mission in the carrying out the provisions of this act. Payment of 
 the money shall be on order of the chairman of the commission and 
 on warrant of the Auditor General. 
 
 Approved— The 25th day of July, A. D. 1917. 
 
 MARTIN G. BRUMBAUGH. 
 
PART I. 
 INTRODUCTORY SUMMARY. 
 
(20) 
 
PART I. 
 
 SECTION I. 
 
 History of the Commission. 
 
 During the session of 1917, the problems created by illness among 
 the employees of the state were brought to the attention of the 
 Tennsylvania Legislature by the introduction of a bill providing for 
 a state-wide system of compulsory Health Insurance. Many persons 
 and agencies interested in social welfare and progress had been in- 
 strumental in securing the passage of a Workmen's Compensation 
 Law in the state, and had noted with great interest the success with 
 which such laws, transplanted from Europe, had been put into opera- 
 tion in this country. Since Workmen's Compensation is but a part of 
 a comprehensive social insurance system in force in many European 
 countries, by means of which protection is afforded, not only against 
 injury, but also against sickness, old age, and unemployment, the 
 possibilities of successfuly adopting oth^r features of the system 
 suggested itself to the authors of the bill. 
 
 The bill was carefully considered by the committee to which it was 
 referred and a public hearing on it was largely attended. 
 
 The discussion at that time brought out strikingly the need for a 
 thorough study of health conditions among employees and their fam- 
 ilies in the state, and resulted in the introduction of a bill creating 
 an unsalaried Commission to conduct the investigation and present 
 a report to the Legislature of 19l9. This bill was passed as No. 414 
 of the Acts of the Legislature of 1917. 
 
 At the first meeting of the Commission, on December 28, 1917, in 
 Philadelphia, Hon. Edward E. Beidleman was elected Chairman, and 
 Hon. Isadore Stern, Secretary and Treasurer. A Committee on Plan 
 of Work, consisting of Dr. Lewis, Mr. Eamsey and Mr. Stern, was 
 appointed and charged with the duty of formulating a plan for the 
 work of the Commission, taking into consideration the limited appro- 
 priation of |5,000 which had been made for the work. 
 
 This Committee secured the advice of Mr. Miles M. Dawson and 
 Dr. I. M. Rubihow, consulting actuaries, and on May 13, 1918, sub- 
 mitted a report, recommending a careful investigation by trained 
 workers. 
 
 This report was accepted, and Dr. McAlister was made an addi- 
 tional member of the Committee, which was authorized to open an 
 
22 
 
 ofiflce and engage an investigating staflf to carry on the work for 
 three months, until August 15th. At that time a preliminary report 
 was to be submitted. The sum of |2,175 was appropriated for th« 
 expenses of the investigation during this period. The office of the 
 Commission, 802 Franklin Bank Building, was officially opened on 
 May 15th, at which time the work of investigation Was actively begun 
 under the direction of Miss Edith Hilles. 
 
 At a meeting of the Commission held on July 19th, an additional 
 $2,100 was appropriated for continuing the investigation after 
 August 15th, and the Committee on Plan and Work and Investiga- 
 tion was designated as the finance comniittee to act with the 
 treasurer. 
 
 The Preliminary Keport was submitted as planned and has been 
 used as the suggestive basis for the remainder of the investigation. 
 In December it was agreed to devote the remaining funds of the Com- 
 mission to the completion of the report. 
 
 The members of the Committee on Plan of Work and Investigation 
 have conferred from time to time with authorities on the subject 
 of Health Insurance, and have been in constant touch with the worli 
 of the investigation. 
 
23 
 
 PART I. 
 
 SECTION II. 
 
 Pennsylvania as an Industrial State. 
 
 The importance of Pennsylvania as an industrial state serves to 
 emphasize the importance of the health of her wage earners. Health 
 is the greatest asset of the wage earner, and no other single factor has 
 so close a relation to his efficiency. We realize this strikingly at the 
 time of a great epidemiic, when suddenly with no warning industry 
 after industry is crippled, and output seriously lowered, because em- 
 ployees are ill. Yet constantly, year in and year out, preventable 
 illness goes on, lowering efficiency and output, causing great social 
 and economic waste, and we pay little attention, because it is not 
 spectacular. 
 
 According to the census of 1910, Pennsylvania ranked second only 
 to New York in the total number "of persons gainfully employed in 
 her industries, and in the value of her manufactured products. Per- 
 sons gainfully occupied numbered 3,130,681, or more than one tenth 
 of the total number in this group in the United States.^ 
 
 These gainfully occupied persons constituted more than half of the 
 total population in Pennsylvania over ten years of age ; and included^ 
 81 per cent, of the men, and 21 per cent, of the women of the state. 
 
 The proportion of men and women gainfully occupied was approxi- 
 mately one woman to four men. The occupations where women were 
 most numerous were trade with 16.1 per cent., manufacturing and 
 mechanical with 17.3 per cent., clerical with 30 per cent., the profes- 
 sional group with 42.1 per cent., and domestic and personal service 
 where 68 per cent- were women. This was the only group where the 
 number of women exceeded the number of men.^ 
 
 Some 23 per cent, of these gainfully occupied persons were classi- 
 fied, in 1910, as "laborers." The next largest group belonged to the 
 classification, "manufacturing and mechanical," which comprised 19.3 
 per cent. Agriculture, extraction of minerals, trade and domestic 
 service included 11.6 per cent., 10.4 per cent., 9.3 per cent., and 9.6 
 per cent., respectively, and the other 16 per cent, were divided be- 
 tween transportation, public service and professional and clerical 
 work.* 
 
 It is interesting to note the geographical distribution of these 
 groups. 
 
 (')A list of the Pennsylvania Industries employing more than 100,000 persons Is given as Table 
 I at the end ol Part I-, , „ . ^ 
 (2) See Table II at end 0/ Fart I. 
 ;(»)See Table III at end of Part I. 
 
24 
 
 Forty-two per cent, of the gainfully occupied were in the twenty 
 cities in the state having a population of over 25,000. Fifty-eight per 
 cent, were distributed among the smaller cities, towns and the rural 
 districts. Seven hundred and eleven thousand, one hundred and 
 sixty-nine, or 23 per cent., were centered in Philadelphia, and 233,637, 
 or seven per cent., were in Pittsburgh. 
 
 The proportion of "laborers" employed in the Pittsburgh district 
 far exceeded the proportion in the state as a whole. Thirty-nine and 
 four-tenths per cent, of the workers in this district were classified as 
 "laborers," while the percentage for the whole state was 23.1 and for 
 the Philadelphia district, but 13.3. The influence of the steel mills 
 is obvious. 
 
 On the other hand 36.7 per cent, of the workers in Philadelphia 
 were in the "manufacturing and mechanical" group, while in the 
 state as a whole there were but 19.3 per cent., and in Pittsburgh less 
 than 10 per cent, so classified. 
 
 It would be difficult to over-emphasize the industrial importance 
 of Pennsylvania or the diversified character, of her industries. 
 
 In 1914, before war time expansion began, 293,370 persons were 
 employed in the great steel works, rolling mills and other branches 
 of the metal trades in the state, and 124,986 in the textile industry. 
 Of the 1,065,000 workers employed in mjining in the United States in 
 1910, nearly a third, or 357,671, were found in the coal mines of 
 Pennsylvania. It is well known that Pennsylvania leads all the 
 states of the union in mining and that practically the entire anthra- 
 cite coal supply of the country, including certain smokeless varieties 
 required by the navy, is produced within this state. A third of the 
 bituminous coal as well comes fpom Pennsylvania. When the in- 
 fluenza epidemic reduced the coal output suddenly the whole country 
 felt it, and it was to Pennsylvania that the country looked for in- 
 creased production later, to make up this loss. 
 
 Besides producing coal, steel, ships, chemicals products, hosiery, 
 knit and woolen goods, Pennsylvania is doing her full share in feed- 
 ing the nation. Approximately 65 per cent, of her land is devoted 
 to agriculture, and in 1910 she produced farm crops valued at 
 $147,000,000 and gave employment to 362,000 agricultural workers, 
 or 11.6 per cent, of the total number of persons ten years and over 
 gainfully occupied in the state. 
 
 During the Great War tremendous demands were made upon 
 Pennsylvania ; it became a center for war contracts and for "essential 
 industries." A quarter of all the war contracts let during the first 
 months of our participation were located in Pennsylvania and Ohio. 
 Pittsburgh, long recognized as the greatest center for the iron and 
 steel industry, became the site of heavy artillery plants. In the east, 
 along the Delaware River, approximately 100,000 men were employed 
 in ship building.^ It has been suggested that the Delaware be called 
 
 (MAnthorlzed statement of Henry R. Seager of the Shipbuilding Labor Adjustment Board, May 
 
25 
 
 '•The Clyde of America" but the reply was made that the Clyde was 
 instead "The Delaware of England," for the the magnitude of Ameri- 
 can construction far exceeds the British output. 
 
 If merely the rate of increase of the decade 1900 to 1910 had been 
 maintained between 1910 and 1918, by the latter year the number of 
 gainfully occupied persons would have risen to 3,827,257. In reality, 
 owing to the wartime expansion of Pennsylvania industries, a con- 
 siderably higher number of persons are probably at work in the state 
 at the present time- It is usually estimated that not more than 25 
 per cent, of the workers are proprietors of their own farms or busi- 
 nesses, so that it may safely be said that there are now more than 
 2,800,000 employees in the state. 
 
 To investigate the heal,th problems of these 2,800,000 employees has 
 been the task of the Commission. In an industrial state the cost of 
 sickness to industry alone is tremendous. Output depends very 
 largely on the individual worker, and the efficiency of the wage earner 
 depends in large measure uj>on his health, and the health of his 
 family. The United States Public Health Service estimates that 
 each wage earner in the United States loses on an average nine days 
 work each year because of sickness. Physicians and sanitary experts 
 tell us that at least half of this loss is due to illness which could be 
 prevented. The facts which we have collected lead us to believe that 
 large numbers of Pennsylvania employees are each year rendered 
 incapable of working with their highest efficiency because of a general 
 lack of proper measures for the presentation of public health an<l 
 because of the neglect of many minor ailments which, untreated, 
 often develop into serious disabilities. We know the stimulus to 
 preventive effort and to prompt treatment in cases of industrial 
 accidents which has come because of the enactment of Workmen's 
 Compensation laws. Mr. Harry A. Mackey, Chairman of the Penn- 
 sylvania Workmen's Compensation Board, stated, in January 1917, 
 "No statistician can ever calculate the tremendous advantage to the 
 industries of Pennsylvania or to society generally, because of the fact 
 that this law has furnished to nearly 200,000 men free medication so 
 successfully administered that they have been cured of all resulting 
 complications or infection — and their injuries have not become com- 
 pensable." 
 
 If the Commission can suggest methods which will reduce the time 
 lost by Pennsylvania workers through sickness, and which will make 
 more nearly possible the maintenance of proper health standards, it 
 will not only have given valuable help to the industrial world, but 
 will have mpde a permanent contribution ' to the character of our 
 citizenship. 
 
(2C) 
 
PART I. 
 
 SECTION III. 
 
 Work of the Investigating Staff. 
 
 The general scope of the investigation possible was determined on 
 the one hand by the Commission's requirement of a preliminary re- 
 port on August 15th, to be used as a basis in deciding whether or not 
 to continue the work beyond that date, and on the other hand by the 
 five general lines of study outlined by the Act creating the Commis- 
 sion and used by the staff as a foundation for all work : 
 
 1. Sickness and accident of employees and their families not cov- 
 ered by workmen's compensation. 
 
 2. Loss resulting from sickness to individuals and the public. 
 
 3 Adequacy of the present methods of meeting the financial loss 
 from illness and giving medical treatment and eare. 
 
 4 Influence of working conditions on health. 
 8. Sickness prevention. 
 
 In view of the limited time and money at its disposal, the Com- 
 mission realized that material already in print must be utilized to the 
 fullest possible extent and that the field work done in Pennsylvania 
 must be in a large measure by means of free aid from existing organ- 
 izations either co-operating independently with the Commission or 
 working under the direct supervision of the staff. 
 
 This policy has been adopted, and we believe it has produced more 
 favorable results than might have been expected. In so far as the 
 staff can learn of its existence, all printed matter bearing specifically 
 on the Pennsylvania conditions about which the Commission was 
 required to report has been collected and studied, together with the 
 more recent and significant general material. Unfortunately much 
 of this local printed matter was found to be so superficial or in- 
 accurate that it was impossible to use it. 
 
 For our field work we have been most fortunate in securing the 
 co-operation of representative social and educational agencies in 
 various parts of the state, and of several state and national depart- 
 ments. We have attempted so to plan our investigations that they 
 would represent the different sections of the state, both industrially 
 and geographically. 
 
 Money limitations have prevented special studies among the min- 
 ing aiid rural population which could not have been made except 
 through our own staff. However, seven organizations have undertaken 
 special studies ibv us, and only one of these studies is unfinished ; 
 
28 
 
 three of the seven are state-wide in scope. Seven other organizations 
 have compiled, or segregated, special material, and in many instances 
 . unpublished studies of great value have been secured. In this con- 
 nection we have especially appreciated the co-operation of the United 
 States Bureau of Labor Statistics, the Pennsylvania Department of 
 Labor and Industry, the Pennsylvania Department of Health, the 
 Metropolitan Life Insurance Company, the Morris Plan Company of 
 Philadelphia, the Pennsylvania Old Age Pension's Commission and 
 the Ohio Health and Old Age Insurance Commission. 
 
 Special thanks are due the Philadelphia Bureau of Municipal Re- 
 search, and the sixteen volunteer workers who from time to time gave 
 their services. In addition to these, the staflE wishes to record its 
 hearty appreciation Of the services of the many persons, private or- 
 ganizations and oificial bureaus, whose help and co-operation ha^'e 
 made this report possible. 
 
 A list of the special studies made for, or by, the Commission and 
 used constantly in this report, follows: 
 
 I — Kensington Sickness Survey made by the students of the Penn- 
 sylvania School for Social Service in Philadelphia, in May 
 and June, 1918. This was a house to house canvass of 743 
 families, containing 3,198 persons, in a census enumeration 
 district in Kensington, carefully selected to insure its repre- 
 sentative character. The primary purpose of the study was 
 to get the illness history of these families for the year end- 
 ing April 1, 1918, but the cases of sickness existing at the 
 time of the survey were also noted. Disabling and slighter 
 illnesses were not distinguished. 
 
 II — Sickness Histories of Special Groups. 
 
 A — Sickness and Dependency. A study of 1,500 of the 
 families in which illness was a problem, under the 
 care of the Charity Organization Societies of seven 
 cities in the State, during 1917. This study was 
 made by the societies and tabulated by the Commis- 
 sion and by the students of the Carnegie Institute of 
 Technology, Pittsburgh, under the direction of Irene 
 Farnam Conrad. 
 
 B — Sickness History of Working Girls. A study of 502 
 members of Young Women's Christian Association 
 Industrial Clubs in seventeen cities of the State. 
 This covered the illness histories of these working 
 girls for the period June, 1917, to June, 
 1918. Wage figures and occupations for 1914, be- 
 fore the war, were obtained for comparative pur- 
 poses. This study was made by the Association 
 Secretaries and tabulated by the Commission. 
 
29 
 
 C— Sickness Histoiy of Wage Earners' Families. A 
 study of 500 families given nursing service in July, 
 1918, by the Philadelphia Visiting Nurse Society. 
 The families were not limited to a particular group, 
 but were chosen consecutively. The illness at the 
 time of the visit was disregai-ded, but the sickness 
 history for the preceding year was obtained. This 
 study was made by the nurses of the Society, and 
 tabulated by the Commission. 
 D — Sickness History of Wage Earners. A study of the 
 fatal illness of the fathers of families now under the 
 care of the Mothers' Assistance Fund in Lancaster 
 and Lackawanna Counties. This study was made by 
 agents of the Mothers' Assistance Fund and tabu- 
 lated in the office of the State Supervisor, Harris- 
 burg. 
 
 Ill — Studies of Health Hazards in Industry. 
 
 A — Occupational Diseases in Pennsylvania. An article 
 prepared especially for the Commission by Dr. 
 Alice Hamilton, United States Bureau of Labor 
 J Statistics, November, 1918. 
 
 B — Factory Health Conditions. A study of 100 factories 
 in the Pitt^burlgh district, made during the sum- 
 mer and fall of 1918 by the Women in Industry 
 Division of the Council of National Defense of Alle- 
 gheny County. 
 
 IV — Studies of Existing Insurance Facilities. 
 
 A — Special study of the sick benefit funds of the Penn- 
 sylvania Railroad (lines east), J. G. Brill Company, 
 J. B. Stetson Co., Nelson Valve Company and 
 Tabor Manufactijring Company, made by the Com- 
 mission in co-operation with the Ohio Health and 
 Old Age Insurance Commission. 
 
 B — Brief study of existing commercial insurance com- 
 panies, trade union and fraternal sick benefit funds 
 in Pennsylvania ; madei by the Commission. 
 
 In addition to these special studies, two sickness surveys are used 
 so constantly in the report that a brief description of them here 
 seemed advisable. Other sources are explained in the text. 
 
 A sickness survey of seven districts in Philadelphia was made in 
 1917 by nurses from the city Bureau of Health, under the direction 
 of the Chief of the Bureau of Vital Statistics. Five southern dis- 
 tricts of the city were covered by a house-to-house canvass in August, 
 
30 
 
 and a district in Manayunk and one in Gennantown were added in 
 mid-September. The study included 12,019 individuals in 2,655 dif- 
 ferent families, and covered all sickness existing at the time of the 
 survey, and duration to that date. The enumerators were instructed 
 to work slowly and carefully and to win the confidence of the families 
 whom they visited. When the information secured seemed to be in- 
 complete, families were revisited, sometimes as often as three times. 
 In view of the precautions taken, we may assume that the sickness 
 rate is reasonably accurate, although the time of year, August and 
 September, was one at which sickness is at the minimum. This 
 survey will hereafter be referred to as the Philadelphia Survey. 
 
 A study of sickness conditions in the principal cities of central and 
 vt^estern Pennsylvania, including Pittsburgh, was carried on in 1917 
 among industrial policyholders of the Metropolitan Life Insurance 
 Company. The enumerators were the regular agents of the com- 
 pany, who gathered the survey facts in the course of their door-to-door 
 collections. The study was made in March, "a time of year when 
 physical disability on account of disease is probably at its maximum," 
 and covered 328,051 persons, a much larger number than was reached 
 by the Philadelphia Survey, but only "serious cases of sickness" ex- 
 isting at the time of the survey were noted. This survey will hereafter 
 be referred to as the Western Pennsylvania Survey. As the flg^ires 
 for Pittsburgh have been tabulated separately, they wiU be referred 
 to as the Pittsburgh Sickness Survey. 
 
:i[ 
 
 PART I. 
 
 SECTION IV. 
 
 Conclusions and Recommendations. 
 
 CONCLUSIONS. 
 
 EXTENT OF SICKNESS AMONG EMPLOYEES. 
 
 I — More than 385,000 persons in the State are constantly suffer- 
 ing from illness; approximately 140,000 from severp, and 
 245,000 from slighter illnesses. 
 
 Il^-The average loss of working time among employees in the 
 state is at least six days each year because of sickness. In 
 1916, 3,025,071 working days were lost because of industrial 
 accidents in the State; sickness causes approximately five 
 to seven times as much loss as industrial accidents. 
 
 Ill — Pennsylvania stood highest of any state in the Union in the 
 percentage of men rejected for physical reasons in the draft 
 of April, 1917. Of her young men between twenty-one and 
 thirty-one years of age, 46.67 per cent, were rejected. The 
 average for the country as a whole was 29.11 per cent., and 
 one State had but 14.13 per cent, of her men rejected. 
 
 IV — Death rates in Pennsylvania are higher than those for the 
 registration area of the country as a whole. The infant 
 death rate — "that most sensitive index to sanitary condi- 
 tions" is highly excessive in many parts of the State. It 
 was higher in 1917 in Philadelphia than in New York, 
 Brooklyn, Boston or Chicago. Pittsburgh ranked second 
 among cities of its size, having an infant death date of 116 
 per 1,000. The State as a whole had an infant death rate 
 in 1916 of 114 per 1,000, while that for the whole registra- 
 tion area was 101. 
 
 LOSSES DUE TO SICKNESS OF EMPLOTEES. 
 
 I — The losses to employees consist of (a) loss of wages (b) cost 
 
 of care (c) reduced earning power and standards of living. 
 
 Averages do not measure the losses to individuals, because 
 
 -■ of the uneven distribution of the sickness burden. In one of 
 
 the Sickness Surveys in an industrial district in Philadelphia 
 
 3 
 
32 
 
 each wage earner sick in 1917 lost thirty-eight days. In an- 
 other Sickness Survey each wage earner lost sixty-seven days ; 
 one-third of the total time lost in this group was lost by nine 
 men, and 53 per cent, of the total illness-cost was borne by 
 one-seventh of the entire number of families. In a study of 
 Working Women one-fourth of the total cost of medical care 
 was borne by ten of the women. 
 
 (a) At the nominal rate of $2.00 a day the wage loss to em- 
 
 ployees of this State every year because of illness is at 
 least $33,000,000. 
 
 (b) The tendency to secure needed medical care is in direct 
 
 relation to income of the family. As the family in- 
 come incaeases, the amount spent on medical care in- 
 creases. The average cost of medical care for every 
 employee's family is between |30.00 and |50.00 a year. 
 In the Visiting Nurse Study this average was |47.00. 
 Medical Charity given, in many instances cannot he 
 considered as in any way an untimaie solution of the 
 illness proMem in a country claiming democratic 
 ideals. 
 
 (c) Because most wage earners "cannot afford to be ill," 
 
 many develop chronic illnesses and greatly reduce their 
 future earning capacity; this reflects an inestimable 
 loss to society in productive power, vigorous citizen- 
 ship, and the possibility for maintining family stand- 
 ards which permit proper nourishment, care, and op- 
 portunity for the children. 
 
 II — The losses to industry consist of (a) decrease in production, 
 due to the absence of sick wage earners or to the lessened 
 efflciency of half -sick workers; (b) cost of labor turn -over. 
 
 (a) Employees in the State lose at least 16,800 000 days 
 
 work annually because of sickness, and large numbers 
 of actually sick men and women are at work every 
 day. These facts, while not an exact measure of the 
 loss to industry, give an indication of the extent to 
 which production suffers. During the influenza epi- 
 demic anthracite coal production dropped behind 
 500,000 tons in a few days. A constant limiting of 
 production exists at allJ;imes because of constant ill- 
 ness, not spectacular and therefore not seriously con- 
 sidered. 
 
 (b) Four large industrial establishments state that it costs 
 
 on an average from |30.00 to |50.00 to hire and train a 
 new worlcman. The greater the labor turn-over, the 
 greater the cost of production ; the greater the amount 
 of sickness, the greater the labor turnover. Some pro- 
 gressive employers are engaging industrial physicians 
 and nurses, opening dispensaries and establishing sick 
 benefit funds as a business principle; because it pays 
 to see to it that sick workmen receive care. 
 
33 , 
 
 m — The losses to the community consist of (a) money loss; (b) 
 social loss. 
 
 (a) The State spends over !p6 000,000 every year directly for 
 
 the treatment of siclcness.-- In addition, |4,000,000 is 
 spent for the maintenance of institutions for the care 
 "of defectives, a large part of which expenditure is un- 
 doubtedly made necessary by the neglect of sickness 
 and its consequences. Besides the ten State Hospitals 
 for Miners, 17:5 other hospitals reported to "the State 
 Board pf Charities in 1916 that 57 per cent, of their 
 in-patients, liod. Deen trea,tedj^ee and^40 per cent, of 
 their hospital 'days had ieenfree days. 
 Illness is no less a burden upon private funds. Aside 
 from the multitude of dispensaries, hospitals, con- 
 valescent homes, visiting nurse societies and other 
 charitable and semi-charitable agencies especially for 
 the care of sickness, organized . relief societies in- 
 variably report illness to he the most frequent dis- 
 ability in the families coming to them for aid. 
 
 (b) The loss from illness to the community is not only in 
 
 money and in reduced efl&ciency of the employees 
 
 ' themselves, but involves the citizenship of the future. 
 
 Growing children, forced to endure periods of under 
 
 nourishment because of straightened family resources 
 
 when the breadwinners are ill — mothers who receive 
 
 ' no prenatal care, working until the last minute before 
 
 confinement and as soon thereafter as they can "stand 
 
 on their feet" — babies who are not given a fair start in 
 
 life — all these mean not only a present problem, but a 
 
 ' serious and unjust handicap for the generations to 
 
 come. 
 
 J There is no more important problem today than safe- 
 
 , guarding the health of the tvage-earning woman; not 
 
 j Only for her own sake, but for the sake of her children, 
 
 whose task it will be to make real the ideals for 
 
 which our men have been layimg down their lives. 
 
 PRESENT METHODS OP MEETING THE SICKNESS PROBLEM. 
 
 I . I^Facilities for medical care among wage-earners are not satis- 
 
 factory, whether considered from the standpoint of extent, 
 - cost, or proportion of persons receiving care in time of sick- 
 ness. Hospital accommodations in the State average little 
 i more than one-half the standard minimum of five beds per 
 
 1 1,000 of the population. Even if good medical care were 
 
 ' available and adequate, most employees could not afford to 
 
 pay for it. Fees are not large, but wages have not kept 
 , pace with the soaring cost of living^ save in a few groups. 
 
 Most employees are unable to save toward emergencies, 
 i The result is that many of them fail to receive medical care 
 
 of any sort, and that many more do not receive medical care 
 
34 
 
 until the illness has passed the stage when it could be 
 quickly remedied. Approximately a fourth of those 
 actually disabled by illness never receive medical care, and 
 a larger percentage of those ill but still trying to work, 
 are without attention. 
 II— Not more than one-third of the workers carry any form of 
 insurance protection against sickness. One-half to three- 
 fourths of this existing sickness insurance is carried 
 through the sick benefit funds of the lodges and fraternals. 
 In most of these, sicknes* insurance is secondary to life 
 insurance. As a rule, no medical benefits are given, and 
 the cash benefit is but $5.00 a week for thirteen weeks in 
 any single year, payable only after a man has been ill more 
 than two weeks. 
 Trade union funds rarely afford better protection. Com- 
 mercial health insurance is costly and subject to many re- 
 strictive rules. Establishment funds afford better protec- 
 tion but are relatively few in number and exist only among 
 progressive employers where health hazards are often re- 
 duced to the minimum. 
 
 the; influence of working conditions on health. 
 
 I — Investigations of the industries of Pennsylvania have shown 
 that "no other State has so wide a variety of those in- 
 dustrial processes which carry with them danger to the 
 workers either because of poison in -the form of fumes, 
 liquids, or dust, or because of mechanically irritating dusts 
 which injure the throat and lungs." 
 II — Seventy-nine per cent, of all the deaths of persons of work- 
 ing age in 1916 were from diseases whose connection with 
 "important Pennsylvania industries has been established." 
 Death rates among pefsons of working age in Pennsylvania 
 from degenerative diseases due in large measure to certain 
 kinds of occupation are steadily increasing. 
 
 SICKNESS prevention. 
 
 I — Fully one-half of existing sickness could be eliminated if 
 proper preventive measure were taken. 
 II — At present from 70 to 75 per cent, of the school children in 
 Pennsylvania are physically defective, and for the most part 
 the defects are correctable if treated in time. 
 III — A large number of communities in the State have no active 
 health work, much less an adequate appropriation for 
 health activities. 
 
35 
 
 'IV — Nothing so stimulates preventive effort as definite responsi- 
 bility for the losses entailed. Preventive measures proved 
 inadequate to meet the problems of industrial accidents un- 
 til stimulated hy the enactment of the Workmen's Compen- 
 sation Law. This form of social insurance has steadily re- 
 duced the number of accidents and the appeals to charity 
 from families affected and has proved practical: in adminis- 
 tration. 
 Our own and other investigations prove that the responsibility 
 for illness rests on three groups: the community, industry 
 and the individual. At present these three groups are meet- 
 ing the losses from illness in wholly unequal shares; the 
 burden on the individual is often disastrous and out of pro- 
 portion to his individual responsibility. Some means of 
 just distrvbuti&n of tMs hwrden should 'be found. There is 
 in Pennsylvania today urgent need for a program of health 
 measures which will (a) Provide for the efficient care of 
 employees and their families when actually ill, and (b) In- 
 gfitute preventive measures which will in so far as it is pos- 
 sible, prevent illness and increase the opportunity for health 
 aud vigor in the citizenship of the State. 
 
36 
 
 EECOMMENDATIONS. 
 
 Since investigation has shown that sickness -among wage earners 
 in Pennsylvania presents a serious problem of vital importance not 
 only to employees, but to industry and to the State, your Committee 
 recommends : 
 
 1— A careful study of possible remedial legislation covering the fol- 
 lowing points : 
 
 a — :Such adequate medical care for employees and their 
 families during sickness as will materially improve 
 health conditions, by reducing the frequency, duration 
 and severity of illness and thus decrease time-loss to in- 
 di^stry, and prevent much needless suflfering. 
 
 b — A means of meeting the wage-loss ordinarily suffered by 
 employees during periods of illness by methods which 
 will apportion fairly the economic burden between the 
 three elements responsible — ^the individual, industry and 
 the State. 
 
 c — A method for stimulating State-wide interest and active 
 work in sickness prevention. 
 
 2 — A special study of proposed 'and existing systems of health in- 
 surance in this and other countries, with special attention to 
 problems concerning constitutionality and the administration 
 of medical benefits. 
 
 3 — That these studies be under the direction of a Commission on 
 which the medical, nursing and legal professions, organized 
 employers and organized employees shall be represented. 
 
37 
 
 PART 1.— SECTION II.— TABLE I.— Leading Occupations of Pennsylvania Wage 
 
 Earners. 
 
 (More than 10,000 Persons Employed). 
 
 Occupati'oD. 
 
 Agriculture, 
 
 Extraction of minerals, 
 
 Building trades, 
 Shipbuilding, 
 
 Iron and steel, steel irorks and rolling 
 mills, 
 
 Foimdries, macbine-sbop products, 
 
 Cars and construction and repair by steam 
 
 railways, 
 
 Silk goods, , 
 
 Hosiery and knit good®, 
 
 Tobacco, 
 
 Printing and publishing. 
 
 Woolen goods, 
 
 Glass, 
 
 Lumber, 
 
 Men's clothing and shirts, 
 
 Brick, tile, pottery, clay products, 
 
 Women's clothing 
 
 Bread and bakery products 
 
 Electrical machinery, apparatus, supplies. 
 
 Cotton goods. 
 
 Boots and shoes, 
 
 Leather goods, 
 
 Chemicals and allied products, 
 
 Liquors and beverages, .. 
 
 Paper and paper products, 
 
 Laundries. 
 
 Number of 
 
 Wage^ 
 Earners. 
 
 Transportation , 
 Trade, 
 
 362,123 
 (Including 
 faxiu 
 owners) 
 336,615 
 (mainly hard 
 and soft 
 coal) 
 49,302 
 
 100,000 
 
 131,955 
 81,820 
 
 64,729 
 *H4,765 
 t*«,130 
 •31,298 
 
 •26,909 
 
 •t24,461 
 
 t23,606 
 
 21,297 
 
 •21,126 
 
 18,976 
 
 •17,217 
 
 •15,167 
 
 14,866 
 
 *tl4,640 
 
 *tlS,414 
 
 11,988 
 
 37,880 
 
 9,405 
 
 •17,979 
 
 9,538 
 
 238,841 
 •307,371 
 
 Source of Information, 
 
 U. S. Census of OccupationB, llilO. 
 
 Fa. Department of Labor and In- 
 dustry, Production K«port, 1916. 
 
 Fa. Department of Labor and In- 
 dustry. Production Report, 1916. 
 
 Henry B. Saeger, Secretary Ship- 
 building Labor Adjustment Board, 
 1918. 
 
 U. S. Census of Manufactures, 1914. 
 
 U. S. Census of Manufactures, 1914. 
 
 U. S. Census of Manufactures, 1914. 
 
 If. S. Census of Manufactures, 1914. 
 
 CJ. S. Census of Manufactures, 1914. 
 
 Pa. Department of Laljor and In- 
 dustry, Production Report, 1916. 
 
 Fa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Pa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Pa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Pa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Pa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Pa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Fa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Pa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Fa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Pa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Pa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Pa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Pa. Department of Labor and In- 
 dustry. Production Report, 1916. 
 
 Fa. Department of Labor and In- 
 dustry. Production Report, 1916. 
 
 Fa. Department of Labor and In- 
 dustry, Production Report, 1914. 
 
 Fa. Department of Labor and In- 
 dustry, Production Report, 1916. 
 
 U. S. Census of Occupation. 1910. 
 
 IT. 8. (Census of Occupation. 1910. 
 
 •Large proportion of females employed. 
 
 tLarge number of children under 16 years employed. 
 
88 
 
 I'ART I. -SECTION II.— TABLE II.— Number aud I'crcoiitage of I'orsons 10 
 Years of Age and Over Gainfully Employed, 1910, in Pennsylvania, Philadel- 
 phia, and Pittsburgh by Principal Occupational Groups. 
 
 
 Pennsylvania . 
 
 Philadelphia. • 
 
 Pittsburgh. 
 
 Occupation. 
 
 Number 
 Employed. 
 
 Per cent. 
 
 Number 
 Employed. 
 
 Per cent. 
 
 Number 
 Employed. 
 
 Per cent. 
 
 TotaJ employed, 
 
 3,130,681 
 
 100 
 
 711,169 
 
 100 
 
 233,637 
 
 100 
 
 
 
 
 362,133 
 327,670 
 
 607,079 
 294,?52 
 172,498 
 30,309 
 131,036 
 169. te 
 301,383 
 734,166 
 
 11.6 
 10.4 
 
 19.3 
 
 9.3 
 
 5.5 
 
 .96 
 
 4.2 
 
 , 5.4 
 9.6 
 
 23.1 
 
 5,7ff4 
 1.332 
 
 260,438 
 99,113 
 44,496 
 11,477 
 34,r?9 
 62,487 
 95,919 
 95,^4 
 
 .81 
 .18 
 
 36. T 
 13.9 
 5.2 
 1.6 
 4.8 
 8.7 
 13.4 
 13.3 
 
 962 
 840 
 
 22,000 
 31,559 
 15,065 
 3,453 
 11,265 
 23.864 
 32,403 
 92,130 
 
 .41 
 
 Extraction of minerals, 
 
 Manufacturing and mechani- 
 cal, 
 
 Trade, - - 
 
 .36 
 
 9.4 
 13.5 
 
 
 6.^ 
 
 Public service 
 
 1.04 
 
 
 4.5 
 
 Clerical. __ 
 
 10.2 
 
 Domestic and personal, 
 
 Laborer. - 
 
 13.9 
 39.4 
 
39 
 
 g 
 g 
 
 1 
 
 I 
 
 > 
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 ns 
 
 a 
 
 si 
 
 
 l-ri i3§ 88SS58aS!SSgS3g"°S!SS g 
 
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 to n'r^^ eQiHi-TiHi-Tefr-r « i-I'to nihw 
 
 
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 wir- oooe<ic6^Cui-Hq)U3Ttir-< CO ra03M.iAro> 
 
 
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 Ttt in I 
 
 
 WiHrHiHesHNt-TrHMrHiHt-rW CQiH 
 
 ! ! 
 
 ^h«i 
 
 ^2 w I •S.SS i 
 
PART II. 
 
 SECTION I. 
 
 The Nature and Extent of the Sickness Problem. 
 
(42) 
 
43 
 
 PART II. 
 
 SECTION I. 
 
 The Nature and Extent of the Sickness Problem. 
 
 No part of the United States has as yet established adequate ma- 
 chinery for keeping complete sickness statistics. Pennsylvania is 
 no exception to the rule. Our information then, must be based on 
 more or less fragmentary material, covering certain selected groups, 
 from which conclusions can be drawn, and averages taken. 
 
 Averages and rates tell little of the human story. 
 
 The real nature and extent of the sickness problem among em- 
 ployees and their families is most clearly brought out by studies of 
 conditions among groups of people for a considerable period. For 
 this reason we have summarized briefly the results of three studies 
 giving the sickness experience of three different groups for a year. 
 In this way it is possible to see how sickness really affects the com- 
 munity, and to place it in its natural human relations. 
 
 The first study is of a typical wage earning group dn a census 
 enumeration district of an industrial section of Philadelphia ; the 
 second covers a group seeking medical care from the Philadelphia 
 Visiting Nurse Society ; ihe third is a study of a group of working 
 women. The sickness experience of a dependent group is discussed 
 in Section II. 
 
 THE KENSINGTON SUKVEY.i 
 
 The Kensington Survey was a door-to-door investigation made for 
 the Commission by the Pennsylvania School for Social Service. ' The 
 area of the survey was chosen because it forms part of the industrial 
 district of Kensington, because of the presence therein of numerous 
 manufacturing establishments engaged in the production of a variety 
 of goods, and also because of its proximity to the Cramp Shipbuild- 
 ing Yards and the ease of access to the center of the city, thus assur- 
 ing a diversity of industrial and commercial employment. From a 
 study of the 1910 census figures for this area it was noted that various 
 nationalities would be found and that the home life would be typical 
 of the working population of the State. The district was chosen only 
 after representatives of the School had not only studied the city atlas 
 for the types of buildings, but had made a thorough canvass in the dis- 
 trict itself so as to assure the School that the population was a normal 
 working group. 
 
 Owing to the care with which this district was chosen, there is rea- 
 son to feel that a fairly typical group of families of industrial wage- 
 earners was selected. There were 743 families, including 3,198 in- 
 
 (>)See Table II at end of this section. 
 
44 
 
 dividuals. The district presented some eight to ten nationalities, but 
 77.9 per cent, were native born Americans. The highest percentage of 
 foreign-born were, in the order named, Germans, Austrians, Irish and 
 Russians. 
 
 That the group was in no way a dependent group, or the district a 
 "slum" district, is witnessed bjjhe thrift of these families — 189 of 
 them.,owned their own homes,,.and 626, or 88 per cent., had purchased 
 liiberty Bonds. "The house rent in over 8() per cent, of thejental cases 
 Ws between $1^ 
 
 WhUe the average size of the families was only 4.3 persons, it is 
 noteworthy that the number of wage-earners averaged 1.94 per family. 
 In sixty-three cases, the mother of the family was at work as well as 
 the father, and in another seventy cases, a working woman was the 
 "head of the house." Eight per cent, of the families were in re- 
 ceipt of weekly incomes of less than $15.00 and 47 per cent, more had 
 between |15.O0 and f 30.00, making more than half — 55 per cent. — in 
 receipt of weekly incomes of |30.00, or less. The largest single group 
 received between $20.00 and |2.o.00. As there was an average of prac- 
 tically two wage earners per family, this does not indicate an espe- 
 cially high wage-rate for individual wage-earners. The amount of 
 the individual's wage-loss from illness, in cases where this could be 
 learned, averaged in fact just about $2.00 a day. 
 
 Nearly half of the wage-earners were employed in "manufacturing 
 and mechanical" occupations ; that is to s*y, factory work and hand 
 trades. The next largest group was "trade," with 18 per cent., and 
 the third, "domestic and personal service." accounted for 11.5 per 
 cent., while "professional service" accounted for but 1.4 of the num- 
 ber, indicating an industrial group ; "laborers" were only 7.3 per cent, 
 of the total, showing that the group was above the average for in- 
 dustrial employees. 
 
 Undoubtedly, in going over a year's illness experience, many minor 
 ailments were ignored, yet only 12.4 per cent, of the 734 families 
 about whom these facts could be obtained had had no sickness during 
 the year. One case of illness was reported in 179 families, two cases 
 in 173, three or four in 162, and five or more in 126. Twenty-six 
 families reported ten or more cases of illness. Of the 1,994 cages 
 reported, a comparatively high proportion, 42.5 per cent, were those 
 of wage-earners, and 66 per cent, of them were illnesses either of wage- 
 earners or of housekeepers, thus causing a serious wage or house- 
 keeping loss. In 527 instances illness of the principal wage earner 
 was reported, 319 cases of illness of other wage-earners, 466 cases 
 of illness of the housewife, and only 677 cases of illness of other mem- 
 bers of the family. 
 
 In the 1,472 cases where accurate information on duration was ob- 
 tained, 57.6 per cent, lasted four weeks or under; the largest single 
 number falling between one and two weeks, when 351 cases were re- 
 
45 
 
 corded. Those lasting from one to three months comprised 19.2 per 
 cent., and another 12.1 per cent, lasted more than a year. When over 
 42 per cent, of the illness registered lasted more than four weeks we 
 begin to realize how disastrously illness may affect theJ families in a 
 group such as this. The average days lost from work on account of 
 sickness among the 421 cases of wage-earners' illness causing loss of 
 time was thirty-eight. Three hundred and sixty-seven of these work- 
 ers had a wage loss of |28,S23, or an approximate average of $79.00 
 for each case. In addition to the loss of wages, the families had to 
 bear the cost of medical care. Eighty-iive of these illnesses were 
 treated free, 144 had only home treatment or patent medicines, and 
 no treatment whatever was recorded for an additional' 154 cases. A 
 private doctor was most often consulted, and eighty-five cases had 
 had hospital treatement. The families for the most part met the 
 expenses of illness through their own resources. The employers 
 helped by contributing wages or paying for medical care in a little 
 over one per cent, of the cases of sick wage-earners. In 99 per cent, 
 of the wage-earners' illnesses and in all cases of the illness of de- 
 pendents, industi*y assumed no responsibility. 
 
 Seventy-seven per cent, of the 3,198 individuals covered had pro- 
 tected themselves against a pauper's burial and were carrying indus- 
 trial life insurance policies for small amounts ; 17 per cent, had some 
 form of "sickness and death" insurance. Thirty-four per cent, of 
 the wage earners were insured in this way, carrying the insurance 
 through fraternal organizations in almost three-fourths of the cases. 
 Less than three per cent, were insured against sickness in commer- 
 cial insurance companies. 
 
 This general lack of insurance protection against sickness is not 
 surprising. The average family of four or more, with a weekly in- 
 come of $30.00 or less will risk the somewhat uncertain chance of 
 sickness, rather than pay the relatively heavy premiums necessary for 
 adequate protection. Life insurance is much more frequently carried, 
 for death is a certainty and the desire for decent burial is a part of 
 the worker's self respect. And yet, among these Kensington families, 
 the chance of avoiding illness was very poor — ^less than thirteen in a 
 hundred families escaped at least one case during the year, and some 
 had to meet the emergency many times. 
 
 VISITING NURSE SOCIETY STUDY. 
 The Staff of the Visiting Nurse Society of Philadelphia gathered, 
 for the Commission, data covering a year's sickness experience in 500 
 of the families to which they were called during July, 1918. No at- 
 tempt was made to confine the study to any particular kind of family ; 
 they were chosen consecutively, and. the result was an ordinarily self 
 supporting industrial group, more than half of whom had been, forced 
 by sickness to appeal for nursing care which was wholly or partially 
 
46 
 
 free. The 500 families visited, about one-fourth of whom were col- 
 ored, contained 2,588 individuals, or an average of five per family, al- 
 though 1,420, or more than half the total number of persons in the 
 group, belonged to families of six or more members. More than half 
 the families were Americans by birth; Italians, Eussians and Irish 
 made up about a third ; and the others were Austrians, Germans, Eng- 
 lish and Polish. 
 
 There is nothing particularly striking in the economic history of 
 these families, compared with that of other wage-earning groups of 
 our population. Only five families had no wage earners. Of the 691- 
 wage earners in the group, 509 were heads of families, forty-five were 
 housekeepers who went out to work, and 128 were other members of 
 the family. Nine of these were under sixteen years of age. Only 
 one wage-earner was found in each of 355, or 70.8 per cent, of the 
 families, containxug more than half the total number of individuals, 
 while only forty-two families had more than two wage-earners. More 
 than 69 per cent, of these workers were described as "steady," the 
 others being "seasonal" or "casual," in many instances because of the 
 nature of their occupations. Of the 615 wage-earners whose occupa- 
 tions were known, 243, or 36 per cent, were engaged in manufactur- 
 ing and mechanical trades, and 139, or 20.5 per cent, in transporta- 
 tion and trade, leaving only 17.7 per cent, as laborers and 13.1 per 
 cent, in domestic and personal service. Of these last 41 per cent, 
 were the working housekeepers. 
 
 The incomes reported by these families tell a story strangely at 
 variance with the popular rumors of wealth brought by the war to 
 the working man. Of the 438 families whose incomes were known, 
 with an average membership of more than five, one-third had incomes 
 of less than |20.00 per week, and 353 families, or 80.6 per cent., con- 
 taining more than 77 per cent, of the total number of individuals, 
 had less than $30.00 per week. Only eighty-five families, or 19.4 per 
 cent., had $30.00 or over. The largest single group, 127, or 28.9 per 
 cent., containing about 28 per cent, of the total number of persons, 
 had between $20.00 and $25.00 per week. In 13 per cent, of the 
 households, the incomes had been augmented by lodgers, ranging 
 in number from one to nine. 
 
 In spite of the size of their incomes, 238 families had been able to 
 accumulate small savings ; but it has been only too often demonstrated 
 that under present living conditions, saving by families of five or six 
 members on less than $30.00 per week usually means reducing the 
 allowance for food, clothing, rent and recreation below the safety 
 point. 
 
 All cases of illness which had occurred during the preceding year 
 were recorded, exclusive of the illness for which the "nurse had been 
 called at the time of the survey. In addition, all cases of chronic 
 illness were included, many of which were of more than a year's 
 
4T , . 
 
 duration. There were 418 families, or more than 83 per cent., who 
 had had at least one case of illness during the year, making a total 
 of 1,043 cases. Each of 375, or 75 per cent, of the families reported 
 two or more cases each, while fifty families reported five or more 
 cases. In 561, or 53.7 per cent, of the cases, it was either a wage 
 earner or a housekeeper who was ill,. in 200 cases it was the principal 
 wage earner, and' in 316 the housekeeper. Typhoid fever, tuber- 
 culosis, respiratory diseases including pneumonia, and digestive di- 
 seases, accounted for 290, or 27.8 per cent, of the cases, children's di- 
 seases for 164 cases, diseases of the puerperal state for 89, and acci- 
 dents for forty-eight. 
 
 During the year, 234 wage-earners, or 33.8 per cent, of the total 
 number, were ill; 208, or 89 per cent, of these, or 30 per cent, of the 
 total number of wage-earners, lost time from work because of sick- 
 ness. The total length of time lost, including that lost by those suf- 
 fering from chronic illness, was known in the cases of 201 workers, 
 and amounted to 13 528 working days, or an average of more than 
 sixty-seven days for each of the 201, or more than nineteen days for 
 each of the 691 wage-earners in the study. 
 
 Of this time, which is equivalent to more than forty-five working 
 years, 4,590 days, or almost one-third, were lost by nine men.^ Five 
 men had lost an average of more than 525 consecutive days each, and 
 one man hal been at home sick for 720 days. He was suffering from 
 tuberculosis, a curable disease if treated in its early stages, and be- 
 cause of his illness his two daughters, sixteen and seventeen years of 
 age and both tubercular, were forced to work regularly, earning to- 
 gether about 129.00 per week for the support of the family of five. 
 
 Only forty of these 201 workers lost less than two weeks time be- 
 cause of sickness, while ninety-three, op 46 per cent, lost from one to 
 six months each. Of these last, only nineteen belonged to families 
 whose incomes were as much as $30.00 per week. 
 
 Of the total time lost, 9,577 days were lost by families whose in- 
 comes were known, and of this loss more than half was suffered by 
 100 families with incomes of less than |25.00 per week. The average 
 loss for these families was more than ninety-five working days each. 
 
 In addition to the suffering caused by suspension of the family in- 
 come, illness in many cases made necessary expenditures for medical 
 care for which the families were entirely unprepared. Medical and 
 dental care were received by 412 families. This care was obtained 
 free in twenty-two cases, and the cost was unknown in twenty-seven 
 others. The 363,rfamilies whose expenditures were known spent $17,- 
 102.29, or an average of more than $47.00 each, or more than |34.00 
 for each of the 500 families in the whole group. The same uneven- 
 ness of distribution is seen in this expense as in the loss of time. 
 
 (')Sce Table III at end of section. 
 
 4 
 
•48 
 
 Fifty-three per cent, of the entire cost, or |9,193.50, was borne by 
 fifty families, less than one-seventh of the entire number. Of these 
 fifty families, whose expenses ranged from flOO.OO to $416.00 each, the 
 incomes of twenty-six were less than $30.00, and of fifteen were less 
 than $20.00 per week. Two families with incomes of $20.00 per week 
 had doctor's biUs of $202.00 and $400.00 resspectively. More than 47 
 per cent, of the families spent over $25.00 each; while only 29 per 
 cent, escaped with less than $10.00. 
 
 Sixteen families spent more than $200.00 each, and of these, ten 
 spent more than $300.00 each; while thirteen families had medical 
 and dental expenditures amounting to more than 20 per cent, of their 
 total incomes. 
 
 As in the Kensington Survey the means of meeting these burdens 
 were left for the worker and his family to devise, the employer help- 
 ing in only three per cent, of the cases. In about a third of the 
 cases, emergencies were met by reducing the usual outlays for liv- 
 ing expenses, while in another third money was borrowed, credit 
 obtained and help received from charity, friends and relatives. Sav- 
 ings were a help in about 20 per cent, of the families. The amount 
 of health insurance carried was small; only seventeen families had 
 complete insurance protection and eighty-five were partially insured. 
 
 Industrial policies of the Metropolitan Life Insurance Company, 
 entitling the holder to nursing care, were held by 199, or 39.8 per 
 cent, of the families ; thirty-seven others, or 7.4 per cent, were classed 
 as "pay" patients, 189, or 37.8 per cent., as "part pay," and seventy- 
 four, or 14.8 per cent, as "free." 
 
 The very large proportion of instances in which an attempt was 
 made to secure medical care is probably due, in part, to the fact that 
 so many of the families carried industrial life insurance which se- 
 cured nursing care for them and strongly encouraged medical treat- 
 ment. 
 
 A private doctor was consulted in 650, or 64.3 per cent, of the 1,038 
 cases, where the nature of treatment was known; a visiting nurse 
 was used in 130, or 12 per cent, of the cases, a hospital or convalescent 
 home in 19 per cent., and no medical care at all, or medicine only, 
 in 17 per cent. 
 
 The experience of these families brings out vividly the universal 
 nature of the sickness risk, and the severity of the losses of time and 
 money which may fall on the whole group, but which are sure to fall 
 with crushing weight on a certain number, regardless of individual 
 responsibility or resources. » 
 
 When wages among comparatively skilled workers are insufficient 
 to provide even the necessities for comfortable, healthful living ; when 
 there is at least an 80 per cent, chance that some one in each family 
 will be ill every year; when in at least 30 per cent, of the families ill- 
 
49 
 
 ness will cut off the family income and necessitate an additional ex- 
 penditure for medical care, frequently amounting to a large part of a 
 year's wages, it is apparent that industry and the state, both in part 
 responsible, must share with the individual in the distribution of the 
 sickness risk. 
 
 WORKING WOMEN'S RECORDS. 
 
 In August and September, 1918, a study was made of 502 working 
 women who were members of the Young Women's Christian Asso-' 
 elation Industrial Clubs in twenty-two different cities in seventeen 
 counties of Pennsylvania. Because of the time of year in which the 
 study was made, it was impossible to obtain records for a larger num- 
 ber, but all club members who could be reached by the Secretaries 
 were included, and the study was not limited to a special occupation 
 or group. 
 
 In all probability these girls had more education and advantages 
 than many other working women. In age, 35 per cent, of them were 
 under twenty, 45 per cent, between twenty and twenty-five, and only 
 six per cent, were over thirty. , 
 
 Nine-tenths of them were Americans, and almost three-fourths were 
 native-born of native-born parents. Four-fifths of the girls were liv- 
 ing at home, with their families. T'here were 100 who were living in- 
 dependently. Eleven of these 1 00 contributed to the support of their 
 families, as well as supporting themselves, and 127 of the girls who 
 lived at home were giving all, or part of their earnings towards the 
 family budget. Moi*e than a third of the 368, about whom this fact 
 was known, had one or more persons wholly dependent on their earn- 
 ings. Forty-eight were married women, more than half of whom 
 had dependents, and the percentage of these married women who 
 had others wholly dependent upon them was double that of the un- 
 married women. 
 
 Of 439 of these girls, but fifty-five had entered work for the first 
 time since the war. Sixty-six had changed the type of work they 
 were doing, in forty-eight cases because of the possibility of making 
 better wages. Over 70 per cent, had continued the same type of work 
 which they had been doing before the war; and of these 62 per cent, 
 liad had a wage increase. 
 
 Comparative wage statistics were obtained for 240 girls, showing 
 tlie weekly amount received in 1916 and that received in 1918. Even 
 in the latter year, with the supposed great increase in wages, 89 per 
 cent, of them were earning less than |20.00 a week. In 1916. 99 per 
 cent, had been earning less than this amount, the wages of 55 per 
 cent, being under flO.OO ; in 1918 this percentage had dropped to in- 
 clude only a third ; while the percentage earning between flO.OO and 
 $20.00 had increased from 44 to 55 per cent. 
 
50 
 
 The foUofwing table shows the changes in the numbers in the dif- 
 ferent wage groups. 
 
 Weekly Wages. 
 
 1916. 
 
 1918. 
 
 Under $5.00( 
 
 24 
 
 65 
 
 43 
 
 46 
 
 SO 
 
 25 
 
 4 
 
 2 
 
 1 
 
 8 
 
 5— V.99 . - 
 
 30 
 
 8— 9.99 . - - 
 
 43 
 
 10—11.99, - — ^ 
 
 S9 
 
 12—14.99 . - 
 
 44 
 
 15 — 17,99, _ __ 
 
 Ad 
 
 18—19.99, . 
 
 14 
 
 20— 24199, 
 
 21 
 
 
 6 
 
 
 
 
 • It was found that in 243 cases, 168 had liad wage increases, seventy 
 were receiving the same wage, and five had had their wages decreased. 
 
 More than half of the girls — 56 per cent. — ^were doing work on a 
 time basis. The piece workers were apparently somewhat better 
 paid, for while only forty-two of the time workers were receiving 
 over $15.00 a week, seventy-seven of the piece workers were earning 
 over this amount. A large proportion of both-^83 per cent, of time 
 workers and 59 per cent, of piece workers— received less than $15.00 
 weekly. ^ 
 
 Over 60 per cfent. of the girls worked in factories, of these a large 
 number in garment and textile faictories. Forty-eight girls worked in 
 stores, and forty-three in oflSces, thirty-five did housework, and the 
 rest were scattered in various other occupations. 
 
 But 154 of these 502 girls had escaped illness expenditure during 
 1917. Three hundred and forty-eight, or over 69 per cent, had suf- 
 fered rflnancial loss in varying degrees because of accident or disease. 
 The type of care and the cost of that care were known in 284 (tf the 
 348 cases. The average expenditure was |27.78 for each of the 284 
 girls, or. $15.72 fOr each of the 502 girls in the group studied. This, 
 however, gives no idea of the burden imposed upon the few who suf- 
 fered severe illness. The total expenditure for the 284 girls was $7,- 
 890.02. Thirty^ninS per cent, of this, over $3,000.00, was spent by 
 nine per cent, (twenty-eight persons) of the group, and one-fourth of 
 this total expenditure was paid out by only ten girls. 
 
 A doctor was called in by 199 of the girls, medicine was bought by 
 139, ten girls had hospital treatment, and three had nursing care. An 
 unusually large proportion— 256— had had some expenditure for 
 dental care, due in part, no doubt, to the special talks which the Clubs 
 liave had, laying emphasis on the care of the teeth. Every girl who 
 Iiad had some expenditure had spent more than $5.00. The largest 
 number spent between $20.00 and $30.00. 
 
 One girl, making less than $5.00 a week in a factory, was trying to 
 pay off a bill of $166.00. Another, earning $5.00 a wedi at house- 
 work, had been ill for six months, had had two operations, and was 
 
51 
 
 confronted with a bill of 1^85.00. She had managed to pay a part of 
 this with some money she had saved, and was paying the remainder 
 on the installment plan. A third girl, working in a restaurant, earn- 
 ing 112.50 a week, hurt her knee and was obliged to be away from 
 work for six months and to spend over a hundred dollars. A fourth 
 girl, a cotton winder, earning |14.00 a week, had a bill of |119.00 for 
 weekly treatments of her nose and throat. Three of these girls were 
 living away from home, and had to meet these bills as best they could. 
 It is significant that two-thirds of the twenty-eight girls who had ex- 
 penditures of over 150.000 were earning less than 115.00 a week. 
 , The methods used to finance the cost of sickness were known in 383 
 cases. In many instances more than one method was used. Savings 
 were used almost four times as often as any other method — 210 times. 
 The girl's family helped her in fifty-nine cases. In forty cases she 
 belonged to a lodge, which was of some assistance, although the 
 benefits were too small to be of great help, and often were not re- 
 ceived. Eight girls carried commercial health insurance. In only 
 three cases were wages continued while the girl was ill. In no case 
 did a girl go to a charitable relief agency or to a money lender. Only 
 one girl had a "gift" to help pay her doctor's bill. In several cases 
 it was noted that the doctor made special rates. 
 
 No girl who must live on |12.00 a week can by herself save enough 
 to meet the unusual expenses of illness, and this, too, when her regular 
 income is suspended. Upon the health of the woman in industry de- 
 pends not only her efficiency and the profit of her employer, but the 
 welfare of the race and the vigor of our future citizenship. In the 
 face of these obvious truths, it cannot be questioned that some method 
 must be found by which the girl worker shall no longer have to bear 
 99 per cent, of the sickness burden alone, but that the industry and 
 the community to which her well being is essential, and upon which 
 rest a part of the responsibility for illness, shall also ^hare the cost. 
 
 EXTENT OP SICKNESS. 
 
 In studying, sickness as a problem, one of the first questions to be 
 considered is its extent. How many people are sick every year or 
 every day, how long do their illnesss last, and how much do they 
 lose on account of illness ? The most common method of answering 
 these questions and the one which will first be used, is by giving the 
 "average sickness rate"^ among large groups of people. 
 
 The facts are drawn mainly from the Kensington, Philadelphia, and 
 Western Pennsylvania Surveys, the Sickness and Dependency Study, 
 and i;^e establishment fund and Workmen's Circle statistics. 
 
 (') sickness rates are usually stated as follows: 
 
 1. Number of persons per 1,000 of the group or population under consideration disabled 
 
 per year. 
 
 2. Average length, of disability per disabled person. 
 
 3. Average number of days of disability per year per person included In group or pop- 
 
 ulation' under consideration. 
 
 4. Number of persons per 1,000 of the group or population under consideration disabled per 
 
 day. 
 
52 
 
 LIMITATIONS OF SURVEY^ FIGURES. 
 
 The rates of sickness deduced from sickness surveys must not, 
 of course, be taken as anything but a rough index of the actual 
 amount of illness. Aside from differences in race, sex and age com- 
 position of the population, which are to be taken into account in all 
 forms of social statistics, much depends upon the care with which 
 the figures are collected. Other things being equal, nurses, who were 
 the enumerators in Philadelphia Survey, are probably able to secure 
 more complete figures than lay investigators. Persons who have 
 the confidence of the families interviewed naturally obtain better 
 information than those of whom they feel suspicious. 
 
 The season of the survey is likely to have a decided effect on the 
 sickness rate, as sickness is generally more prevalent in winter and 
 in early spring, at the time when the Western Pennsylvania Survey 
 was taken. In August and September, the season of the Philadel- 
 phia Survey, sickness is usually at the minimum. 
 
 Even the definition of "sickness" used, varies from survey to sur- 
 vey. For instance, only "serious" cases of sickenss were enumerated 
 in the . Western Pennsylvania Survey. In any enumeration of the 
 illnesses occurring during a long period such as the illness histories 
 in the Kensington Survey, much sickness, especially that which is 
 trivial, is forgotten. Serious illnesses, especially those of wage- 
 earners, are likely to be remembered, but slighter ailments and chil- 
 dren's diseases are apt to be passed over. 
 
 The possibility of considerable variation in sickness rates is well 
 illustrated 'by three sickness surveys made in Framingham, Mass.,* in 
 the spring of 1917. In the first, special care was used to secure com- 
 pleteness and to include both disabling and less serious illnesses. 
 The enumeration was made by nurses and insurance agents. The 
 rate found was 6.2 per cent, for all sickness and 3.3 per cent, for per- 
 sons unable to work. But by adopting the definition of sickness used 
 in the Metropolitan Life Insurance Company surveys, which was 
 said to be "actual complete disability", the sickness rate fell to 1.8 
 per cent., while in a "patriotic census" taken among practically the 
 same group a few weeks later, a sickness rate of 3.2 per cent, was 
 reported. 
 
 SICKNESS KATES IN SICKNESS SURVEYS. 
 The Philadelphia Survey as has already been explained, included 
 all illnesses existing on the day of the investigator's visit. Of the 
 12,019 persons covered, 514 were found to be actually ill. at the time 
 of the survey. This indicates an average daily sickness rate ofi4.28 
 per cent. In other words, approximately forty -three persons in every 
 one thousand in the district covered by the survey are ill every day 
 
 (') Framingham Community Health and Tuberculosis Demonstration of the National Tuberculosis 
 Association. "The Sickness Census," Framtngham Monograph No. 2, MedicsJ Series No. 1. 
 
53 
 
 ill the year. Of these cases, however, only 36.7 per cent, were 
 '•unable to work", showing that on this basis an average of 1.57 per 
 cent, or sixteen per thousand of the persons visited are afflicted each 
 day with sickness which actually disables them. The Western 
 Pennsylvania Survey on the other hand, included only "serious" ill- 
 nesses and showed a daily sickness rate of 1.96 per cent. Of the 
 sick persons found, 94 per cent were "sick, unable to work," indicat- 
 ing that an average of 1.87 per cent, or approximately nineteen per- 
 sons out of every 1,000 were suffering from actually disabling illness 
 every day in the year. The fact that the Philadelphia Survey was 
 made in August and September, and the Western Pennsylvania Sur- 
 vey in March would easily account for T:he difference in the amount 
 of sickness found. 
 
 In the Visiting Nurse Study the illnesses existing on the day of 
 the visit were not recorded, and it was, therefore,. impossible to secure 
 the daily sickness rate. A total of 1,043 cases of illness were reported 
 for the year among_ the 2,588 individuals covered, indicating that 
 of this group 40 per cent, suffered illness during the year. 
 
 Some interesting calculations are suggested by the survey figures. 
 The average daily sickness rates which we have quoted seem to show 
 that in the district covered by the Philadelphia Survey each person 
 suffers on an average 5.7 days of actually disabling sickness each 
 year, and that the corresponding rate in the Western Pennsylvania 
 group is 6.8 days*per person.^ If we accept the rates of 1.57 per 
 cent, for disabling sickness and 2.71 per cent, for slighter ailments 
 established by this study as a fairly complete measure of sickness, 
 an average of 140,000 persons in the state are constantly, suffering 
 from severe, and 245,000 more from lesser illnesses, making a total 
 of 350,000 sick persons in the state every day in the year.'' The 
 average number of days of disabling sickness of adults per year 
 is probably over seven and the average number of days lost from 
 work is about six.^ 
 
 These figures we feel are undoubtedly lower than those which more 
 complete investigations would yield. Considering the mortality 
 rates in Pennsylvania, the comparative status of public health 
 appropriations and the large proportion of the population engaged 
 in industry, the days loss is probably much higher. The United 
 States Public Health Service estimates that an average of 3,000,000 
 persons are ill in the the United States at any given date, and that 
 each of the nation's 30,000,000 wage earners loses an average of nine 
 working days each year because of sickness. 
 
 SICKNESS RATES IN ESTABLISHMENT FUNDS. 
 Sickness rates, which are to a certain extent inaccurate may be 
 obtained from the records of societies paying sick benefits. As a 
 
 (i)See Table IV at end ot this section. 
 (!)0n tlie basis of 1918 estimated population. 
 
5i 
 
 rnle these funds have a "waiting period"^ and their records do not 
 take into account illness of a shorter duration than that period, or 
 that portion of illness cases continuing after the expiration of the 
 benefit period. 
 
 Therefore, only benefit funds which have the same "waiting period" 
 have comparable siclcness rates. Seventeen of the twenty Pennsyl- 
 vania funds studied by the U. S. Bureau of Labor Statistics) having 
 a membership of 97,000 persons, had the same seven day "waiting 
 period." The figures compiled indicate that during each year about 
 30 per cent, of the members of these funds have illnesses for which 
 they receive sickness benefit.^ 
 
 The Pennsylvania Funds'^ closely resemble those in other parts of 
 the country in this respect, for the average number of illness cases 
 per 100 members in all the funds studied is twenty-six. The average 
 numbjer of illness cases in the "Workmen's Sick and Death Benefit 
 Fund of America," covering a five-year experience, was twenty-four 
 per 100 members. The reports of the Workmen's Circle for the year 
 1916 shows a slightly lower rate, twenty-three cases per 100 members 
 per year.* A disproportionate number of its members, however, are 
 clerks and "business men" (probkbly proprietors of small retail 
 stores.) Persons in such occupations are subject to the health 
 hazards of a sedentary life, but comparatively little exposed to the 
 more definite occupational poisonings and hazards. 
 
 DURATION OF ILLNESS. 
 
 Average rates of illness covering persons both sick and well indicate 
 the magnitude of the sickness problem, as a whole, but do not in any 
 way show the burden of sickness to the individual. One man may es- 
 cape illness altogether, and his neighbor lose two weeks from work, 
 while a third is ill six months, uses up his savings and is left with a 
 burden of debt. 
 
 Statistics on the duration of illness have been collected from two 
 sources; Sickness Surveys, and the actual records of Establishment 
 apd Sick Benefit Funds. 
 
 SICKNESS SURVEY FIGURES.' 
 
 The Western Pennsylvania and the Philadelphia Survey figures 
 would seem to be on the most closely comparable basis, as both cover 
 only diseases existing at the time of the survey and duration to that 
 date. 
 
 !^)?'®,^''^f"i5?^P'''*'°5" '^ P'*,*i,"!^ "* ?^ beginning of an Illness before benefits are paid. 
 (2) See Table XIV at the end of this section. h""i. 
 
 («)Infonnation f^onceining twenty Pennsylvania "establiEhment fuiids" -was included In a natinn. 
 wide InTestigation of such funds by the United States Bureau of Labor Statisti™ in ini7 
 Through the kindness of Dr. Royal Meeker, the Chief of the Bureau, it was possfble for the Com^ 
 mission to secure this material, as well as figures on the "Workmen's Circle" a natinnni Tniihiai 
 benefit society with about 40,00.0 members, in advance of pnblieation a, national mutual 
 
 '(*)I'or the year 1916, the ''Workmien's Circle" reported 6.9 per cent, of Its membershin 111 
 in tte first quarter; 5.9 per cent in the second; 5 2 per cent, in the third; and 5 per cent in the 
 fourth, or a total, disregarding illnesses of more than one quarter, of twenty-three casetf iipr iSn 
 members, for the year. ' >."ioc!. nei x\"j 
 
 ("jThe Western Pennsylvania figures do not include negroes, 
 
55 
 
 But in the Philadelphia Survey special effort was made to ferret out 
 chronic illness, while the Western Pennsylvaniaf Survey dealt only 
 with "serious illness." The results for Philadelphia are startling. 
 Twenty-eight per cent, of the cases in this study were chronic, last- 
 ing three years or more, and an additional 25 per cent, lasted longer 
 than one year. In other words, over half the cases where duration 
 was known lasted more than a year, bearing out the conclusion that 
 illness among employees is too often untreated in its early stages 
 and that many half-sick men continue at work. Even the 25 per cent, 
 of illness of more than a year's duration found in the Western Penn- 
 sylvania Survey is significant of a situation which demands attention."^ 
 
 In the latter study 56 per cent, lasted longer than a month, while 
 this figure is raised to 76 per cent, in the Philadelphia Survey. In 
 both surveys, the number of very short illnesses, of less than one 
 week's duration, was relatively insignificant. 
 
 In the Sickness and Dependency Study, it was possible to tabulate 
 tlie average length of the 386 cases of illness which had ended at the 
 time of the survey. Seventy-five per cent, of these lasted longer than 
 one month, the largest proportion, or 22.2 per cent., falling in the one- 
 to-three month group, while in the Kensington Survey, 42.3 per cent, 
 of the illnesses lasted longer than a month. In this survey, 421 cases 
 of illness of wage-earners were reported with a total duration of 16,- 
 090 days, or more than thirty-eight days per case. In these two 
 studies a small percentage of long illnesses of over a year's duration 
 was found. But this is probably due to the relative incompleteness 
 of these studies as compared to the Philadelphia and Western Penn- 
 sylvania Surveys. 
 
 ESTABLISHMENT AND SICK BENEFIT FUND FIGURES. 
 
 A study of +welve well organized establishment funds, four per 
 cent, of which were in Pennsylvania, was made during the summer 
 and fall of 1918 by the Connecticut, Ohio, Illinois and Pennsylvania 
 Health Insurance Conimissions with the help of Mr. Boris Emmet of 
 the United States Bureau of Labor Statistics. The results of this 
 study were tabulated by the Ohio Commission in ten groupings. The 
 benefit associations selected for study include employees in the fol- 
 lowing occupations: railroad transportation, manufacture of iron 
 and steel products, textiles, steel mill, general foundry work and let- 
 ter carriers. 
 
 The most important facts to be gathered from this study relate to 
 the duration of the illnesses for which benefit had been paid. As 
 most of the funds had a seven day "waiting period," only cases of 
 more than eight days' duration were used in the combined experience 
 tables. Because of differences in administration of benefits and 
 hazards of the several occupations represented, the proportions of 
 cases of long and short duration vary widely in the different funds. 
 
 (')See Table X at end of this sention. 
 
56 
 
 For instance, 55.73 per cent, of the sickness in Fund No. 1 lasted less 
 than two weeks, while in Fund No. 10 only 16.1 per cent, was of 
 This duration. In the "over-six-months" group, Fund No. 1 had 1.39 
 per cent, of its cases, while Fund No. 10 had 5.24 per cent. 
 
 Taking the combined experience of these funds, however, it was 
 found that 34.56 per cent, of the cases lasted less than two weeks; 
 34.68 lasted more than a month, and 3.26 per cent, more than six 
 months.^ 
 
 The illnesses of females seem to be of longer duration than those 
 of males, according to the experience of one fund having both men 
 and women in its membership ; for while 40.98 per cent, of the illness 
 c^ses among the men were of less than two weeks' duration, only 27.73 
 per cent, of the women's illnesses were in that group. Thirty and^ 
 six; one-hundredths per ceiit. of the men's -illnesses and 42.65 per cent, 
 of the women's, lasted longer than one month, raising the percentage 
 of illnesses for the fund, of more than one month's duration, to 37.0^ 
 per cent., or slightly higher than the combined experience of the 
 twelve funds. ^ We cannot be sure, boAvever, that this higher rase 
 is due to the inclusion of wonaen, because in the United States Letter 
 Carriers 'Association, one of the twelve funds studied, 42.9 per cent. , 
 of the illnesses lasted more than one month. 
 
 One of^the funds studied by the Pennsylvania Commission was the 
 Pennsylvania Eailroad (East) "Voluntary relief Department. Al- 
 though, as is explained in the section on "Losses to Industry because 
 of Sickness among Employees," this study is not complete, 64,849 
 of the completed cases of illnesses and non-industrial accidents which 
 had occurred between 1913-1917 were tabulated. As this fund has a 
 waiting period of only three days, a larger number of short illnesses 
 are included than in the studies of the other funds. Seventy-four per 
 cent, of the cases lasted less than two weeks, and 15 per cent, from 
 two to four weeks, leaving only 11 per cent, in the group which lasted 
 longer than one month-^ When we deduct the 27,234 cases of less 
 than eight days duration, we find that the proportion of the remainder 
 which lasted less than two weeks is reduced to 55.7 per cent., and that 
 18.11 per cent, lasted longer than one month. As this Fund pays sick 
 benefits during the entire period of illness, and as only completed 
 cases were included in the study, there were undoubtedly a very large 
 number of chronic and serious cases of more than one month's dura- 
 tion which were still receiving benefits and for that reason were not 
 recorded. 
 
 It is clear that of course the shorter the "waiting period," the larger 
 the percentage of short illnesses. Statistics from one fund which 
 pays benefits from the first day of illness, were studied.* The results 
 
 (>)See Table XI at end of Section. 
 
 (")See Table XII at end of this sention. 
 
 (")See Table XIII at end of this sefition. 
 .«<',',2*** ^""^ * flve-year period, 1912 to 1916 inclusive, for approximately 47,000 persons In some 
 42 different occupational groups was made available to the Commission Ini advanoe of publication 
 through the kindness of Dr. Royal Meelter, of the Bureau of I,abor Statistics. 
 
57 
 
 of five years' experience showed that 19.1 per cent, of the illnesses 
 in this group ware of less than one week's duration. Forty-six and 
 eight tenths per cent, lasted less than two weeks, and a total of 71.5 
 per cent, lasted less than a month. Of the 28.5 per cent, lasting ovi^r 
 one month, more than two-thirds were between one and four month t?, 
 and 2.2 per cent., or 954 cases, were over six months in duration. 
 
 However we may interpret these varying figures, we are struck 
 with the fact that in all the different groups studied at least one- 
 third of the illnesses are of relatively long duration, and when we 
 realize that a large proportion of those who are ill are the house- 
 keepers or wage-earners whose sickness means not only expenditures 
 for medical and hospital care, but also suspension of the family in- 
 coine, we begin to see the enormity of the burden which sickness is im- 
 posing. 
 
 EXTENT OP SICKNESS IN PENNSYLVANIA AS SHOWN BY DRAFT 
 REJECTIONS FOR PHYSICAL CAUSES.i 
 
 Another index of health conditions among a considerable group of 
 Pennsylvania employees is the proportion of rejections for physical 
 cases in the dtaf t of April, 1917. The men of draft age may be as- 
 sumed To be at the height of their physical powers. Yet in Pennsyl- 
 vania the proportion of thofee examined who were rejected for 
 physical causes was 46.67 per cent.^ This was the highest proportion 
 found in any state in the union, the average for the whole United 
 States being but 29.11 per cent. It is unfortunate that the rejections 
 by the various local boards are not given on the same basis so that 
 variations in different localities can be discussed at this time. In- 
 dividual boards and physicians may, of course, vary in the strictness 
 of their examinations, but it would seem that over a whole state these 
 differences would tend to balance each other. 
 
 The years from twenty-one to thirty-one are those in which men 
 should be vigorous and fit, in prime physical condition. The draft 
 army represents a large proportion of our wage-earning population, 
 and the figures in the Provost Marshal General's report are startling. 
 When almost half the men examined are not in condition for military 
 service, sofliething is radically wrong. 
 
 The conclusion seems justified that Pennsylvania men between 
 twenty-one and thirty-one years of age are in poorer physical condi- 
 tion than in any other state.' This fact is not surprising, however, 
 when we consider that almost three-fourths of our school children 
 who are examined are found to be physically defective. The nature 
 of the defects found among both the school children and mjen of draft 
 age are discussed in section V. 
 
 (')A detailed study of the nature of disabilities causing rejection is now being made In the 
 office of the Provost Marshal General. 
 
 (')Report of the Provost Marshal General to the Secretary of War; November, 1917. 
 (')See Table I at end of this section. 
 
38 
 
 EXTENT OF ILLNESS BY SEX AND AGE. 
 
 The results of the Philadelphia, the Western Pennsylvania and 
 the Pittsburgh Sickness Surveys have been tabulated to show the 
 extent of sickness by sex and age groups.^ The general experience 
 under health insurance laws shows a higher sickness rate for females 
 than for males. In contrast to this, both the Western Pennsylvania 
 Survey and the figures for Pittsburgh alone show' a lower rate for 
 females, where all ages are considered, but in the age groups fifteen 
 to thirty-four the sickness rates for females are higher than the cor- 
 responding rates for males, both for all illnesses, and for disabling 
 illness. In the Philadelphia Survey however, the rate for illnesses at 
 all ages was slightly higher for females than for males, 4.3 per cent, 
 instead of 4.2 per cent., but for disabling sickness it was 1.4 per 
 cent, for females and 1.7 per cent, for males. The difference in favor 
 of the female sex does not show itself clearly until the age period 
 thirty-five to forty-four years is reacTied. In the earlier years, cover- 
 ing childhood and the principal periods of childbearing and wage- 
 earning for the sex, the sickness rate is slightly higher in most cases, 
 bearing out the experience under Health Insurance.^ 
 
 A possible explanation of these differences in the sickness rates of 
 males and females suggests the responsibility of industry for a cer- 
 tain part of existing illness. The great majority of women between 
 thirty-five and fixty-five years of age are housewives, whereas most 
 men are gainfully employed during this age period. Not only the 
 direct, but the cumulative eiffect of industrial conditions may begin 
 to be felt in middle life, and thus appreciably raise the sickness rate 
 of older men. The higher rate for women under Health Insurance 
 applies only to working women, and most women workers are found 
 in the age-groups fifteen to thirty-five years. 
 
 Such an explanation is borne out by the statement of Dr. B. S. 
 Warren and Mr. Edgar Sydenstricker of the United States Public 
 Health Service, that: 
 
 "In view of the generally accepted fact that in the population as a 
 whole the female mortality rate is less than the male, it would seem 
 reasonable to assume that, excluding confinements, the female mor- 
 bidity rate is not greater than the male. Among women employed 
 as wage-workers, however, these conditions are apparently reversed."' 
 
 Variations in the sickness rate according to age are simpler than 
 The sex differences. There is a steady rise in each case from the 
 youngest to the oldest groups, with the exception of disabling sickness 
 for females in the Philadelphia Survey. In that case, the rate for 
 
 OWhlte persons only in Western Pennsylvania. 
 (2) See Tables VI, Vn and VIII at the end of this section. 
 
 (»)B. S. Warren and Edgar Sydenstricker; Health Insurance; Its Belation to the Public Health, 
 Bulletin 76, page 28. ■ ' ' 
 
59 
 
 the years thirty-five to forty-four is slightly lower than for the twenty 
 years preceding. This again points to the possible influence of wage- 
 earning and child-bearing in the Philadelphia group. 
 
 EXTENT OF SICKNESS BY COLOR, RACE AND LOCATION. 
 
 The negro population has a higher sickness rate than the white, 
 according to available evidence. Since negroes from the south are 
 at present migrating to Pennsylvania in large numbers, this meaiis 
 the possibility of a great increase in the sickness problem of the 
 .statBj particularly during the period of acclimation when pre-dis- 
 position to disease is markedly shown. The average daily sickness 
 late among white policy-holders in the Western Pennsylvania Survey 
 was 1.75 per cent ; among colored, 2.08. 
 
 In each city for which these comparative figures have been tabu- 
 lated, negroes have the larger amount of sickness. In Pittsburgh the 
 rates were 1.62 per cent, for whites and 1.72 for negroes ; in Brad- 
 dock, 1.^6 and 2.34 ; in McKeesport, 1.95 and 2.41 ; in Uniontown, 2.22 
 and 2.79 respectively.^ 
 
 Three of the seven districts covered by the Philadelphia Survey 
 were inhabited mainly by negroes, and, while the average sickness 
 rate found in the survey was 4.28 per cent,, the rates in these districts 
 were 4.45, 9.30 and 3.87 per cent., respectively. The abnormal rate 
 of 9.30 was in a district of negroes fresh from the soiifch, receiving low 
 wages and living under crowded, insanitary conditions. Dr. Miller, 
 who had the survey in charge, felt that unless drastic measures to 
 improve health conditions were taken in this neighborhood, there 
 was danger of an epidemic which might menace the city. 
 
 If we consider mortality statistics as an indication of the extent 
 of sickness, the same high rate among negroes appears. In 1916 the 
 death rate in Pennsylvania from all causes was 14.3 per 1,000 white 
 persons as against 23.6 for the colored population. 
 
 The rate among negroes in the cities was about 15 per cent higher 
 than among those in the rural districts. Analyzed by diseases, the 
 greatest differences appear in organic heart diseases, pneumonia and 
 tuberculosis in all its forms, where the rates for the colored are more 
 than double those for the white population. Tuberculosis of the 
 lungs, for instance, had a rate in 1916 of 105.0 per 100,000 for the 
 white population, but a rate of 389.3 for the colored. Other forms of 
 tuberculosis showed rates of 7.7 vs. 16.3 and 9.4 vs. 25.8, more than 
 twice the rate for the white population in each case. Communicable 
 diseases, diabetes, cancer and suicide are apparently slightly less 
 frequent among the colored than among the white. 
 
 The Metropolitan Life Insurance Company made for the Commis- 
 sion a special compilation of claim-rates in Pennsylvania among 
 Industrial Policy Holders, classifying the insured by color, over a 
 
 (')See Table V at the end of this section. 
 
GO 
 
 period of three years — 1915, 1916, and 1917.^ Rates are given for 
 twenty-six localities in the state, in additiofl to fourteen districts in 
 Philadelphia and four in Pittsburgh. In practically every instance, 
 the rates are from 50 to 100 per cent, higher for the colored than for 
 the white policy-holders. For the entire state the claimrates were 
 12.4 for the white, in 1917, and 15.7 for the colored. In AUentown, 
 Erie, Johnstown, McKeesport and York, the rate for the colored was 
 practically double that for the white, although in Bristol, PottstoWDj, 
 Pottsville and Scranton, it was appreciably lower. These claimrates, 
 of course, must be viewed in the light of varying sex and age charac- 
 teristics of the several groups, and of the degree to which the com- 
 pany has developed its Nursing Service in the district. 
 
 Examining the claimrates by cause of death, the same differences 
 appear as are evident from the general mortality statistics of the 
 state. Deaths from typhoid fever, tuberculosis, and pneumonia; show 
 decidedly higher rates for the colored, while communicable diseases, 
 cancer, cerebral hemorrhage and external causes are somewhat lower. 
 
 In 1910 there were 193,919 negroes in Pennsylvania, an increase of 
 23.6 per cent, over the number in 1900. The great majority of the 
 108,186 who were gainfully occupied, were unskilled laborers, ser- 
 vants, teamsters, and laundresses — belonging to a group where 
 standards of wages, housing, and occupation subject them to special 
 hazards. Philadelphia in 1910 ranked fifth among the cities of over 
 100,000 population in which lived more than 1,000 negroes, and the 
 increase had been 34.9 per cent, over the number in 1900. In Pitts- 
 burgh the increase had been 25.9 per cent. It is probable that since 
 1910 the increase in the negro population has been much greater. As 
 Dr. Miller says, unless drastic measures are taken to improve health 
 conditions, the negro population may become a serious danger. 
 
 The newer immigrants from overseas appear in the Philadelphia 
 survey to have a lower sickness rate than the whole area surveyed. 
 The district inhabited by Jews, Poles, and Austrians had a sickness 
 rate of 3.88 per cent. ; the Italian district, one of 3.23 per cent.,'' as 
 against the average rate of 4.28 found in the survey. 
 
 Considerable variation in different localities is brought out by the 
 sickness rates for various towns in the Western Pennsylvania Sur- 
 vey. The highest rate for wliite persons is 2.22 per cent, in 
 Uniontown, the lowest, 1.56 in Braddock, a difference of 42 per cent. 
 What the main factors in producing such a difference may be, 
 whether race, age distribution, epidemic, occupation, or general 
 sanitary conditions, we have at present no means of knowirig 
 
 As a rule, however, it would seem that in the industrial communi- 
 ties of the state and the parts of large cities inhabited chiefly by 
 wage-earners, the sickness rates are much higher than in residential 
 
 (MSee Table XVII at end of this sentlon. 
 C'jSee Table IX at the end of this section. 
 
61 
 
 sections. In the Western Pennsylvania Survey the six- highest sick- 
 ness rates in the fifteen districts enumei-ated were those for Union- 
 town, 2.22.; Altoona, 2.16 ; Scranton, 2.10 ; Shamokin, 2.08 ; McKees- 
 Ijort, 1.95; and Shenandoah, 1.88. Death rates indicate the same 
 tendency. For instance, the United States Public Health Service 
 phows that the death-rate throughout the United Stiates registration 
 area in 1913 was 14.1 per 1,000 of population, but in Johnstown it 
 was 16.9 ; in McKee's Rocks, 16.9 ; in Shenandoah, 18.9 ; and in Brad- 
 dock, 23.2.^ It is further stated that "As it is generally recognized 
 that mortality returns in localities of this type are more or less 
 incomplete, it is safe to say that the rates cited are lower than more 
 thorough and complete vital statistics would show." 
 
 This fact is brought out particularly by studies of infant death 
 rates, and of the death rates of the professional vs. the wage earning 
 groups in various communities. 
 
 An interesting comparison is made by Dr. Hayhurst in his study 
 of Occupational Diseases in Ohio, between the death rates among 
 members of the professional class, and those in a wage earning group. 
 Six preventable causes of death were taken and a higher death rate 
 was found from each of the six, among the wage earning group. The 
 death rates from "tuberculosis" and "accidents and injuries" for the 
 wage earning group were more than double those for the professional 
 group. i> 
 
 Mortality Rate 
 
 per 100 
 
 
 Deaths. 
 
 
 
 
 
 
 1 
 
 
 
 2. 
 
 o 
 
 
 
 A 
 
 ^ 
 
 
 
 § 
 
 •a . 
 
 
 
 
 H 
 
 
 
 bo 
 
 a 
 
 
 
 
 a 
 
 •sr 
 
 
 
 
 
 
 03 
 
 .■SB 
 
 
 
 <K 
 
 S 
 
 
 
 & 
 
 fi^ 
 
 
 
 
 Tuberculosis, 
 
 Accident and injuries, 
 
 Pneumonia, 
 
 Suicide, 
 
 Typhoid, 
 
 Accidental Poisoning, 
 
 Total, 
 
 
 ^ 
 
 8.22 
 
 17.53 
 
 5.20 
 
 11.85 
 
 6.89 
 
 8.48 
 
 2.13 
 
 2.76 
 
 1.S8 
 
 2.35 
 
 .43 
 
 .7§ 
 
 24.75 
 
 43.75 
 
 A comparison of rural and urban death rates indicates that while 
 the urban death rate is higher than the rural, within the last ten 
 years greater decreases in this rate have been effected in cities than 
 
 <')U. S. Public, Health Bulletin, No. 76, p. 27. 
 
 (^)H!. R. Hayhurst, Industrial Health Hazartls and Occupational Diseases in Ohio, page .16. 
 Table compiled from United States Bureau of Vital Statistics Report. 
 
G2 
 
 in country districts. In Pennsylvania botli the rural and the urban 
 rates are higher than the corresponding rates for the registration 
 area as a whole. From 1906 to 1916 the decrease of the urban death 
 rate in the state was three times as great as the decrease in the 
 I'ural districts. 
 
 EXTENT OF SICKNESS AS SHOWN BY THE GENERAL DEATH 
 RATES IN PENNSYLVANIA. 
 
 The extent of sickness in the state can be roughly estimated by a 
 study of d6ath-rates, since mortality statistics are considered to some 
 extent an index of morbidity rates. Pennsylvania has been part of 
 the United States registration area for death-rates since 1906, and it 
 is therefore possible to study the death rates in the state from that 
 year. The last published rates are those for 1916, obtained from the 
 Census volume on Mortality Statistics. Unfortunately the last 
 published report of the state board of health is for 1914. 
 
 In spite of a general decrease in the death-rate, certain most 
 alarming features are evident. In Pennsylvania the death-rate as a 
 whole fell from 16.0 per 1,000 of the population in 1906 to 14.6 in 
 1016, or 8.7 per cent.^ But the rate in Pennsylvania from diseases 
 of the circulatory system rose from 149.3 to 189.8 per 100,000, or 27.1 
 per cent., and for genito-urinary diseases (nonvenereal) from 101.1 
 to 120.5 per 100,000 or 19.1 per cent. 
 
 In 1916, Pennsylvania showed a higher death rate in nine of the 
 fourteen groups in the International Classification of diseases than 
 the rate for the registration area. The general death rate per 1,000 
 population in 1916 was 13.9 for the registration area, and 14.6 for 
 Pennsylvania. The greatest difference was between the rates for 
 deaths from diseases of the respiratory ^stem, where Pennsylvania 
 had a rate of 202.3 per 100,000 and the registration area 165.4. 
 Between 1915 and 1916 in Pennsylvania marked increases in the 
 death rates are noted in nine of the fourteen international disease 
 classifications. 
 
 Marked increases were noted in Chester, the general death ' rate 
 there being 21.1 per thousand in 1916, whereas it had been 16.1 in 
 1915 ; in Philadelphia the rate increased from 15.6 in 1915 to 16.2 in 
 1916 and showed a further increase in 1917 to 17.1, higher than e'ithor 
 the New York or the Chicago rate. In Pittsburgh the rate was 
 higher and the increase more rapid. In 1915 it was 15.2 ; in 1916 it 
 rose to 17.4 and in 1917 to 18.1. 
 
 The most significant decreases in the death rate in the last ten 
 years have been made in those diseases which can be controlled in 
 large measures by community action. Typhoid fever dropped from 
 54.8 per 100,000 in the state in 1906 to 13.6 per 100,000 in 1916. 
 Most of this decrease has been in the urban rate. In Philadelphia 
 
 (')Table XV at the end of this section gives the dPath rates in Pepnsylvjinia for the various 
 classes of diseases between 1?0§ and 3?iq. - . • 
 
63 
 
 the trate has fallen from 74.3 to 7.6, and in one year, 1914, it was 
 reduced ivom 15.7 to 7.6. In Pittsburgh the rate from typhoid has 
 nuetuated from 141.1 in 1906 to 9.0 in 1916. 
 
 In a study published in 1916, called "The Sanitary Index,"^ Dr. 
 Batt expresses the opinion that the decline in the death rate during 
 the last ten years is not satisfactory outside "those diseases that are 
 the objects of sanitary attack." lie enumerates among the latter the 
 "acute communicable diseases of epidemic type," infant mortality, 
 and tuberculosis. These diseases form "the adopted field of public 
 Jvealth activities," and the «death-rate from them is termed "the 
 Sanitary Index." The death-rate from the other diseases, which 
 make up about three-fifths of the total mortality, is calledr-the "resi- 
 dual death-rate." Dr. Batt points out that while the "sanitary 
 index" 'decreased from 6.5 to 4.5 per 1,000, or 30.8 per cent., between 
 1906 and 1915, the "residual death-rate" fell only from 9.5 to 9.3 or 
 2.1 .per cent. It increased in second and third-class cities and in bor- 
 oughs of less than 10,000 population. Dr. Batt concludes : 
 
 "It is -therefore apparent that almost the entire reduction that has 
 taken j)lace in the general death-rate has been due to the decline in 
 the deaths from those diseases that are the objects of sanitary attack. 
 
 "By the segregation of the causes'of death into two groups we are 
 also (bringing into due prominence through the residual death rate 
 the mecsessity for safeguarding industrial workers and for personal 
 hygiene on the part of individuals. Old age should be the pre- 
 eminent cause to be attained in this group."^ 
 
 In other words, the death-rate gives direct evidence of the greatest 
 need for discovering ways and means to protect the lives of indus- 
 trial workers whose health now is the least carefully preserved and 
 is subject to the greatest hazards. 
 
 In a study of death rates in the state from the four special causes 
 which most emphasize the community's responsibility for health con- 
 ditions, typhoid fever, tuberculosis of the lungs, diarrhea and enteri- 
 tis, and accidents, we find that in Pennsylvania the rates are higher 
 for three out of four of these causes than are the corresponding rates 
 for the registration area."* 
 
 The rates for all four causes of death decreased materially during 
 the ten year period, but in every case they increased alarmingly 
 between 1915 and 1916; diarrhea and enteritis from 90.7 to 101.7, 
 accidents from 92.6 to 107.8, typhoid fever from 12.3 to 13.6, tubercu- 
 losis of the lungs from 110.6 to 112.3 per 100,000. Altogether these 
 four causes accounted for approximately one-fifth of the total number 
 of deaths in the state in 1916, and the death rate from diarrhea and 
 enteritis is the most important factor in determining the infant death 
 rate. In 1916 in the registration area this was the cause of almost 
 25 per cent, of the deaths under one year of age. 
 
 (i)PemisrlTania Health Bulletin, rebniary, 1916. 
 
 (2)WhiIe Dr. Batt inoludes tuberculosis in the "sanitary index," Dr. Miller of the Philadelphia 
 Bureau Of Health states that "The tnbenmlosis death-rate remains practically constant with little 
 fluctuation from year to year.*' 
 
 (»)See Table XV at the end of this section. 
 
64 
 
 The possible power of control over these four causes of death is 
 well illustrated by the reductions which individual districts have 
 succeeded in making. Typhoid fever has been spoken of. Just as 
 marked is the reduction in the rate from accidents which Pittsburgh 
 and Scranton made in the ten year period 1906-1916, or the decrease 
 in deaths from diarrhea and enteritis affected in Philadelphia, during 
 the same period.' The rate from diseases of the puerperal state in 
 Pennsylvania increased from 16.9 per 100,000 in 1906 to 18.0 in 1916. 
 The figures of the Philadelphia Bureau of Vital Statistics show that 
 in 1917 there were in the city 259 deaths of women from diseases of 
 the puerperal state. Since the total number of births was 43,000, 
 this makes a rate of over six per thousand — or over 600 per 100,000 
 births. 
 
 The crying necessity for improved maternity care is clearly illus- 
 trated by these figures. The United States Children's Bureau 
 estimates that over half the deaths from causes connected with 
 childbirth are preventable. The time of confinement is the most 
 critical period in the lives of both mothers and babies, and every 
 means should be used to provide protection for these lives at this 
 crucial time. Not only may the-future health of the particular child 
 depend upon this care, but the lives and health of many more poten- 
 tial babies whose strength so often is permanently impaired through 
 inadequate care of the mother at childbirth. 
 
 INFANT DEATH-KATE. 
 Since infant mortality is truly, as it has be^ called by the great 
 English authority. Sir Arthur Newsholme, "the most sensitive index 
 we possess of social welfare and of sanitary administration," then, 
 indeed, health conditions in Pennsylvania demand improvement, and 
 never before so insistently. The war has taught us conservation on 
 every hand, but particularly the conservation of the lives of those 
 who must carry on the ideals for which our soldiers went to death — 
 the lives of little children, upon whom rest the future of the nation. 
 And in so far as Pennsylvania has been extraordinarily wasteful in 
 the past, she must now make every eflfort to make good the loss, and 
 allow no life to be needlessly sacrificed. What once might have been 
 considered a humanitarian task now becomes a patriotic necessity. 
 President Wilson, in approving the plan for "Children's Year" 
 recently inaugurated by the Children's Bureau and the Woman's 
 Committee of the Council of National Defense, said : 
 
 "Next to the duty of doing everything possible for the soldiers at 
 the front, there could be, it seems to me, no more patriotic duty than 
 that of protecting the children, who constitute one-third of our popu- 
 lation. 
 
 "The success of the efforts made in England in behalf of the chil- 
 dren is evidenced by the fact that the infant death rate in England 
 for the second year of the war was the lowest. in her history. Atten- 
 
 (>)See Table XVI at the end ol this section. 
 
65 
 
 tion is now being given to education and labor conditions by the 
 legislatures of both France and England, showing that the conviction 
 among the allies is that the protection of childhood is essential to 
 winning the war." 
 
 The infant death-rate in Pennsylvania in 1916 was 110 per 1,000 
 births ; ill 1916, 114 per 1,000. The county having the lowest rate in 
 1915 was Gameron, with 53 per 1,000 the highest, Fayette, with 160 
 per 1,000.^ In 1917, the death-rate for children less a year old 
 was higher in Philadelphia than in any other city of similar size 
 (over 1,000,000) jp the United States. The rate in Philadelphia was 
 101.0 per 1,000 living births in 1916. This increased to 110 in 1917. 
 The rate in Brooklyn in 1917 was 84.9 and in New York 88.8. The 
 rate for the registration area as a whole was 101. The Pittsburgh 
 rate in 1917 was 116.2. This was the second highest rate for any city 
 in the country of 150,000 population. 
 
 Every city in the United States with a population of over 500,000, 
 had a material decrease in the infant mortality rate between 1916 
 and 1917 with the exception of Philadelphia, Pittsburgh and Balti- 
 more. The increases in both Philadelphia and Pittsburgh were much 
 greater than in Baltimore, although the Baltimore rate was higher. 
 In 1916 and 1917 the infant mortality rate in Pittsburgh formed 18 
 per cent, of the total mortality. Among cities having less than 
 50,000 population, Norristown had the highest rate in the country in 
 1917^-167.7 per 1,000. Five cities of similar size had infant death 
 rates in 1917 of less than 50 per 1.000. . 
 
 A comparison of these shamefully increasing Pennsylvania rates 
 with those shown by countries where intelligent and patriotic meas- 
 ures are being taken to preserve the lives of children by adequate pre- 
 ventive measures is illuminating. The infant mortality rate in Eng- 
 land in 1916 was only ,91 per 1,000, the lowest in her whole history, 
 while New Zealand succeeded in reducing her infant deaths from 80 
 per 1,000 in 1907 to 50 in 1915. 
 
 The differential death-rate between industrial and residential 
 localities is particularly marked in connection with infant mortality. 
 For instance, in Pittsburgh, in the year ending April 1, 1916, the 
 infant death-rate in the crowded twenty-second ward was 135.9. In 
 the fifteenth, along the river in a mill district, it was 121.9. In the 
 seventh and the fourteenth wards, which are high-grade residential 
 sections, it was 60.4 and 89.5 respectively.^ 
 
 The United States Public Health Service found as marked an excess 
 in the proportion of infant deaths in the iron and steel towns of the 
 state as in the general death-rate. In these towns, moreover, wage 
 work by mothers of young children, to which high infant mortality 
 
 :.(>) Figures enpplled by PeraisylTania Department of Health to Chief of Division of CSilld 
 'p)Dfapensary Ai(} Sooiety, Tuberculosis League of Pittsburgh, 1st Surrey Heport, pages 80-51. 
 
66 
 
 is often attributed, was very infrequent ; yet, while deaths of children 
 under five formed 27 per cent, of all deaths in the United States 
 registration area during the five-year period — 1909-1913, 10 per cent, 
 and 17 per cent, in the residential towns of Brookline, Massachusetts 
 and East Orange, New Jersey, they were 67 per cent, of all deaths in 
 Monessen, 57 per cent, in Homestead, 55 per cent, in South Bethle- 
 hem, 51 per cent, in Braddock, 47 per cent, in Carnegie, 45 per cent, 
 in Steelton, and 40 per cent, in Johnstown.^ 
 
 The &fst of the well-known studies of infant mortality of the 
 Federal Children's Bureau was made in Johnstown, and furnishes 
 additional information on the dangerous state of Pennsylvania's 
 infant death-rate. The investigation covered all of the Johnstown 
 children born in 1911, who could be traced, and all death-rates are 
 based on the number of this group who died within one year of birth. 
 
 There is a marked difference in that city also in the infant death- 
 rates in residential and industrial sections. In the downtown section 
 where the homes of many of the well-to-do are found, the rate of 
 infant deaths was only 50 per 1,000. In Kernville, which also con- 
 tained a large proportion vyf prosperous families, it was 57.7. The 
 rate in Woodvale, among unskilled mill workers, was 271 per 1,000, 
 and in Prospect, near one of the large steel plants, it was 200 per 
 1.000. The average rate for the city as a whole was 134 per 1,000. 
 Other tabulations show the difference in the rate according to the 
 kind of infant care. For mothers who were attended by physicians 
 at confinement, the rate was 100.5, 93.2 for Americans and 139.7 for 
 the foreign bom, but the rate was 179.7 in all cases in which a mid- 
 wife attended the birth, there being no appreciable difference in the 
 rate between native and foreipi-bom. Most striking of all is the 
 difference in the rate according to the income of the father. In cases 
 wbere fathers had incomes of |521.00 a year or less, the rate of infant 
 mortality was 197.3 ; it steadily declined in the higher income groups, 
 reaching 102.2 in cases in which the father's annual income was 
 .lil ,200.00 or more.2 
 
 The health problem theo seems to be largely dependent upon the 
 sibandards of living and the economic status of the family, and the 
 responsibility for making these what they should be rests not only 
 itpon the individual effort, but in a large measure upon the com- 
 munity. 
 
 The conclusion reached by the Children's Bureau is that : 
 
 "The Johnstown report shows a coincidence of <nid{rp?iicl fathers 
 overworiied and ignorant mothers, and those hazards to the life of 
 the offspring which individual parents cannot avoid or control 
 because they must be remedied by community action." 
 
 A similar need exists in many other places besides Johnstown. 
 The problem will no doubt be rendered more acute by the inevitable 
 
 (>)TTnltert States Public Health Bulletin No. 78, page 27 
 (')See Table XIX at the end pt this section. 
 
67 
 
 influx of married women into industry as the war continues. Even 
 in the last year or two before the war, the rising cost of living caused 
 many mothers to take up work outside their homes. 
 
 It is now especially imperative that the state increase its efforts 
 to provide more adequate maternity care and to conserve the lives of 
 mothers and babies. 
 
 KINDS OF SICKNESS. 
 
 Evidence as to the relative prevalence of various kinds of 'diseases 
 may be drawn from facts in the various surveys and records and 
 from the only official sickness statistics in the state, those of "report- 
 able" diseases. Owing to differences in the way in which they are 
 collected, the signiflcanee of these figures must not be exaggerated, 
 but certain facts stand out in such a striking manner that they seem 
 worthy of mention. 
 
 The first point of special interest is that apparently the beginnings 
 of many chroni€ diseases receive no attention. One of these is 
 tuberculosis of the lungs. 
 
 In the Western Pennsylvania and Pittsburgh Surveys no attempt 
 was made to record any except serious and disabling ailments, but in 
 the case of tuberculosis the investigators attempted to note not only 
 all cases which involved incapacity for work or were receiving treat- 
 ment away from home in a tuberculosis sanitorium, but all who wert- 
 personally aware of their condition. Thus the chances are that 
 practically all cases receiving treatment were recorded. Yet, 
 although this disease caused 7.6 per cent, of the total deaths in the 
 state in 1916, it accounted for only 4.0 per cent, of the illnesses 
 found in the two surveys, apparently confirming the statement made 
 in the report, that "it is evident that there must have been a large 
 number of undiagnosed cases of tuberculosis among the groups sur- 
 veyed by our agents." 
 
 According to Dr. Emery E. Hayhurst. of the Ohio State Board of 
 Health, "investigations in Ohio show that there are seven cases of 
 tuberculosis to every death,"^ and there is no reason to believe that 
 coiiditions in Pennsylvania are radically different. In 1916, tuber- 
 culosis made up 22.1 per cent, of 52,306 cases of serious communicable 
 ellseases reported to the State Department of Health,^ but during 
 the same year it was responsible for 45.7 per cent, of the deaths from 
 this same group of diseases. Among 1,200 widows and their families, 
 cared for by the Mothers' Assistance Fund in 1914, tuberculosis had 
 been responsible for the death of the father in 30 per cent, ot the 
 cases where the cause was known. 
 
 In the Philadelphia Survey, where a special effort was made to 
 locate all tuberculosis suspects, the disease made up 7.4 per cent, of 
 those reported; and over two per cent, of all the persons surveyed 
 
 (^Industrial Health Hazards and Occupational Diseases in Ohio, page 15. 
 (')Figures supplied by Dr. Wllmer E. Batt, State Registrar, Department of Health. 
 
68 
 
 were noted as suspected cases; in the Visiting Nurse Society Study 
 it accounted for 5.7 per cent, of the cases. In two of the negro dis- 
 ti-icts in the Philadelphia Survey, the percentages of cases of tuber- 
 culosis were 14.7 and 8.3 per cent, of the whole population. 
 
 Organic Heart disease and other diseases of the circulatory system 
 seem also to escape recognition and early treatment. The first of 
 these accounted for 9.9 per cent, of the deaths in Pennsylvania in 
 1916, but made up only 2.8 per cent, of the illnesses in the Pittsburgh 
 and Western Pennsylvania Surveys and 4.2 per cent, of those in the 
 Philadelphia Survey. All diseases of the circulatory system accounted 
 for only 3.67 per cent, of the illness cases in the surveys for which 
 they were recorded, but made up more than 13 per cent, of the causes 
 of death in the state in 1916. 
 
 The same evidence seems also to apply to cancer, which caused 5.2 
 per cent, of the deaths in 1916, but claimed only 86 per cent, of the 
 diseases in the surveys where it was reported at all. 
 
 These ailments of course are not easily detected in their incipient 
 stages and do not cause complete disability for work until well 
 advanced. For this reason, some cases may have been receiving 
 treatment, but may not have been considered serious enough to men- 
 tion to the investigators. It is probable, however, that in most 
 instances the diseases had not been recognized. 
 
 In a group of four surveys, the Pittsburgh and Western Pennsyl- 
 vania, the Philadelphia, the Visiting Nurse Society and the Sickness 
 and Dependency, twelve disabilities account for 66.4 per cent, of the 
 total cases of illness. These are in the order named, accidents and 
 injuries, tuberculosis, influenza, "other respiratory diseases", child- 
 ren's diseases, stomach and digestive disorder, diseases of the puer- 
 peral state, rheumatism, pneumonia, nervous disability, heart and 
 circulatory diseases, and typhoid fever. Their relative importance 
 in the four studies varies somewhat, but on the whole, accidents and 
 injuries, tuberculosis, rheumatism and digestive diseases may be said 
 to be the most frequent causes of disability among the employees 
 themselves, diseases of the puerperal state among the housekeepers, 
 and "children's diseases" among the dependents. The comparatively 
 small proportion disabled because of industrial accidents in the Sick- 
 ness and Dependency Study bears out the statement of social workers 
 that since the enactment of the Workmen's Compensation Law, the 
 number of families suffering from such disability who come to seek 
 charitable aid is much reduced. . 
 
 Tuberculosis accounted for 18.2 per cent, of the illness in this 
 study, and for more than 25 per cent, of the cases of disability of the 
 wage-earner. Fifty-eight per cent, of all the cases of tuberculosis 
 were wage-earners, and 21 per cent, were housekeepers. 
 
Next in importance came diseases of the puerperal state, which 
 covered 9.2 per cent, of the total illnesses of the group, and 31 per 
 cent, of the housekeepers' disabilities. Within this dependent group 
 these two ailments were more than three times as serious as in other 
 surveys. This affords again confirmation of a well known fact, that 
 tuberculosis and illness connected with child birth all too frequently 
 drive wage-earners' families to seek charitable relief. 
 
 An application for charitable aid means, in practically every 
 instance, a period of strain and struggle, and a decline in the stand- 
 ard of living before the appeal is made, conditions which in maternity 
 cases are directly harmful to the health of both mother and child. 
 Yet the crisis of child-birth is one of the periods when families are 
 most likely to be forced into dependency, and the integrity of the 
 family group to be threatened at a time when it is most important 
 that it should be maintained. 
 
 The inability of many families to meet this crisis unaided is again 
 emphasized by a special study of 418 illness cases cared for by two 
 large relief organizations and studied by the Bureau for Social 
 Kesearch. In this study, 24 per cent, of the mothers were ill as a 
 result of child-bearing, while in the Western Pennsylvania Survey 
 less than one-tenth of one per cent, of the women of child-bearing age 
 were disabled from this cause. The Bureau for Social Eesearcb 
 found that the two main disabilities in the group studied were tuber- 
 culosis and child-birth ; 28 per cent, of the mothers and 48 per cent, 
 of the fathers were tubercular. 
 
 From the investigations made, it is evident that the sickness rate 
 in the state and especially in the industrial centers and in the large 
 cities, the striking evidence of l^ck of adequate maternity care, and 
 the failure to prevent, by thorough public health measures, the be- 
 ginnings and spread of well-known chronic degenerative diseases, 
 all point to the existence of a sickness problem that Pennsylvania 
 cannot afford to ignore. 
 
70 
 
 Part II, Section I, Table II. 
 KENSINGTON SURVEY. 
 -Nativity of Individuals. 
 
 Nationality. 
 
 Number. Per Cent 
 
 United States, 
 
 Germany, 
 
 Austria-Hungary, 
 
 Ireland, 
 
 Russia, 
 
 Great Britain, , 
 
 All others, _. 
 
 1 
 
 2,483 
 
 77.9 
 
 214 
 
 6.7 
 
 m 
 
 6.3 
 
 120 
 
 3.8 
 
 85 
 
 2.7 
 
 29 
 
 0.9 
 
 56 
 
 1.8 
 
 B — Number of Wage-Earners. 
 
 No information, 73 families. 
 
 Male heads of families working, 636 persons. 
 
 Female heads of families working, 52 persons. 
 
 Working mothers, 81. 
 
 All other wage-earners, 590. 
 
 Total number wage-earners (exclusive of duplications) 1,341. 
 
 C — Total Weekly Income per Family. 
 
 
 
 Wage Group. 
 
 Number ol 
 Families. 
 
 Per Cent.* 
 
 Unknown 
 Under $5, 
 $ 5— 9.99 
 
 
 
 135 
 1 
 14 
 14 
 20 
 40 
 64 
 
 114 
 80 
 
 271 
 
 
 
 
 
 
 
 2.3 
 2 3 
 
 $10—11.99 
 
 
 $12—14.99 
 
 
 
 $16-17.99 
 
 
 
 $18—19.99 
 
 
 8 9 
 
 $20^24.99 
 
 
 
 $25—29.99 
 
 1 
 
 
 $30— and < 
 
 jver, 
 
 44 6 
 
 
 
 
 •Based on the 608 families in which total weekly income is known. 
 D — Occupations of Wage Earners. 
 
 V 
 
 
 Occupation. 
 
 Number of 
 
 Wage 
 Earners. 
 
 Per cent. 
 
 Manufacturing and 
 
 mechanical, 
 
 635 
 247 
 165 
 98 
 98 
 65 
 34 
 19 
 
 47.3 
 18.4 
 11.6 
 7.3 
 7.3 
 4 1 
 
 Domestic and personal, — 
 Laborer, - - 
 
 
 
 Transportation, . 
 
 Miscellaneous, 
 
 
 
 
 
 
 
 
 
 Total, - 
 
 -1,341 
 
 100.0 
 
 
 
 
71 
 
 E — Number of Cases of Illness during Year ending April 1, 1918. 
 
 Number of Cases. 
 
 Number 
 
 of 
 Families. 
 
 Per Cent.* 
 
 No information. 
 
 None, 
 
 One, 
 
 Two, f 
 
 Three, 
 
 Four, 
 
 Five, -- 
 
 Six, 
 
 Seven, --, 
 
 DIght, 
 
 Nine, 
 
 Ten, 
 
 Over ten, 
 
 9 
 91 
 179 
 173 
 91 
 71 
 Si 
 Hi 
 17 
 17 
 8 
 17 
 9 
 
 Total, 
 
 740 
 
 18.4 
 24.4 
 2S.7 
 12.4 
 9.7 
 4.7 
 3.3 
 2.3 
 2.3 
 1.1 
 2.3 
 1.2 
 
 •Based on the 731 families about which this information was available. 
 F — Member of Family 111. 
 
 
 Person. 
 
 Number 
 of Cases. 
 
 Per Cent.* 
 
 
 5 
 
 627 
 319 
 468 
 677 
 
 
 Principal wage 'earner, ; - 
 
 2S.5 
 
 
 23.4 
 
 All others, 
 
 34 
 
 
 
 
 Total, — - 
 
 1.984 
 
 100.0 
 
 
 
 
 •Based on the 1,989 cases for which this information was available. 
 G — ^Duratidn of Cases of Illness* 
 
 
 Length of Illness. 
 
 Number 
 of Oases. 
 
 Per Cent. 
 
 1 week 
 
 194 
 351 
 
 219 
 85 
 
 283 
 97 
 85 
 
 178 
 
 13.2 
 
 1 — 2 weeks ' ~ - 
 
 23.9 
 
 2 — 3 weeks - ' 
 
 14.8 
 
 3 — 4 weeks. 
 
 6.7 
 
 1— 3 months, 
 
 19.2 
 6.6 
 
 
 4.6 
 
 12 mouths and over, — 
 
 j- 
 
 12.1 
 
 Total 
 
 1,472 
 
 lOO.O 
 
 
 
 
72 
 
 EH 
 
 1 
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74 
 
 'Part II, Section I, Table V. 
 NUMBER OF PENSONS ENUMERATED. NUMBER OP CASES OF SICK- 
 NESS. RATES OF SICKNESS PER 1,000 EXPOSED. METROPOLI- 
 TAN LIFE INSURANCE COMPANY POLICY HOLDERS. PRINCIPAL 
 DISTRICTS IN WESTERN PENNSYLVANIA. 
 
 State and District. 
 
 White Fersons. 
 
 ^ 
 
 Colored Persons. 
 
 a 
 
 
 Permsylvania,^ 
 
 Pittsburgh, 
 
 Braddock, 
 
 McKeesport, 
 
 Pottsville, 
 
 Uniontown, 
 
 ConnelJsville, 
 
 Johnstown, 
 
 Altoona, 
 
 Scranton, 
 
 ShamoTcin, 
 
 Wilfces-Barre, - 
 New Kensington 
 
 Hazleton, 
 
 Shenandoah, 
 
 Washington, -_. 
 
 308,009 
 
 5,399 
 
 17.5 
 
 20,042 
 
 417 
 
 20.8 
 
 115,618 
 
 1,869 
 
 16.2 
 
 12,049 
 
 214 
 
 17.8 
 
 15,866 
 
 248 
 
 15.6 
 
 1,199 
 
 28 
 
 28.4 
 
 14,7S6 
 
 288 
 
 19.5 
 
 1,199 
 
 37 
 
 24.1 
 
 16,906 
 
 "51 
 
 15.8 
 
 48 
 
 2 
 
 • 
 
 11,561 
 
 257 
 
 22.2 
 
 2,366 
 
 66 
 
 27.9 
 
 2,767 
 
 52 
 
 18.8 
 
 613 
 
 15 
 
 « 
 
 22,408 • 
 
 404 
 
 18.0 
 
 406 
 
 17 
 
 4,855 
 25,525 
 
 105 
 531 
 
 21.6 
 
 %.o 
 
 98 
 188 
 
 
 
 7 
 
 • 
 
 1,589 
 
 33 
 
 20.8 
 
 4 
 
 1 
 
 
 45,945 
 
 814 
 
 17.7 
 
 230 
 
 5 
 
 • 
 
 11,486 
 
 186 
 
 16.2 
 
 317 
 
 9 
 
 « 
 
 5.579 
 
 11,0S4 
 
 3,272 
 
 96 
 
 17 2 
 
 
 
 
 207 
 
 18 8 
 
 
 
 
 58 
 
 17.7 
 
 992 
 
 16 
 
 • 
 
 "Insufficient data. 
 
75 
 
 Part II, Section I, Table Vl. 
 
 NUMBER OF CASES OJF SICKNESS AND RATES PER 1,000 EXPOSED, 
 TOTAL SICK, AND SICK PERSONS UNABLE TO WORK CLASSIFIED 
 BY AGE AND BY SIX. PITSBURG SICKNESS SURVEY. 
 
 
 § 
 1 
 
 o 
 
 9 o 
 3 ft 
 
 Total Sick Persons. 
 
 Sex and Age Period. 
 
 i 
 
 
 
 
 All Persons: 
 
 AH ages, L 
 
 115,618 
 75,714 
 
 1,869 
 1,631 
 
 16 2 
 
 15 years apd over, ; 
 
 20 2 
 
 
 
 Under 15, ^ 
 
 15 to 24, 
 
 39,761 
 
 20,106 
 20,263 
 16,521 
 10,784 
 
 5,555. 
 
 2,48» 
 143 
 
 335 
 205 
 325 
 SlSi 
 283 
 21-8 ■ 
 185 
 3 
 
 8.4 
 
 25 to 34, 
 
 - 16 
 
 35 to 44, 
 
 19 1 
 
 45 to 54, _ 
 
 26 2 
 
 55 to 64,. ■- 
 
 39.2 
 
 65 and over, 
 
 74.4 
 
 
 
 
 
 Males: 
 
 All ages, 
 
 56,615 
 36,760 
 
 952 
 781 
 
 16 g 
 
 15 years and over, 
 
 21.3 
 
 
 
 Tinder 15, 
 
 19,792 
 9,538 
 97847 
 8,284 
 5,331 
 2,659 
 1,101 
 63 
 
 169 
 
 92 
 
 154 
 
 165 
 
 162 
 
 118 
 
 90 
 
 2 
 
 8.5 
 
 15 to 24, „ ..-._- - .. 
 
 9.6 
 
 25 to 34, - 
 
 15.6 
 
 35 to 44, -■_ 
 
 19.9 
 
 45 to 54, . — -. 
 
 30.4 
 
 55 to 64 . 
 
 44.4 
 
 65 and' over, - _ - 
 
 81.7 
 
 
 
 
 
 Females: 
 
 All ages - 
 
 69,003 
 38,954 
 
 917 
 "750- 
 
 16.5 
 
 
 19.3 
 
 
 
 Under' 15, : 
 
 18,969 
 
 10,665 
 
 10,416 
 
 8,237 
 
 5,453 
 
 2,896 
 
 1,387 
 
 .60 
 
 186 
 113 
 171 
 150 
 121 
 100 
 95 
 1 
 
 8.3 
 
 10.7 
 
 -jg ^Q 34 
 
 16.4 
 
 35 to 44 
 
 is; 2 
 
 it; t.o 54 - - 
 
 22.2 
 
 55 to 64 - 
 
 34.5 
 
 65 and over, 
 
 6S.5 
 
 
 
fe 
 
 Part II, Section 1, Table VII. 
 
 NUMBER OF CASES, KATES PER 1,000 EXPOSED. CLASSIFIED BY 
 
 EXTENT OF DISABILITY, SEX AND AGE PERIOD. 
 
 WESTERN PENNSYLVANIA SURVEY (i). 
 
 Sex and Age Period. 
 
 State of Pennsylvania. 
 
 e 
 
 Total Siick Persons. 
 
 Sick, Unable to Work. 
 
 
 M 
 
 
 M 
 
 
 
 
 
 u 
 
 rnna 
 
 8 
 
 ,-tiQ 
 
 S 
 
 •|' 
 
 1 
 
 . ^' 
 
 Males: 
 
 153,440 
 97,387 
 
 2,823 
 S,314 
 
 18.4 
 23. 8 
 
 2,654 
 2,161 
 
 17.3 
 
 Ages 15 and over, 
 
 23.1 
 
 tinder 15, 
 
 55,887 
 25,989 
 26,223 
 21,848 
 13,679 
 6,891 
 2,757 
 166 
 
 504 
 302 
 393 
 464 
 508 
 379 
 268 
 5 
 
 9.0 
 11.6 
 15.0 
 21.2 
 37.1 
 55.0 
 97.2 
 
 498 
 288 
 369 
 421 
 459 
 352 
 262 
 5 
 
 8.9 
 
 IB to 24, 
 
 11.1 
 
 25 to S*. 
 
 14.1 
 
 35 to 44, — 
 
 19.3 
 
 45 to 54 
 
 33.6 
 
 55 to 64, 
 
 51.1 
 
 
 96.0 
 
 Unknown age 
 
 
 
 
 . 
 
 Females^ 
 
 154,565 
 98,568 
 
 2,576 
 2,069 
 
 16.7 
 21.0 
 
 2,430 
 1,936 
 
 16.7 
 
 Ages 15 and over, 
 
 19.6 
 
 Under 15, 
 
 55,827 
 
 28,011 
 
 26,834 
 
 20,236 
 
 12, W9 
 
 7,113 
 
 3,395 
 
 174 
 
 504 
 334 
 424 
 410 
 355 
 270 
 2(76 
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 . 9.0 
 11.0 
 15.8 
 20.3 
 27.4 
 38.0 
 81.3 
 
 491 
 318 
 403 
 375 
 326 
 246 
 268 
 3 
 
 ' 8.8 
 
 15 to 24, 
 
 11.4 
 
 25 to 34 „ 
 
 15.0 
 
 35 to 44, 
 
 18.5 
 2S.1 
 
 45 to 64 
 
 55 to 64 
 
 34.6 
 
 65 and over, 
 
 78.9 
 
 Unknown age 
 
 
 
 
 
 C-) Mgures for white persons only. 
 
77 
 
 Part II, Section I, Table VIII. 
 SICKNESS RATES BY AGE AND SEX. PHILADELPHIA SURVEY. 
 
 
 All Persons. 
 
 Males. 
 
 Females. 
 
 
 Total. 
 
 Unable 
 to Work. 
 
 Total. 
 
 Unable 
 to Work. 
 
 Total. 
 
 Unable 
 to Work. 
 
 AH persons, 
 
 15 years and 
 
 4.280 
 
 5.335 
 2.196 
 2.669 
 4.358 
 5.280 
 7.293 
 9.338 
 12.658 
 2.041 
 
 1.573 
 
 1.958 
 814 
 1.628 
 1.533 
 1.674 
 2.370 
 3.501 
 5.379 
 .816 
 
 4.2S2 
 
 5.242 
 2.246 
 3.163 
 4.202 
 5.482 
 7.890 
 7.835 
 14.598 
 • 2.162 
 
 1.714 
 
 2.19D 
 749 
 1.734 
 1.401 
 1.907 
 2.744 
 4.S50 
 7.299 
 1.081 
 
 4.301 
 
 5.431 
 
 2.147 
 4.092 
 4.523 
 5.042 
 6.614 
 10.976 
 11.173 
 1.666 
 
 1.428 
 
 Under 16, i. 
 
 16-24, 
 
 1.717 
 87S 
 
 25-34, 
 
 1.635 
 
 35-44 
 
 1.672 
 
 45-54, — 
 
 55-64, 
 
 65 and over, 
 
 Age unknown, _. 
 
 >^ 1.40O 
 
 ^ 1.946 
 
 2.033 
 
 3.9U 
 
 
 
 
 Part II, Section 1, Table IX. 
 SICKNESS RATE PER 100 BY DISTRICTS. PHILADELPHIA SURVEY. 
 
 Nationality. 
 
 Bate Per 100. 
 
 1. Jewish, Polish, Austrian, 
 
 2. Italian, 
 
 3. Negro, 
 
 4. Negro, 
 
 5. Negro, • — 
 
 6. Irish, American, Polish, 
 
 7. American, negro, 
 
 Average for districts covered 
 
 3.877 > 
 
 3.231 
 
 4.44? 
 
 9.S02 
 
 3.874 
 
 4.367 
 
 4.034 
 
78 
 
 
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79 
 
 Part II, Section I, Tabig XI. 
 
 DISTRIBUTION OF 10,000 OASES OF SICKNESS AND NON-INDUSTRIAL 
 ACCIDENTS FOR EACH OF TEN BENEFIT ASSOCIATIONS (i). 
 
 Duration ju days. 
 
 No. 1. 
 
 No. 2. 
 
 No. 3. 
 
 No. 6. 
 
 No. 6. 
 
 No. 7. 
 
 No. 8. 
 
 No. ». 
 
 No. 10. 
 
 5,573 
 
 i.anu 
 
 TtO 
 415 
 
 2yo 
 
 203 
 
 ise 
 
 12U, 
 
 m 
 
 72 
 
 55 
 
 M 
 
 33 
 
 40 
 
 37 
 
 21 
 
 22 
 
 15 
 
 12 
 
 13 
 
 10 
 
 9 
 
 12 
 
 6 
 
 7 
 
 7 
 
 132 
 
 2,031 
 MB 
 553 
 346 
 252 
 
 mt 
 
 lis 
 
 ij» 
 84 
 73 
 07 
 67 
 
 ty 
 
 if! 
 34 
 31 
 22- 
 20 
 17 
 15 
 14 
 12 
 10 
 9 
 11 
 249 
 
 4,474 
 
 1,04)0 
 
 893 
 
 883 
 
 320 
 
 330 
 
 273 
 
 210 
 
 95' 
 
 116 
 
 106 
 
 88 
 
 66 
 
 02 
 
 55 
 
 46 
 
 35 
 
 31 
 
 22 
 
 28 
 
 20 
 
 19 
 
 18 
 
 1/ 
 
 16 
 
 15 
 
 260 
 
 4,276 
 
 1,601 
 
 924 
 
 610 
 
 445 
 
 313 
 
 215 
 
 139 
 
 115 
 
 105 
 
 185 
 
 lb 
 
 00 
 
 47 
 
 40 
 
 33. 
 
 71 
 
 ^ 
 
 24 
 
 19 
 
 18 
 
 18 
 
 18 
 
 16 
 
 16 
 
 14 
 
 3,472 
 
 1,/14 
 
 1,176 
 
 791 
 
 602 
 
 394 
 
 33/ 
 
 240 
 
 205 
 
 164 
 
 135 
 
 1* 
 
 100 
 
 00 
 
 45 
 
 34 
 
 66 
 
 25 
 
 . 22 
 
 20 
 
 17 
 
 16 
 
 15 
 
 13 
 
 13 
 
 12 
 
 221 
 
 2,510 
 
 2,043 
 
 1,293 
 
 baj 
 
 (09 
 
 437 
 
 369 
 
 276 
 
 226 
 
 165 
 
 164 
 
 161 
 
 111 
 
 112 
 
 79 
 
 er 
 
 71 
 
 2,383 
 1,937 
 1,491 
 783 
 533 
 609 
 468 
 185 
 294 
 174, 
 
 
 11 
 22 
 11 
 413 
 
 3,366 
 
 1,911 
 
 1,021 
 
 599 
 
 434 
 
 362 
 
 308 
 
 217 
 
 209 
 
 143 
 
 115 
 
 126 
 
 90 
 
 Si 
 
 104 
 
 38 
 
 66 
 
 49 
 
 60 
 
 65. 
 
 25 
 
 33 
 
 44 
 
 33 
 
 29 
 
 33 
 
 439 
 
 2,384 
 2,272 
 1,289 
 785 
 448 
 433 
 357 
 280 
 188 
 173 
 137 
 132 
 87 
 102 
 6a 
 61 
 51 
 4a 
 46. 
 66. 
 31 
 41 
 36, 
 15 
 31 
 51 
 392 
 
 1,610 
 2,260 
 1,520 
 9^0 
 714 
 461 
 383 
 291 
 219 
 153 
 152 
 119 
 108 
 
 67 
 34 
 
 37 
 
 30 
 11 
 -22 
 15 
 8 
 
 5ia 
 
 DURATION PERCENTAGE. 
 
 8 days. 
 
 No. 1. 
 
 No. 2. 
 
 No. 3. 
 
 No. 4., 
 
 No. 5. 
 
 No. 6. 
 
 No. 7. 
 
 No. 8. 
 
 No. 9. 
 
 No, 10. 
 
 Total. 
 
 
 55.73 
 
 46.12 
 
 44.74 
 
 42.76 
 
 34.72 
 
 25.10 
 
 23.83 
 
 33.66 
 
 23.84 
 
 16.10 
 
 ' 84.56 
 
 2-4 wks.,- 
 
 26.00 
 
 29.77 
 
 25.83 
 
 27.52 
 
 28.90 
 
 33.36 
 
 34.28 
 
 29.32 
 
 35.61 
 
 37.80 
 
 30.83 
 
 
 14.51 
 
 18.24 
 
 22.33 
 
 22.08 
 
 29.95 
 
 33.87 
 
 32.85 
 
 25.13 
 
 29.33 
 
 34.91 
 
 26.42 
 
 3 6 mo.,— 
 
 2.37 
 
 3.27 
 
 4.35 
 
 4.06 
 
 4.46 
 
 6.80 
 
 4.80 
 
 7.17 
 
 6.79 
 
 5.95 
 
 6.00 
 
 Over 6 
 mo. , .. 
 
 1.39 
 
 2.60 
 
 2.75 
 
 4.04 
 
 2.33 
 
 .87 
 
 4.24 
 
 4.72 
 
 4.43 
 
 5.24 
 
 3.2S 
 
 (1) DiBtribution No. 7 is the combination ,ol the distributions given by three relatively snian 
 asioclations," each of which is organized and administered m such a way as to give 
 trustworthy results. The actual number of cases. used in formmg No. 7 was 919, 
 
80 
 
 Part II, Section I, Table XII. 
 
 SEPARATE DISTRIBUTION OF 10,000 CASES EACH OF SICKNESS AND 
 NON-INDUSTRIAL ACCIDENTS FOR MEN, FOR WOMEN, AND FOR 
 MEN AND WOMEN AS DETERMINED BY THE DATA FROM AN IM- 
 PORTANT BENEFIT ASSOCIATION. 
 
 Duration in Days. 
 
 Males. 
 
 Females. 
 
 Males 
 
 and ' 
 
 FemaleB. 
 
 8- U 
 
 IB- 21, 
 
 4,098 
 
 1,968 
 
 908 
 
 564 
 
 368 
 
 245 
 
 221 
 
 243 
 
 209 
 
 147 
 
 86 
 
 86 
 
 49 
 
 74 
 
 3T 
 
 25 
 
 74 
 
 37 
 
 25 
 
 61 
 
 12 
 
 25 
 
 25 
 
 25 
 
 37 
 
 37 
 
 294 
 
 2.773 
 
 1,849 
 
 1,113 
 
 626 
 
 487 
 
 457 
 
 378 
 
 199 
 
 208 
 
 139 
 
 139 
 
 159 
 
 139 
 
 89 
 
 159 
 
 50 
 
 60 
 
 60 
 
 88 
 
 SO 
 
 30 
 
 40 
 
 eo 
 
 40 
 20 
 30 
 557 
 
 s.see 
 
 1,911 
 
 22- 28, - — 
 
 29- 36 
 
 37- 42, — . — - 
 
 i.oa 
 
 E99 
 434 
 
 43- 49 
 
 sat 
 
 50-66 - ' __ „ 
 
 308 
 
 57- 63. . 
 
 64- 70. - - 
 
 217 
 209 
 143 
 
 78- 84i . 
 
 85- 91 - 
 
 92- 98, 
 
 115 
 1S8 
 W 
 
 99-105, 
 
 82 
 
 
 lot 
 
 
 SB 
 
 120-126 - 
 
 60 
 
 
 49 
 
 
 60 
 
 141-147 
 
 5S 
 
 148-164 
 
 2S 
 
 
 33 
 
 
 44 
 
 169-175, 
 
 176-182. 
 
 183-189 
 
 190 
 
 33 
 29 
 33 
 439 
 
 
 
 
 10,000 
 815 
 
 10.000 
 1,006 
 
 10,000 
 
 
 1,821 
 
 
 
 The actual number of cases for men, for women, 
 the table were 815, 1,006, and 1,821, respectively. 
 
 and for men and women used In forming 
 
 Part II, Section I, Table XIII. 
 
 PENNSYLVANIA RAILROAD (EAST), VOLUNTARY RELIEF DEPART- 
 MENT, 1913-1917. 
 
 Number and duration of completed cases of sickness and non-industrial accident 
 tabulated. 
 
 Duration. 
 
 Number 
 
 of 
 Gases. 
 
 Per cent. 
 
 Actual 
 Duration 
 In Days. 
 
 4 days— 2 weeks, — t— 
 
 2 weeks — 4 weeks. — 
 1 month— 3 months. . 
 
 3 months— 6 months. 
 6 months— 1 year. — 
 Over 1 year, 
 
 Total. 
 
 48,198 
 
 9,782 
 
 6,416 
 
 920 
 
 356 
 
 177 
 
 64,849 
 
 74.3 
 
 15.0 
 
 8.3 
 
 1.4 
 
 .64 
 .27 
 
 99.81 
 
 365,987 
 191,397 
 257.754 
 111,090 
 
 1,167,279 
 
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 ^" 
 
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 5^ 
 
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 and 
 
 .:§§! 
 
 
 
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 t,Z. 
 
 
 
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82 
 
 Part II, Section I, Table XV. 
 
 MORTALITY IN THE GENERAL POPULATION OF PENNSYLVANIA, 1906 
 TO 1916. DEATH RATES PER 100,000. 
 
 Area. Year. 
 
 All 
 Causes. 
 
 Typhoid 
 ¥evei. 
 
 Tubercu- 
 losis of 
 Lungs. 
 
 Diarrhoea 
 
 and (ij,. 
 
 Enteiitis. 
 
 Accident i 
 
 Registration area (1916), _-, 
 
 Total State of Pennsylvania: 
 
 191.6, .. 
 
 1916, 
 
 1914, 
 
 1918 
 
 1913, 
 
 1911, 
 
 1S>W. 
 
 1909, 
 
 1908,, 
 
 1907, 
 
 190S, 
 
 1,398.9 
 
 Urban. 
 1916,. 
 191S, 
 1914, 
 1913, 
 1912. 
 1911, 
 1910, 
 1909. 
 1908, 
 1907, 
 1906, 
 
 Rural: 
 1916, 
 1916, 
 1914, 
 1913, 
 1912, 
 1911, 
 1910, 
 1909, 
 1908, 
 1907, 
 1906, 
 
 461.8 
 
 sr6.& 
 
 392.6 
 466.3 
 403.3 
 421.0 
 657.3 
 469.9 
 
 513. a 
 
 693.0 
 602.3 
 
 594-1 
 48T.6 
 630.6 
 665.3 
 510.9 
 548 .S 
 688; 7 
 579.2 
 61S.3 
 Til.8 
 803.6 
 
 339.1 
 270.9 
 266.2 
 ,364.0 
 304.6 
 804.6 
 437...5 
 377.2 
 399.1 
 442.3 
 4S2i7 
 
 13.6 
 12.3 
 13.0 
 18.6 
 16.4 
 ■21.9 
 24.6 
 22.7 
 33.0 
 4S.6 
 64.8 
 
 13.6 
 12.6 
 13.4 
 20.2 
 
 16r5 
 
 23.8 
 26.1 
 24.9 
 39.0 
 S7.0 
 76.7 
 
 13.6 
 12.2 
 12.6 
 16.2 
 16.4' 
 20.2 
 24.2 
 20.8 
 28.0 
 33.1 
 36.4 
 
 112.3 
 110.6 
 
 ior.2 
 
 104.6 
 108.3 
 117.9 
 117.0 
 115.1 
 117.3 
 128.0 
 129.6 
 
 126.8 
 124.4 
 124.7 
 122.4 
 126;9 
 140.7 
 140.1 
 140.1 
 145.2 
 168.4 
 164.8 
 
 98.9 
 97; 8 
 91.2 
 88.1 
 91.1 
 97.0 
 96.1 
 94. a 
 93.8 
 102.4 
 100.0 
 
 65.6 
 
 101.7 
 
 90,7 
 
 96.4 
 
 106.3 
 
 93.7 
 
 104.1 
 
 144.0 
 
 130.9 
 
 140.1 
 
 137.0 
 
 167.5 
 
 105.3 
 95.7 
 105.7 
 111.6 
 103.1 
 118.4 
 166.8 
 141.6 
 151.0 
 166.4 
 176.9 
 
 9B.3 
 
 86.0 
 
 86.'9. 
 
 101.5 
 
 85.1 
 
 91.1 
 
 132.4 
 
 121.8 
 
 130.9 
 
 121.4 
 
 141.1 
 
 90.9 
 
 ior,8 
 
 106.2 
 102,2 
 106.2 
 107.1 
 108.4 
 116.5 
 137.0 
 
 131. a 
 
 113.0 
 94.4 
 9Ti8 
 104.1 
 104.2 
 105.7 
 111.5 
 108.7 
 108.0 
 132.4 
 135.6 
 
 102.9 
 91.0 
 96:7 
 106.3 
 IGOsS 
 106.8, 
 103.1 
 106.2 
 123.3 
 140.4 
 12S.1 
 
 (i-V'AU ages," 190S-1S00I; "under 2 years" attei 1909. 
 C^V Includes! Allegheny -after, 1807. 
 O Included in Pittsburgh after 1907. 
 
 V 
 
83 
 
 Part II, Section I. Table XVI. 
 
 MORTALITY IN THE GENERAL POPULATION OF PENNSYLVANIA, 1906 
 TO 1916. DEATH RATES PER 100,000. 
 
 Area. Year. 
 
 Causes. 
 
 Typhoid 
 Fever. 
 
 Tubercu-. 
 losis of 
 Lungs. 
 
 Diarrhea 
 
 and (1) 
 
 Eiiteritis. 
 
 Accident. 
 
 Fbiladelpbia': 
 
 1916 - 
 
 1916 . : 
 
 1,620.5 
 1,561.6 
 1,612.9 
 1,669.4 
 1,528.2 
 1,662.8 
 1,739.9 
 l,6Sr.4 
 1,726.3 
 1,860.5 
 1,913.7 
 
 1,740.1 
 1,625.9 
 1,587.9 
 1,712.2 
 1,591:2 
 1,493.0 
 1,793.7 
 1,579.3 
 1,732.6 
 1,929.0 
 1,990.0 
 
 1,939.2 
 1,980.8 
 
 1,441.3 
 1,467:2 
 1,678.3 
 1,483.9 
 1,462.2 
 1,482:8 
 1,640.7 
 1,K9.8 
 1,640.4 
 1,574.4 
 1,641.6 
 
 1,447.1 
 1,615.3 
 1,535.4 
 1,510.4 
 1,501.2 
 . 1,553.9 
 1,656.5 
 1,551.5 
 1,560.2 
 1,671.8 
 1,469.0 
 
 7.6 
 6.8 
 7.6 
 16.7 
 12.8 
 14.6 
 17.6 
 22.3 
 36.2 
 60.3 
 74.3 
 
 9.0 
 10.3 
 16.6 
 19.5 
 13.1 
 25.6 
 27.8 
 24.6 
 48.9 
 131.2 
 141.1 
 
 108.7 
 150.7 
 
 6.1 
 1Z.5 
 9.2 
 9.4 
 10.3 
 14:3 
 16.9 
 llS.4 
 11.2 
 76.2 
 61.0 
 
 15.8 
 10.8 
 6.8 
 12.5 
 17.0 
 11.6 
 37.1 
 13.7 
 23.3 
 44.6 
 Sl.O 
 
 170.6 
 1S4.3 
 
 167.7 
 165.0 
 170.2 
 193.5 
 193.5 
 189.0 
 801.7 
 220.8 
 225.1 
 
 110.7 
 108.4 
 109.2 
 106.5 
 100.4 
 106.0 
 104.2 
 109.0 
 114.2 
 112.4 
 128.2 
 
 145.9 
 176.6 
 
 74.2 
 72.2 
 78.4 
 76.5 
 75.8 
 99.9 
 90.5 
 84.8 
 80.0 
 81.7 
 71.9 
 
 69.9 
 
 89.1 
 
 66.5 
 
 61.3 
 
 83.6 
 
 84.1 
 
 71.2 
 
 89.8 
 
 59.1. 
 
 79.7 
 
 70.3 
 
 88.3 
 90.0 
 107.4 
 100.6 
 93.4 
 118.0 
 160.3 
 129.8 
 137.8 
 147.3 
 172.0 
 
 117.8 
 97.6 
 103.7 
 134.8 
 113.6 
 130.3 
 l77;s 
 , 166^9 
 182.7 
 209.2 
 230.0 
 
 181.6 
 194.1 
 
 141.7 
 136.7 
 162.7 
 138.5 
 16^.8 
 173.6 
 230.8 
 230.2 
 207.1 
 183.9 
 85.8 
 
 93.8 
 
 146.2 
 
 91.0 
 
 88.8 
 
 93.8 
 
 131 .'9 
 
 136.0 
 
 118.4 
 
 158.6 
 
 169.3 
 
 114/4 
 
 91.5 
 70.7 
 
 
 74.7 
 
 i9ia, . 
 
 79.2 
 
 1911, 
 
 89.2 
 
 1910. 
 
 S3. 6 
 
 1906, 
 
 90.0 
 
 1907, 
 
 103.5 
 
 Pittsburgh: 
 
 1916, 
 
 1915, 
 
 lOOil 
 
 1^.2 
 109.8 
 
 1914, 
 
 109.6 
 
 1913 
 
 136.3 
 
 1912, - - 
 
 U2-.8 
 
 1911, 
 
 1910, 
 
 106.6 
 134.3 
 
 ■ 1909, 
 
 1908 
 
 1'24:4 
 1U.6 
 
 1907 _ 
 
 184.7 
 
 1906 
 
 190.6 
 
 Allegheny: 
 
 i9(yr, -- - - 
 
 165:8 
 
 1906, - - 
 
 197:8 
 
 Scranton: 
 
 1916, _ __ 
 
 138.3 
 
 1915, - 
 
 1914, ■ 
 
 1913, _ 
 
 130.5 
 157.1 
 167.3 
 
 1912, - 
 
 19U, . ^- 
 
 1910, c 
 
 1909, --- 
 
 1908, _ 
 
 147.2 
 177.3 
 167.1 
 197.1 
 181:8 
 
 1907, ^ - 
 
 18Sj9 
 
 190g __ _. 
 
 .188.9 
 
 iTCilkes-Barre: 
 
 19X8 _ - — 
 
 181.0 
 
 
 190.1 
 
 
 184 1« 
 
 1913, 
 
 1912, __ 
 
 134.6 
 
 182/9 
 
 IMl, 
 
 207;3 
 
 \Cf\Q 
 
 225/4 
 
 1909 
 
 195.8 
 
 1908, 
 
 isiyr, : 
 
 1906, 
 
 -225.5 
 287.7 
 220.8 
 
 (1) "All ages," 1908-1909; "under 2 years" 
 m Includes Allegheny alter 1907. 
 (s) Included in Pittsburgh lafter 1907. 
 
 after 1909. 
 
84 
 
 Part II, Section I, Table XVII. 
 
 METROPOLITAN LIFE INSUPANCE COMPANY, INDUSTRIAL DEPART- 
 MENT, STATISTICS FOR PENNSYLVANIA. 
 
 Claim rates per 1,000, by color. 
 1917(1). 
 
 Principal districts in state, 1915, 1916, 
 
 Aiea. 
 
 Total State of Pennsylvania, 
 
 AUentown, .. 
 
 Braddock, 
 
 Bristol, 
 
 Chester, 
 
 Ooatesville, 
 
 DuBois, 
 
 Easton, 
 
 Erie, 
 
 Harrisbuig, 
 
 Hazleton, 
 
 Johnstown, 
 
 Lancaster, 
 
 McEeesport, 
 
 MlUvale, 
 
 New Oastle, 
 
 New Kensington, 
 
 Norristown, 
 
 Philadelphia (total), 
 
 Faiimount, 
 
 Pranklord, . 
 
 Germantown, ^. 
 
 Girard, 
 
 Harrowgate, 
 
 Eehsington, 
 
 Manayunk, 
 
 Middle, 
 
 Nlcetown, 
 
 Schuylkill 
 
 Shackamaxon, 
 South, 
 
 Southwark, 
 
 West, 
 
 Pittsburgh (total), 
 
 Pittsburgh, ^. 
 
 Allegheny, 
 
 East Liberty, 
 
 South, - 
 
 Pottstown, 
 
 Pottsville,"^- 
 
 Reading, 
 
 Scranton, 
 
 Shenandoah, 
 
 Uniontown, 
 
 Wilkes-Barre, 
 
 Williamsport, - 
 
 York, 
 
 White. 
 
 1917 
 
 12.4 
 
 11.; 
 10.' 
 13. 
 IS. 
 
 g. 
 
 7. 
 9, 
 9. 
 
 10. 
 
 14. 
 
 1916 
 
 12.5 
 
 10.6 
 10.6 
 10.4 
 ll.S 
 10.2 
 
 7.9 
 11.4 
 
 7.8 
 18.4 
 IS.l 
 
 9.6 
 10.4 
 
 9.3 
 10.9 
 U.7 
 
 7.8 
 11.4 
 13.6 
 12.9 
 12.9 
 10.9 
 16.7 
 13.2 
 14.0 
 12.2 
 18.9 
 IS.l 
 12.0 
 15.8 
 16.4 
 14.4 
 12.6 
 11.8 
 14.6 
 12.4 
 11.6 
 
 9.5 
 11.4 
 16. S 
 12.8 
 14.4 
 19.8 
 
 9.7 
 14.6 
 10. g 
 
 8.1 
 
 11.9 
 
 11.2 
 9.9 
 
 10.8 
 6.0 
 9.4 
 16.2 
 6.2 
 9.2 
 13.9 
 9.3 
 10.8 
 9.3 
 9.3 
 9.7 
 6.9 
 11.6 
 13.1 
 12.9 
 11.0 
 10.7 
 13.8 
 IS. 6 
 16.0 
 12.8 
 13.8 
 11.1 
 12.9 
 16.1 
 15.3 
 14.1 
 11.9 
 11.0 
 12.5 
 12.2 
 10.2 
 9.5 
 
 14.0 
 11.7 
 13.8 
 18.3 
 7.9 
 13.1 
 9.9 
 8.1 
 
 Colored. 
 
 15.7 
 
 14.7 
 4.4 
 16.1 
 12.8 
 9.4 
 23.1- 
 24.3 
 17.7 
 
 15.2 
 11.3 
 15.7 
 
 7.8 
 lO.T 
 13.1 
 14.7 
 16.4 
 22.9 
 12.9 
 13.2 
 17.0 
 22.4 
 20.0 
 
 9.5 
 12.7 
 13.2 
 13.4 
 16.5 
 18.6 
 20.5 
 14.2 
 16.3 
 18.8 
 17.4 
 14.1 
 14.4 
 
 8.1 
 
 6.S 
 14.9 
 
 9.0 
 
 1916 
 
 16.9 
 12.1 
 18.4 
 24.8 
 
 15.6 
 
 19.7 
 16.9 
 24.4 
 16.5 
 16.7 
 28.2 
 3.4 
 5.0 
 16.5 
 
 18.6 
 18.3 
 11.7 
 20.1 
 19.9 
 16.6 
 13.8 
 15.0 
 10.6 
 17.6 
 
 16.8 
 12.7 
 
 13.9 
 8.1 
 9.2 
 16.8 
 26.4 
 16.2 
 22.3 
 11.7 
 16.9 
 16.3 
 18.4 
 16.5 
 14.6 
 9.6 
 21.6 
 34.4 
 10.0 
 
 16.7 
 24.1 
 10.9 
 15.0 
 
 1916 
 
 16.4 
 
 18.9 
 17.3 
 
 18.9 
 15.3 
 
 8.6 
 23.6 
 
 21.6 
 lO.S 
 13.3 
 
 7.6 
 18.0 
 12.6 
 12.4 
 14.5 
 10.5 
 23.3 
 11.7 
 15.0 
 46.0 
 20.4 
 
 8.5 
 21.5 
 16.5 
 12.6 
 17.1 
 14.0 
 20.1 
 13.1 
 14.8- 
 14.1 
 16.6 
 16. D 
 12.7 
 
 52.2 
 15.2 
 6.9 
 
 17.6 
 23.0 
 20.1 
 14.6 
 
 (•) The number ol policy holders In Pennsylvania is unknown; approximately 70 per cent, of 
 the number ot policies. The claim rate per 1,000 must be interpreted in the light ol varying 
 sex and age characteristics of the several groups. 
 
85 
 
 Part II, Section I, Table XVIII. 
 
 State of Pennsylvania, 1917 by 
 
 Claims and claim rates per 100,000 policies, 
 color. 
 
 • 
 
 
 White. 
 
 Colored. 
 
 Cause of Death. 
 
 Claims. 
 
 Claim 
 Rate. 
 
 daims. 
 
 Claim 
 Bate. 
 
 AH causes of death, 
 
 18,094 
 
 1,244.4 
 
 2,482 
 
 1,569.2 
 
 
 
 Typhoid fever, 
 
 185 
 
 435 
 2,212 
 
 177 
 
 , 1,294 
 
 Vl,229 
 
 8,479 
 
 196 
 2,165 
 
 125 
 1,885 
 ■ 293 
 1,580 
 
 9.3 
 
 29.9 
 
 152.1 
 12.2 
 89.0 
 84.5 
 
 170.5 
 13.5 
 
 148.9 
 8.3 
 
 129.8 
 20.2 
 
 108.7 
 
 28 
 
 43 
 499 
 
 63 
 108 
 106 
 298 
 
 22 
 374 
 
 la 
 
 224 
 
 35 
 
 157 
 
 17.7 
 27 2 
 
 Oommunioable diseases of childhood: Measles, 
 scarlet fever, whooping cough, diphtheria and 
 croup, 
 
 TnhflrmilosiR of thp Innpflj 
 
 315 3 
 
 Other forms of sutmrculosis, ^_ 
 
 33 5 
 
 
 
 Cerebral hemorrhage and softening of 
 Organic diseases of the heart, 
 
 the brain. 
 
 sr.o 
 
 188.4 
 
 Bronchitis, 
 
 13 9 
 
 
 
 
 Diarrhea and enteritis (under 2 years of age) , 
 
 Acute nephritis and Brlght's disease, 
 
 10.1 
 141 6 
 
 
 22.1 
 
 External causes— Including suicide, 
 
 
 99.3 
 
 Part II, Section I, Table XIX. 
 
 INFANT MORTALITY AMONG ALL CHILDREN OF MARRIED MOTHERS 
 INCLUDED IN JOHNSTOWN INVESTIGATION BY FATHER'S AN- 
 NUAL EARNINGS. 
 
 Father's Annual Earnings. 
 
 Infantile Mortality 
 
 Bate (Deaths 
 
 Under 1 Tear per 
 
 1,000 Births). 
 
 Under S521. 
 
 197.3 
 
 $521— 624, 
 
 
 193.1 
 
 $625— 779, — — 
 
 163.1 
 
 
 16S.4 
 
 $900—1,199, . — - 
 
 142.3 
 
 $1,200 and over, — 
 
 
 
 102.2 
 
86 
 
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 as 
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PART II. 
 
 .SECTION II. 
 
 Losses Due to Sickness. 
 
 (87) 
 
(88) 
 
89 
 
 LOSSES TO EMPLOYEES. 
 
 Tlie chief losses to employees from sickness embrace their loss 
 of time and, consequently, of wages during absence from work on 
 account of sickness ; the cost of medical care for themselves and their 
 dependents, and the possible loss of future working power. To form 
 any judgment on the seriousness of such losses, it is necessary first 
 to get an idea of the economic status of the employees in Pennsyl- 
 vania, their wage-rates, the amount of unemployment, and the mini- 
 mum cost of healthful living. 
 
 The present is a peculiarly difficult time to secure any such facts. 
 Wage readjustments, especially in the many war industries of Penn- 
 sylvania, are frequent, while the cost of living is rising to record 
 heights. An attempt will be made to give very briefly the situation 
 in 1914, just before the European war, which may be regarded as 
 comparatively normal. The wage rates for 1916, compiled especially 
 for the Commission by the Department of Labor and Industry, have 
 been used to suggest the earlier effects of the European war, and 
 certain facts have been gathered on recent changes since America 
 entered the conflict. 
 
 The 1914 wage statistics published by the Department of Labor 
 and Industry covered 20,571 establishments in the various forms of 
 manufacturing, the building trades, and "horticultural and floricul- 
 tural products." A comparatively small number of "mines and quar- 
 ries", excluding coal mines, were also included. The average yearly 
 wage for ^11 males was |720, or |14.40 a week. The lowest wage, 
 $323, was found in "engineering and laboratory service," but this 
 covered only a few establishments. Next came "mines" with |469 — 
 probably at this low level because of the amount of slack time — and 
 "tobacco and its products," with $512. The highest annual wages, 
 $1,002, were received in "liquors and beverages," and the "printing 
 trades" were second with |865. The average annual wage for all 
 females was |385, slightly over |6 a week, with somewhat less strik- 
 ing variations from trade to trade than was the case with males. 
 For boys under sixteen it was |224 and for girls of the same age, 
 $191. The average for all "salaried and office help" was $1,207,^ 
 
 A joint investigation by the Consumers' League of Eastern Penn- 
 sylvania and the State Department of Labor and Industry, of the 
 wages of wonjen in five Philadelphia department stores, carried on 
 between November 15, 1913, and June 15, 1914, showed that in this 
 occupation 16.5 per cent, of the women received less than $5 a 
 week, 63.8 per cent, more, between |5 and |10, and only 8.2 per cent. 
 $15 or over. 
 
 No figures could be obtained for the wages of farm help, but the 
 present shortage of farm labor has emphasized the fact that they 
 range lower than in the factories. 
 
 (i)See Table II at the end of this eectlon. 
 
90 
 
 The "average annual wages" make allowance for reduction for 
 unemployment which, it will be remembered, was especially p;^ 
 valent in 1914. An unemployment census of Metropolitan Life In- 
 surance Company policyholders in Philadelphia indicated that there 
 were in the city at that time 79,000 persons out of work and 150,000 
 more on part time, or about 30 per cent, of all wage-earners. This 
 was, of course, the result of "hard times," but Mr. Joseph H. Willitts, 
 discussing these and other figures on the extent of unemployment in 
 Philadelphia, stated that normally much unemployment and part-time 
 employment were to be found in the^ principal industries such as 
 textiles, clothing and railroad equipment, due to the increasing tend- 
 ency to manufacture only on order.^ 
 
 The same factor making for irregular employment is evident under 
 ordinary peace-time conditions in the iron and steel industry in the 
 western part of the state. The dependence of the coal miners on the 
 supply of cars' is likewise well-known. It is commonly estimated 
 that they normally have work for about two-thirds of the time. 
 
 Food prices had not in 1914= begun their present rapid increase 
 but had risen slowly about 25 per cent, since 1907, so that the average 
 wage, $2.40 a day, in 1914 was, in terms of the cost of food, equivalent 
 to less than |2 a day in 1907. 
 
 Prom figures supplied by the Department of Labor and Industry, 
 a special compilation was made of the percentage of wage-earners in 
 various wage-groups in 1915 for the following leading industries of 
 the state^-r-building and contracting, textiles, metal products (pre- 
 paration of raw materials), metal products (finished products), and 
 anthracite and bituminous coal. ^ In these industries, only a sixth 
 of the males covered received less than |15. Wages seemed to be 
 somewhat above the average in the bituminous coail industry, where 
 32.0 per cent, had weekly wages between ^15 and $18. They were 
 especially low in the textile industries, in which 50.2 per cent, of 
 the males earned less than |12 a week. The latter was the only one 
 of this group of industries in which large numbers of females were 
 employed, five-eighths of whom received between $5 and |10 a week. 
 
 During 1915 and 1916, the industrial depression was succeeded 
 by a boom in the many Piennsylvania establishments having war 
 contracts for the Allies, and the average daily wage for males in 
 the industries covered by the Production Report of the Department 
 of Labor and Industry was slightly higher in 1916 than in 1914, 
 12.76 instead. of |2.40.'' For females the rise reported was from fl.ll 
 to $1.30. In the latter year, "steam railways," and "street railways" 
 were included in a "public service" classification which was added to 
 the list of occupations covered. Th'e average daily wage of males in 
 
 (^)AjmalB of the American. Academy of Political and Social Science, Supplement, May 1918, 
 pp. 1-35. 
 -(^)See Table III at the end of Ibis section. 
 (") See Table I at the end of this section. 
 
91 
 
 tliis group was |2.56. Variations between the different trades were 
 similar ;to tkose in 1914. ' 
 
 The entrance of the United States into the war, feverish activity 
 dm all war industries, auany wage readjustments, including some by 
 specially-formed government boards, along with a never-ceasing rise 
 in tlie cost of living, are the chief features affecting the economic 
 status of the employees of the state during the past year and a half. 
 It is probable that any gain in the real wages of employees during 
 the period is rather the result of steadier work and of overtime than 
 of higher wage-rates. Wages in the ship-building yards were fixed 
 by the Shipbuilding Labor Adjustment Board on March 1, 1918, at 
 about sixty to seventy-five cents an hour for skilled craftsmen, forty- 
 five cents for helpers, and thirty-five cents for common laborers, 
 with time and a half for all overtime between forty-four and sixty 
 hours a week. This means about $30 a week for the skilled man, 
 $20 for the helper and $16 for common labor, with the possibility of 
 $15, $10 or $8 more for overtime. The railway wage increase dating 
 from January 1, 1918, applied to employees of railroads in Pennsyl- 
 vania as well as in other sections, and provided graduated increases 
 of from^3 per cent, for those earning |50 a month or less, to nothing 
 for those earning $250 or more. In 1916 and 1917 five increases total- 
 ling 60.6 per cent, have been granted in the iron and steel industry 
 The organized anthracite coal miners sought and obtained a raise 
 of 10 per cent, in the spring of 1917 on the ground of the increased 
 cost of living. A previous 7 per cent, increase, in 1916, was the first 
 since 1912. 
 
 No student of wages is surprised at these low figures. After a 
 most exhaustive study of wealtlh distinction, Dr. Willford I. King 
 estimated that in 1910, 95 per cent, of the families of the continental 
 Umted States had incomes of less than $2,000 a year; that 82 per 
 cent, had incomes of less tham $1,200, and that 69 per cent, were 
 living on less than $1,000.^ 
 
 The wages found in the stndy of infant mortality im Johnstown, 
 Pennsylvania, showed that in 63.5 per eent. of the 1,491 families, the 
 fn.ther was earning less than $1,200 a year. In only 33 per cent, was 
 the income designated as "ample". This study included rich and 
 poor alike, and covered the homes of all babies born in 1®11 in that 
 tity, with no regard for district or circumstances. 
 
 Wage statistics obtained in the various surveys available showed 
 figures at wide variance with the common statement that "all wages 
 have increased 100 per cent."^ In January and F'ebruary 1918 a 
 study was made of four representative blocks in Manhattan, and wage 
 figures for 377 self-supporting families were obtained. The incomes 
 C'f these families in 40 per cent, of the cases had increased between 
 January, 1917 and January, 1918. In another 40 per cent, no increatse 
 had come, and in 20 per cent, an actual decrease had been suffered. 
 
 OWUITora Isbell Kins, "Health and Income of the People of the United States," pp. 214-230. 
 ejSee Table IV at end of section. 
 
92 
 
 There were 574 wage earners in these families; the wages of 31 per 
 cent, had increased ; 57 per cent, had had no increase and 12 per cent, 
 had had their wages, decreased. Yet in January, 1918 in New York 
 the cost of living had so risen that a dollar had only four-fifths the 
 purchasing power which it had in January, 1917. 
 
 In the Philadelphia Survey which covered 1,850 families in seven 
 districts in Philadelphia the ^erage family income was but f 21.60 
 a week, and almost a third of these families contained over five 
 persons — the normal standard. 
 
 In the Visiting Nurse Study, 80.6 per cent, of the 438 families had 
 incomes of less than $30.00 a week. In the Sickness and Dependency 
 Study 94.3 per cent, of the families had incomes of less than this 
 amount. 
 
 Wages for women, proverbially lower than those for men, proved 
 in the Working Womens' Study to be in 98.1 per cent, of the cases 
 under ,|25.00 a week ; in 92 per cent, of the cases, under |20.00. 
 
 In the Pittsburgh Factory Investigation, made in August-Novem- 
 ber, 1918, covering the work places of over 9,000 women, it was found 
 that in 70 per cent, of the operations the wages were between $5.00' 
 and 115.00 per week. In only two processes were the weekly wages 
 over 125.00. 
 
 In a study made by the Consumers' League in New York in 1916-17, 
 among 417 women working in steam laundries, it was found that 78..S 
 per cent, earned less than flO.OO a week, and almost half earned less 
 than 18.00. 
 
 The Kensington Survey, which covered the most representative in- 
 dustrial group, showed that more than half — 56.5 per cent, of the 608 
 families — had incomes under ,|30.00 a week. Forty-two per cent, 
 were living on less than $25.00 a week. 
 
 A very comprehensive statement of recent wage changes has just 
 been published by Hugh S. Hanna and W. Jett Lauck.^ As the 
 result of an intensive study of the records and publications of various 
 state and national departments, and several first-hand investigations, 
 they find that the rise in wages between 1914-15 and December, 1917 
 or January 1918, was only 18 per cent, for anthracite miners, 26 per 
 cent, for machinists in the Philadelphia- Navy Yard, 30 per cent, for 
 bituminous miners working by hand, and 34, 36 and 37 per cent, 
 respectively for shipsmiths, shipfltters and pipefitters in the Phila- 
 delphia Na^y Yard. The rise in the building trades was but 12 to 
 20 per cent. Some industries had actual decreases, and some re- 
 mained almost stationary. The chief industries in which exceptional 
 gains occurred during this same period were bituminous mining by 
 machine, 39 pe^r cent., various occupations in the iron and steel in- 
 dustry, 60 to 67 per cent., and certain classes of labor in the ship- 
 yards on the Delaware Eiver, 65 to 105 per cent." 
 
 1\','.3*^™ »"•* *■*« War," publlBhea January, 1918. 
 (2) "Wages and the War," page 6. 
 
93 
 
 In commenting on "the Effect of the War on Wages" they state: 
 "During the past few years, and more particularly during the 
 period of the war, there has been an increase in money wages in 
 practically all branches of American industry. But there has been 
 iibsolutely no uniformity in the rate of increase. In some trades, 
 there have been wage advances that a little while ago would have 
 appeared wildly incredible. In others the advances have been very 
 moderate — little, if any, greater than had occurred during a period 
 of equal length in the preceding years of peace. 
 
 The great advances have taken place in 'those lines of industry for 
 the products of which the war has created a special demand. • * » * 
 In some industries, such as printing, the war made no special de- 
 mands; in still othei-s it had a depressing effect. Many individual! 
 workers in these trades, of course, profited by transferring themselves; 
 to war industries, * * * * but this is not always the case."^ 
 
 In contrast to this wage situation, we find a steady increase in the 
 prices of food, fuel, and other necessities of life. According to the 
 United States Bureau of Labor Statistics, retail food pricesJn Phila- 
 delphia were 68.09 per cent, higher in August, 1918 than in December, 
 1914.2 
 
 The greatest increases occurred in the items of clothing and house 
 furnishing. These items increased over a hundred per cent. 
 
 Philadelphia was included in the studies of the increase in cost 
 of living recently completed in ship-building centers by the Bureau 
 of Labor Statistics. The measurement of increase is based on a study 
 of price fluctuations for five groups of expenditures — food, rent, fuel 
 and light, clothing and sundries. The increased cost of living was 
 found by combining the increased cost of each of these five classes, 
 after this cost had been weighted according to its relative importance 
 in the budget. 
 
 According to the figures for Philadelphia the cost of living for 
 white families based on these necessities, had risen 67.17 per cent, in 
 August, 1918, over the cost in December, 1914.^ In New York this 
 increase was 62.07 per cent. The increase in New York has been 
 computed up to December 1918, and is 75 per cent. If Philadelphia 
 costs increased in like manner, the cost of living was in December, 
 1918, 80.10 per cent, higher than in December 1914. The cost of 
 living in Philadelphia was found by the investigators to be higher 
 than in New York, Boston or Chicago. 
 
 Wholesale figures tell a more startling story. From July 1, 1914, 
 to April 1, 1918, the wholesale prices of forty-six commodities given 
 in Bradstreet's Trade Journal showed a rise of 115 per cent. 
 
 The standard "Minimum of subsistence" budgets made in New 
 York of |845,' .f876* and S?900= for a family of five, became in June, 
 1918, |1,320, |1 360, and $1,390 respectively. 
 
 ,(') "Wages and the War," page 3. 
 
 (2)Monthly Review October, 1918, page 119. ,.. „ ^ ^ „ x. ^ ^ . ^. 
 
 ("jEsMmate of Bureau of Personal Sei-vine of the Board of Estimate and Apportionment of 
 New York City, for unskilled laborer's family, 1915. 
 
 («) Estimate of ' New Tork Factory InTestigatlng CoinmiSBion, 1814. 
 (»)Estlinate of Dr. Chapin, 1907. 
 
94 
 
 The Philadelphia Bureau of Municipal Research stated in Decem- 
 ber 1917, that the necessary minimum cost of healthful living for a 
 family of two adults and three children was $1,200 a year. In the 
 cost of living study which this Bureau is now completing, the mini- 
 mum budget will be between $1,625 and $1,650.^ 
 
 The United States Bureau of Labor Statistics estimates that in 
 November, 1918, the minimum necessary for subsistance for an aver- 
 age family in a large eastern city is about |1500 and the National 
 War Labor Board drew up a "minimum comfort" budget in June, 
 1918, which amounted to -f 1,760 per year for a family of five.^ 
 
 In spite of rumors of jiniversally increased wages, in New York 
 City, the percentage of undernourished school children had more than 
 doubled in 1916-17 as compared with 1914. Five per ^ent. of the 
 children studied in 1914 were "seriously" undernourished. In 
 1916-17, 12 per cent, were so affected.^ 
 
 A few employers have made provision for periodic increases in 
 wages, in accordance with the increase in the cost of living. For 
 the most part, however, the wage increases have been wholly un- 
 standardized, except when fixed by the government. On July 12, 
 1918, the National War Labor Board fixed a minimum of 40 cents 
 an hour for unskilled laiborers in a machine shop at Waynesboro, 
 Pa., stating that this was the smallest sum for which a laborer could 
 support a family. 
 
 On the 23rd of November, 1918, in Kensington, 2,000 carpet weavers 
 went out on strike, claiming that they could not live on their pay, 
 which averaged |25.00 a week, and asking for an increase of $15.00. 
 
 It is signflcant that in 76.5 per cent, of 1,156 strikes, occurring dur- 
 ing the first six months of the war, and studied by the National In- 
 dustrial Conference Board, the demand was for increased wages, and 
 38.5 per cent, of these strikes were called for this reason alone. The 
 Conference Board states first, among the causes responsible for these 
 strikes, the "increased cost of living and failure of ranployers in 
 many cases to anticipate this influence." The second cause of 
 primary importance is the "widespread discontent due to a belief 
 that undue profits had been made by employers out of war business," 
 and the third is the ."inequality between wages paid in plants engaged 
 on private work and government or private plants engaged on war 
 work."* 
 
 It is evident that the wages of Pennsylvania employees during 
 the past four years haVe shown uneven fluctuations, varying from 
 increases of 105 per cent, in certain war industries to less than 20 
 per cent, in a considera;ble number of others, to actual decreases in 
 
 (')AutTiorized statement of William C. Beyer, Assistant Direotor of Philadelphia Bureau of 
 Municipal Research. 
 
 (2)0gbiini, Wm. F., "Measurement of Cost of Living and Wages," Annals of Amerlnan Academy 
 of Political and Social Science. January, 1919. 
 
 OBaker, S. J., "War and Nourishment of Children," 1918, page 7. 
 
 (<)"Stribe8 in American Industiy in War Times," Jfstioijftl Industrial Confergncs Board, March, 
 1918, pp 9 and 20. 
 
1)5 
 
 a few cases. Meanwhile the cost of the necessary articles which poor 
 as well as rich must buy has steadily increased until today, at the 
 .very least it is 75 per cent, higher than it was in December, 1914. 
 The effect of such conditions on the ability of wage-earners to ac- 
 cumulate savings with which to meet periods of sickness needs no 
 explanation. And yet, as every survey has shown, sickness with its 
 accompanying losses is a risk certain in too many instances to bank- 
 rupt the family that has made no adequate provision for it. 
 
 Loss of Working Time, on Account of Sickness. 
 
 An average of .six days lost from work by each employee each year 
 on account of sickness, which was the low figure reached in the first 
 section on the extent of sickness, may not seem a particularly long 
 period. It looms larger, perhaps, when it is realized that the 
 2,800,000 wage-earners^ in the state are losing 16,800,000 days a 
 year through sickness. The coal miners are losing 2,142,000 days, in 
 which time four and one-half million tons of coal could be extracted. 
 
 In the study of the families coming to the Visiting Nurse Society, 
 13,528 working days were lost during the year by 201 wage-earners. 
 This means an average of sixty-seven days for each of them, or nine- 
 teen days for each wage-earner in the study, sick or well. Of this lost 
 time, almost one third was lost by only nine men. Only 40 per cent, 
 of the 201 wage-earners lost less than two weeks, and 46 per cent, of 
 them lost from one to six months each. 
 
 In the Kensington Survey, 421 cases of illness of wage-earners were 
 noted. The average length per case was thirty-eight days, or over 
 five weeks. This comparatively short average period, together with 
 the heavy burden of the actual illness would seem to indicate strongly 
 that some method of equalizing and distributing the loss from illness 
 would be desirable. Under present conditions, employees are either 
 unable or unwilling to take time off for minor disabilities, so that 
 illness when it does occur, is more serious and prolonged. 
 
 Loss of Money on Account of Sickness. 
 
 The figures on the duration of illnesses among employees give some 
 indication of the wage-loss. A total loss of wages almost always 
 occurs during absence from work because of illness. Only the skilled 
 workers and salaried eniployees are more fortunate; in fact, the 
 average wage-earners may consider themselves fortunate if their 
 places are saved for them until their return. In the study of Work- 
 ing Women, the wage was continued in only three instances, while in 
 the 647 cases of the illness of a wage-earner among the families 
 ir. the Sickness and Dependency Study, the wage was continued in 
 
 (1)1918 estimate. 
 
 7 
 
96 
 
 just one instance. In one other case a part of the wage was paid, 
 and in thirty-three cases the employer gave some help as a matter of 
 charity. 
 
 We may roughly reckon the total wage-loss, therefore for Pennsyl- 
 vania employees for a year, as the average wage multiplied by the 
 number of days lost. At 1916 rates this would average a little more 
 than $14.00 per employee per year, or a total of f 39,200,000 for the 
 2,800,000 employees in the state. 
 
 In the Kensington Survey, the wage loss .was reported in 367 cases 
 of the illness of wage-earners. The average per case was |78.53, 
 01 more than a month's pay of a single wage-earner according to the 
 family incomes found in the survey. 
 
 This is an average, giving no picture of the actual suffering of 
 those who are sick for long periods. It tells little of the problem of 
 Mr. R, a laborer earning flS.OO a week and supporting a wife and 
 three little girls, eleven, nine and six, and a baby boy a year old. 
 I'or more than two years, althoiigh suffering with tuberculosis", he 
 kept on at work. But when his strength finally failed and he was 
 sent to a state sanitorium, his family had no means of support, and 
 although he was supposed to have contracted the disease in the course 
 of his work, his employer gave but -flO.OO. For eight months the 
 church and a relief society cared for the family, the latter contribut- 
 ing several hundred dollars. 
 
 It is easy to see that the average owployee, unless he has other 
 wage-earners in the family or relatives attle to help him, may find the 
 vage-loss from illness alone an intolerable iurden, eating up his 
 savings, piling up deMs and lowering his whole standard of living. 
 
 Cost of Medical Care. 
 
 Over and above the loss in wages must be reckoned the cost of 
 medical care for employees and their families. Certain fee-schedules 
 of the medical, dental and nursing professions and of hospitals are 
 presented. Considering the professional skill and the responsibility 
 involved, many of the fees are most moderate. They are given to 
 show what employees in this state must pay, under, present condi- 
 tions, to receive medical care on an independent, full-cost basis'. 
 They cannot be taken to represent the actual charges made but repre- 
 sent merely the standard minimum fee for regular professional serv- 
 ices, exclusive of attention from specialists. 
 
 Physicians' fee schedules, as published by various county medical 
 societies, range from fifty cents to $5.00 for an office visit, and from 
 $1.00 to |3.00 for a house call. Special rates are made for operations, 
 rnd the lowest price for obstetrical services is $10.00. Many of these 
 schedules are being revised and prices raised. In three counties 
 
97 
 
 a 40 to 50 per cent, increase has been announced. Rates are lower 
 in the rural districts than in the cities. Dental rates throughout 
 the state range from $3.00 to |5.00 an hour. When charges are de- 
 termined by the nature of the work done, rather than by the time 
 consumed, amalgam or cement fillings and treatments cost from |1.00 
 up ; gold fillings, from |2.00 ; and bridge work', |8.00 to $12.00 per 
 tooth- Trained nurses' fees are from f25.00 to |35.00 a week for 
 ordinary cases, frequently with extra charges for nervous and ob- 
 stetrical cases. Ward beds in hospitals cost from $10.00 to $14.00 
 a week, and a charge of $5.00 to $10.00 for the use of the operating 
 i(Oom is customary.^ 
 
 Naturally, many employees cannot pay these charge?. As a result, 
 we have physicians and hospitals giving service free, or at reduced 
 rates, a host of medical or semi-medical charities, and throngs at 
 the free dispensaries, as well as numerous cases of entire failure to 
 receive medical care where it is sadly needed. Charity practice im- 
 poses an unjust burden upon the medical profession and undermines 
 the self respect of the recipients to an extent which seems wholly 
 inconsistent in a democracy. 
 
 What wage-earners and their families actually pay out for medical 
 care in time of sickness, has been ascertained' from the available sur- 
 vey material. » 
 
 Here again "average expenditures" give no idea of the real burden 
 imposed. In the Visiting Nurse Society Study for instance, more 
 than half the expenditure for sickness was borne by less than one- 
 seventh the number of families. While 29 per cent, of the fainilies 
 escaped with health expenditures of less than $10.00, fifty families 
 spent over $100.00 ; ten spent over $300.00, and thirteen families had 
 medical and dental expenditures amounting to more than 20 per 
 cent, of their total incomes. In the study of Working Womens' 
 Eecords, one-fourth of the total expenditure was made by only ten 
 girls; the intolerable burden of the self-supporting working woman 
 confronted with a bill of $685.00 for two operations needs no ampli- 
 fication. 
 
 Approximately one-third of the families studied in the various 
 surveys had annual expenditures of more than $50.00. The largest 
 single group spent between .|20.00 and jeSO.OO.^ 
 
 Invariably the largest item of health expenditure was the cost of 
 a physician's care. The following table classifying each detail, gives 
 a fair idea of the proportion spent on different items by low-income 
 families. The group of 260 families covered in the study were "self- 
 supporting," but in no case was the principal wage-earner receiving 
 an income of over $2,000 : 
 
 rnsoe tahlps VI A- B. C. and D at the end of this section, - . . , ^.^ ■ 
 
 H Table Vn at end of section gives the exact distribution of medical and dental expenditures. 
 
08 
 
 AVERAGE ANNUAL HEALTH EXPENDITURES FOR VARIOUS OBJECTS.i 
 
 
 Pamilies 
 
 All 
 
 
 Beporting 
 
 Families 
 
 
 Expenditures. 
 
 (260). 
 
 
 
 « 
 
 « 
 
 Objects- of Expenditure. 
 
 
 
 
 
 
 ■4-a 
 
 
 
 
 -o 
 
 
 
 s . 
 
 s . 
 
 
 
 &>, 
 
 ntx 
 
 
 
 • n 
 
 MS 
 
 
 o 
 
 "S 
 
 
 
 m » 
 
 0103 
 
 
 
 {»•" 
 
 M'" 
 
 
 
 A . 
 
 
 
 a 
 
 s s 
 
 
 
 s 
 
 >°- 
 
 
 3(.^ 
 
 !zi 
 
 <! 
 
 <! 
 
 All objects, 
 
 PliysieianS, 
 
 Dentist, 
 
 Oculist, i 
 
 Nurse, — 
 
 Surgical appliances, 
 
 Medicine prescribed by physician, 
 
 Other medicines, 
 
 Hospital charges, 
 
 Dispensary charges, 
 
 Spectacles (and eye-glasses), 
 
 Unspecified, -— 
 
 25S 
 
 ?32 56 
 
 217 
 
 20 53 
 
 97 
 
 13 02 
 
 80 
 
 936 
 
 22 
 
 17 73 
 
 6 
 
 9 83 
 
 79 
 
 6 11 
 
 184 
 
 5 05 
 
 20 
 
 12 54 
 
 10 
 
 568 
 
 52 
 
 583 
 
 1 
 
 100 00 
 
 17 14 
 4 86 
 
 72 
 1 50 
 
 23 
 1 59 
 3 97 
 
 96 
 
 22 
 1 17 
 
 This average expenditure ut f32.30 per family, raised to 1918 flg- 
 vires, wouldjbecome $37.00, if we may assume that health expenditures 
 have risen in cost at the same rate as general household expenditures.^ 
 This is somewhat lower than average expenditures obtained in 1918 
 surveys. Among the Visiting Nurse Society families the average of 
 the 363 reporting expenditures was over |47.00. For the Working 
 Women the average for the 284 girls where expenditures were known 
 was 127.78. 
 
 Special figures for the health expenditures of the Philadelphia and 
 Chester families covered by the Cost of Living Study of the United 
 States Bureau of Labor Statistics were segregated for the Commis- 
 sion. In Philadelphia 188 families out of 192 reported health ex- 
 penditures—the average being |43.29. In Chester forty families 
 reported an average of |48.93. The average cost of medical care 
 alone was $36.23 in Philadelphia and $37.90 in Chester. Dental ex- 
 penditures were much smaller— 113.83 and $16.98 respectively. In 
 another study of the Cost of Living made by the Bureau of Labor 
 Statistics the average annual health expenditure for 292 white fami- 
 lies was $43.59 ; for 230 negro families the average was $20.19. 
 
 One of the most interesting items of expenditure is that for patent 
 medicine. The large amount of patent medicine consumed by wage- 
 earners and their families was one of the chief points which im- 
 pressed the nurses who made the Visiting Nurse Society Study for 
 the Commission. Many families attempted to ward oflf the need and 
 
 l!j'F''!,.™?*"?*''i^i"S study made by Philadelphia Bureau of Municipal Besearch, 1917. 
 C') Authorized statement of Wm. C. Beyer, Dirertor of the Study. 
 
99 
 
 the expense of a physician by investing in patent medicines. In the 
 Cost of Living Study of the Philadelphia Bureau of Municipa.l Re- 
 search, 184 families out of 258 reported expenditures for medicine 
 other than that prescrilyed iy a physician. The average expenditure 
 was over |5.00, and for all the families covered this average was 
 |3.57, as against an average of $1.55 for the medicine ivhich was 
 prescribed. During the year, ten families had spent over 120.00 oa 
 these patent medicines. Two families in the Sickness and Depend- 
 ency Study reported that often |6.00 or |8.00 a month went for 
 medicines, in the hope that cure would come and prevent further 
 expense or an "out-of-work" period. 
 
 Especially interesting in this connection were the results of the 
 surveys of the Old Age Pensions Commission made in industrial 
 districts of Pittsburgh, Reading and Philadelphia. Facts for men 
 and women over fifty years of age were tabulated, and special items 
 were secured for the Health Insurance Commission on expenditures 
 for medicine. In three cities figures on expenditures for "medicine 
 only" were secured for 1,269 people. Three-fifths of these individuals 
 had monthly expenditures for medicine. In 10.2 per cent, of the 
 cases this monthly expenditure amounted to over |4.00, and in 3.6 
 per cent., to over"|10.00. 
 
 In Pittsburgh 16.5 per cent, of the 207 individuals for whom this 
 information was secured, spent regularly an average of over |4.00 
 a month for "medicine only." In Reading, where information for 
 721 individuals was secured, the percentage spending over four dol- 
 lars a month was 3.6; in Philadelphia it was 4.1 per cent. The in- 
 jurious effect of the constant and haphazard use of medicines with- 
 out medical advice is well known. 
 
 The average expenditures for health purposes in wage-earners' 
 families seem to bear a direct relation to the amount of income. In a 
 study in 1917 by the United States Bureau of Labor Statistics health 
 expenditures for a group of families in Washington were tabulated. 
 The average expenditure increased as the income increased: 
 
 Number of Families. 
 
 Average Annual Income. 
 
 Average Expenditure 
 Jor Medical Care. 
 
 46 
 117 
 167 
 198 
 ^ 191 
 
 Less than $800 00 
 
 $600 00— 900 00 
 
 900 00^1,800 OO 
 
 1,200 00—1,300 00 
 
 1,600 00 and over 
 
 $12 83 
 
 42 31 
 4S16 
 59 67 
 
 The cost of medical care comes many times as an emergency amd 
 places upon the individual a hurdcn out of all proportion to his re- 
 sponsibility. The problem is one of a just method of distribution. 
 
100. 
 
 Loss of Future Earning Power. 
 
 The possible loss of future earning power is the most important 
 risk of the wage-earner. Unless he is rehabilitated, he himself, his 
 family, and society all suffer irretrievably. The temporary loss of 
 wages and the cost of medical care are indeed minor matters com- 
 pared with the prospect of facing the future obliged to support him- 
 self and his dependents on reduced earning power, or unable to 
 support them at all. 
 
 Any attempt to aid in the solution of the sickness proMem must 
 have as its goal the complete restoration of the sick man or woman 
 to health. To this end, immediate and adequate medical, surgical and 
 institutional care must be made available, and the contingency of. 
 suspension of earnings during the periods necessary for recovery 
 must he m.et. This is hut justice to the disabled person, to industry 
 and to the community at large. 
 
 LOSSES TO INDUSTRY BECAUSE OF SICKNESS OF 
 EMPLOYEES. 
 
 Industry has not generally counted among its costs of operation, 
 the losses which it suffers because sickness daily keeps thousands of 
 employees from work, sends others to their places in a partially 
 disabled condition, and every year permanently unfits hundreds of 
 men and women for productive effort. Because of the lack of accurate 
 records, it is impossible to exactly measure the extent of this enor- 
 mous industrial loss, but from our knowledge of the extent and 
 seriousness of disease among wage earners, and from the testimony 
 of those few employers who have come to realize that the good health 
 of their work people is an essential to business success, we can draw 
 some conclusions. 
 
 The fact that every year Pennsylvania's working men and women 
 lose over sixteen million working days because of illness gives some 
 indication of the coal that is not loaded, the rivets that are not driven, 
 the seams that are not welded because the workers are away, sick. 
 The co^l mines alone lost at this rate 2,142,000 working days— time 
 enough to mine four and one-half million tons of coal, sufftcient to 
 supply the city of Philadelphia for a year and a half. And to that 
 must be added the wastage and ineflScient work of that large number 
 of employees who, although really sick, "cannot afford to lose the 
 time." The work done by such half sick or, as often happens, by 
 seriously sick men, is almost certain to be inferior in quality and 
 the danger of industrial accidents is greatly increased by their pres- 
 ence. In the majority of such cases, no medical care is secured, 
 powers of resistance are weakened, and gnsceptibility to disease is 
 increased. Often chronic disease develops from an illness which 
 would have amounted to little if treated in its incipient stages. 
 
loi 
 
 ¥he fdcent influenza epidemic reduced the anthracite coal output 
 of the state 500,000 tons in the course of a few weeks. "It went 
 raging through the mines, stri^king down thousands of men, killing 
 some, leaving others so weak that they will not be themselves for 
 months."^ Because it was spectacular, this loss was widely appre- 
 ciated and commented upon — but no attention is paid to the steady, 
 never-ceasing inroads made on production of all kinds by the non-epi- 
 demic sickness. We are so accustomed to it that we do not realize 
 what could be accomplished without the hampering influence of that 
 full half of it which could be entirely prevented. 
 
 In-co-operation with the Ohio Health and Old Age Insurance Com- 
 mission, the record cards of 115,648 members of the Voluntary Relief 
 Department of the Pennsylvania Railroad (East) were examined by 
 the Commission, and all illnesses and industrial accidents for which 
 benefits had been paid to these members during the five years 1913- 
 1917 were tabulated. As it was impossible to tell which men had been 
 members of the Department during the entire period, no sickness 
 rate could be obtained from the study, but the- duration of each of 
 the 27,055 cases of industrial accidents and 64,849 cases of sickness 
 was recorded. For 1917 the cards examined showed 5,103 industrial 
 accidents and 13,028 cases of sickness, each of which was of less than 
 100 days' duration- The total number of icorking days lost through 
 the accidents was 60,215, while the sickness cases caused a loss of 
 165,002 working days. In addition, there were tabulated 111 indus- 
 trial accidents and 236 cases of sickness, each of which lasted longer 
 than 100 days. When we see that the total niimber of sickness cases 
 tabulated in the annual report of the Relief Fund for 1917 is 62,744, 
 or more than four and one-half times the number which the Com- 
 mission studied for that year we realize the tremendous loss to this 
 one company alone through sickness among its employees. 
 
 The Westinghouse Electric and Manufacturing Company of Pitts- 
 burgh also has a relief department, whose records show that for the 
 month of August, 1915, members of the department lost 6,654 days 
 because of sickness. This was not an abnormal month, but records 
 for other months were not available. 
 
 Specifically, sickness has a close relation to several factors whose 
 Ibearing on production and prosperity is important. Not only the 
 .casual laborer, but the skilled mechanic, engineer or miner is at- 
 jfaeked by disease. The absence of such an employee, or the attempt 
 to replace him with a new or inexperienced worker, causes serious 
 loBS tbrough reduction in output, spoilage of material and incomplete 
 use of machinery, lighting and heating equipment. In many indus- 
 tries it costs from, 130.00 to |5i9.00 to hire and initiate a new em- 
 
 (i)Francis A. Lewie, Federal Fuel Administrator for ?liiladelphia, November 24, 1918. 
 
102 
 
 ployee, and in the case of a skilled mechanic the cost may be as high 
 U8 $300,000. In both the Kensington and the Visiting Nurse Studies, 
 covering largely skilled and semi-skilled industrial workers, the 
 average time lost by disabled employees was thirty-eight and 
 sixty-nine days respectively ; approximately half the illnesses in every 
 group studied lasted longer than one month. In many such cases, 
 the employer is forced to fill the place of the absent worker, and 
 "labor turnover," one of the most costly factors in industry, is in- 
 creased. Thomas I. Eead, of tbe New Jersey Zinc Company's Tech- 
 nical Department, after a careful study of working-time lost on ac- 
 count of both sickness and accident states that, "As in the -case of 
 accidents^ when the man is absent another man must be supplied to 
 take his place, and this increases both the labor turnover and the 
 accident rate; in other words it is a source of considerable loss to 
 the company as well as to the man."^ Time lost by employees of this 
 company through illness amounts to four times the loss from acci- 
 dents. 
 
 Realization of the seriousness of the situation is compelling some 
 employers largely as a business proposition to institute more or less 
 complete medical care for sick employees, and to encourage the for- 
 mation of establishment funds for the payment of cash sick benefits. 
 The Bell Telephone System maintains entirely at its own expense 
 a system of sickness insurance providing for the payment of sick 
 benefits to sick employees. The rate and the duration of payment 
 are based on the wage rate and the length of service, and substantial 
 death benefits and pensions are paid. Mr. Charles G. DuBois, Comp- 
 troller of the Bell System, says, "This plan is not in any sense a 
 charity, and it is not so regarded by employees. It is an attempt to 
 deal justly and practically with one of the problems arising under 
 modern industrial conditions. As we sfee it, the men and women 
 who give their working lives to furnishing telephone service are 
 fairly entitled, as a part of their condition of employment, to know 
 that they will not face destitution in sickness or in old age, and 
 that if they die in the service their dependents will receive some 
 financial provision for their immediate needs. If this is a fair and 
 reasonable condition of employment, then its cost is rightfully a part 
 of the cost of giving telephone service and we so regard it. * * * 
 Just as the cost of accidents puts on the employer and manager an 
 economic incentive to develop safety appliances, so the cost of sickness 
 insurance directly stimulates an interest in the prevention of sickness 
 * * * We feel that we are started on the right road, that the 
 problems involved are not essentially different from other business 
 problems which have to be worked out carefully and thoughtfully, 
 that the advantages of sickness insurance from a business point of 
 
 (') Report of New Jersey Health Insurance Commission, page 17. 
 
103 
 
 vieto are prohaMy ivorth the cost, and tlial wliiiU'ver the cost, the 
 responsibility for healthful working contiitions and the duty of pro- 
 viding financial aid for the workers when they are incapacitated rest 
 squarely on the industry."^ 
 
 Satisfaction with the results of attempts to reduce sickness losses 
 seems to be general among employers who have tried them. A large 
 Massachusetts company which has established a system of complete 
 medical treatment, including hospital care, for its employees, finds 
 that "the hours per year lost by employees who take advantage of its 
 hospital facilities amount to only half as many as are lost by those 
 who do not accept this care."^ "It is to the direct interest of the com- 
 pany as well as the individual," declares a member of the famous 
 silk firm of Cheney Brothers, "to bring about a re-establishment of 
 health and consequently efficiency, by supplying the best conditions 
 possible for recovery."^ "The modern employer," according to the 
 medical director of the Cincinnati Milling Machine Co., "has learned 
 that the health of the worker is a definite asset in his business. Med- 
 ical care in industry is not charity. It pays good dividends."^ 
 
 Unfortunately, the employers who are taking effective steps to re- 
 duce this industrial loss are few in number, and the attempts are 
 confined as a rule to the large and more progressive establishments. 
 Moreover, scarcely any provision is being made for sickness among 
 members of employees' families, which, next to the illness of the 
 workers themselves, most reduces their efficiency. In the few cases 
 where industrial nurses are being employed to visit tha homes of em- 
 ployees and give needed care and public health instruction, marked 
 improvements not only in general habits of living, but in the health 
 of the workers, are noted. 
 
 The war, with its emphasis on production, has created a growing 
 recognition of the need for a means of reducing sickness-losses whicli 
 may be shared alike by large and small industrial concerns. The 
 following extract from the January, 1919, issue of "The Nation's 
 Business," published by the United States Chamber of Commerce, 
 y)resents the matter from the point of view of industry. "If the casu- 
 alty list from industry could be printed eveiy day in our newspapers 
 the people of this country would be appalled at its size. In one year 
 from accidents alone it is over eight times as large as the entire 
 carnalties among our troops in the battlefields of Europe. 
 
 "We have no records to show the number who are killed or dis- 
 abled as a result of occupational diseases and diseases partially 
 traceable to working conditions, but these undoubtedly are even more 
 shocking. Bach year adds a quarter of a million men to the total 
 number of incompetents who, on account of disease or accident are 
 permanently thrown on the scrap hgap because their handicaps pre- 
 vfiut them from continuing at their old occupation. 
 
 — mrh iirlps G DuBois in an address before The National Civic federation, January 22, 1917. 
 (2)Third Report, Committee on Health. New York State Federation of Labor, 1918, page 8. 
 
104! 
 
 "This casting of valuable workers needlessfy' <*& the scrap heap must^ 
 eease. Industry must blaze the trail in this' (♦ea^^ervation and re- 
 Clataation of human life. The prevention of acfifiteefts, industrial 
 hygiene and sanitation, adequate medical and surgidaB «aHe for the 
 Sicfe Oi" injttred employees, adequate compensation during: per.n»ds of 
 disability, and better living and working conditions for all eai|glb;gBas, 
 are the proven methods which will stop this human wastage,"" 
 
 LOSSES TO THE SfAfE BECAUSE OF SICKNESS OF 
 EMPLOYEES. 
 
 "In the health of the people lies tk& wealti of the nation." 
 
 Gladstone. 
 
 The direct financial loss to the state because' 6f si'ekffi«S8 repre- 
 sents for the most part public effort to reduce the i^eial lossi 
 
 It would be impossible to estimate the social cost of sickaeas 
 ainong wage earners in Pennsylvania. Serious reductiott* in eiBi- 
 ciency and productive power, lowered morale and broken stasadards'. 
 of living and of home-keeping, encouragement given to the grewthi 
 of invalidism, economic dependency, and physical and moral degenKr-- 
 ation — ^these evils, which can but result from the uneven and oftens 
 losing fight that present conditions force upon the sick wage earner,- 
 are clearly apparent; but because the toll which they annually col- 
 lect is too vital to be calculated in dollars alone, it cannot be ac- 
 curately measured. 
 
 In its effects upon the individual worker and his family, and 
 through them upon the present and potential staifflina of the nation, 
 this social cost of sickness is far niore impiffftainf tli'an the fiBafidial 
 cost. The health and strength of our people a/re the real smerces o| 
 our wealth, and our' contemplation, of money sprfii for sickness relief 
 and prevention must he directed, not so much to' Me amouni of 
 expenditure, as to the results achieved thereby. "If, m alleged by 
 way of criticism, the health service is costly, it can be pretadi fio be: 
 the best possible investment to meet the cost."^ 
 
 Cost of Sickness to PuMic Funds. 
 Although no effort has been made by the state of Pennsylvania 
 to equitably distribute the cost of sickness, state appropriations for 
 the work of the State Department of Health, for medical charity and 
 for relief to persons incapacitated on account of sickness, amount 
 each year to millions of dollars. In 1916, the state spent in subsidies 
 to hospitals, for its tuberculosis work, for the State Department of 
 Health, the Mothers' Assistant Fund, institutions for the care of 
 defectives, and for medical supplies in almshouses and out-door relief 
 to sick persons, over $10,000,000. Of this sum, more than |6,OOO,0W 
 was expended for the work of the State Department of Health and 
 for ho spitals, medical supplies and relief in individual cases of sick- 
 
 1919!"™6l"'"* ''°'""°' ^- ^- ^"""^ "^"""'" SalTage."_Th6 T^atipn's BiMlness, Januai^, 
 Pineport of Pennsylvania State Board of Hpaltli, 1887, page SgO, 
 
105 
 
 ness, while a large proportion of the remaining |4',000,000 undoubt- 
 edly went to pay for the consequences of the prevalence or the neglect 
 of disease. 
 
 The ten state hospitals for miners spent 1439,428.92 during the 
 calendar year, 1916. Of this amount |369,456.25 came from legisla- 
 tive appropriation. Out of 14,451 in-patients treated in that period, 
 12,617 or 87.3 per cent., received free treatment. In addition, there 
 were 15,503 dispensary patients from whom but |53.50 was received 
 for treatment. The total cost of free treatment was |366,955.60.^ 
 
 In the year ending May 31, 1916, 175 other hospitals made statis- 
 tical returns to the State Board of Charities. During the year they 
 spent 17,937,055.10, of which |2,351,723.96 was received from the state 
 and from counties and cities, and .f3,268,287.16 from patients for 
 board and treatment. In spite of state assistance, 102 of these hos- 
 pitals reported deficits for the year amounting to 1743,486.49. Of 
 the 219,834 in-patients reported, 127,678, or more than 57 per cent., 
 had 'been treated free. The total nurnber of free hospital days was 
 j.627,S46, or 40.6 per cent, of the total numl)er of days of treatment, 
 and cost almost three and a half million dollars. There were also 
 873,444 dispensary patients, whose payments for treatment amounted 
 to but 183,727.81, or less than ten cents each.^ 
 
 Two classes of tuberculosis sanatoria receive funds from the state. 
 There is the state organization under the Department of Health 
 which, in 1914, controlled 116 dispensaries scattered throughout the 
 state and three sanatoria at Mont Alto, Cresson and Hamburg. 
 
 Every year more than 15,000 persons receive either free dispensary 
 or sanatorium treatment at a cost which in 1916 amounted to f 1,692,- 
 690 — over half the expenditures of the Department of Health. In 
 addition, the dispensaries^ secure charitable relief for the families 
 under their care, which each year amounts to between $20000 and 
 125,000. About half this sum is secured from the County Commis- 
 sioners and the remainder from private agencies and individuals. 
 
 In addition, the legislature appropriated, for the year ending May 
 31, 1916, subsidies amounting to .f50,500 for nine smaller institTi- 
 tions for the treatnient of tuberculosis under private control, whose 
 total expenditures were |263,108.H. Altogether the nine treated 
 1.098 in-patients, of whom almost 60 per cent, received free treat- 
 ment to the amount of 57.734 free hospital days. They also cared 
 for 5,273 dispensary patients, practically all of whom received free 
 treatment.^ 
 
 Altogether . these institutions for sickness-care, exclusive of the 
 State Tuberculosis Sanatoria, spend annually over |8,000,000 of 
 which almost one-third is' supplied directly by state funds. They 
 
 fMSee TaWe VIII at the end of tliis flection, 
 (2) See Tahle IX at the end of thin sec^tion. 
 (')See Table X at the end of this section, 
 
106 
 
 represent a real estate investment of over |36,000,000, endowments of 
 almost 115,000,000, and fixed indebtedness of four and a half million. 
 The potential annual income from this invested capital would amount 
 to over two and a half million dollars. During 1916, of 1,124,330 
 patients treated, 140,944 were free in-patients, 94,439 paid for treat- 
 ment, and 888,947 were dispensary patients. The receipts, from 
 patients for treatment, for the use of ambulance, laboratory facili- 
 ties, etc., amounted to |3,804.159.67, while the total cost of the 
 ] ,925,921 free hospital days was $3,454,799.65. 
 
 Still another way in which public funds are spent for medical 
 charity and for the care of sick employees is through almshouses and 
 public relief in almshouse districts.^ Even in years of great indus- 
 trial depression, "temporary sickness and death" is the principal 
 cause for which such relief is given. Over a five-year period it ac- 
 counts for from one-third to nearly one-half of all the cases relieved. 
 Such relief cost in 1916, |708,752.10. In addition, eighty almshouses 
 reported the expenditure of $51,258.73 for medicines and medical 
 supplies. 
 
 These heavy drains upon the charitable resources of the state indi- ^ 
 cate plainly that under present conditions many employees are not 
 able to meet the expenses of sickness. Much of the relief that is 
 given has little or, no preventive or curative value, because the hos- 
 pital, the dispensary, or the county almshouse has been resorted to 
 only after a seemingly slight ailment has become a serious and often 
 incurable disability, and the worker and his dependents have been 
 forced from their rightful position of economic independence. Past 
 experience has demoiistrated that any plan for meeting the sickness 
 problem satisfactorily must furnish a stimulus for prompt preventive 
 effort on the part of all elements concerned, instead of providing 
 merely institutional and charitable means of care. 
 
 Cost of Sickness to Private Funds. 
 
 While it has been impossible to obtain accurate and complete 
 figures as to the burcjen imposed on private charity by the sickness 
 of wage earners, it is obvious that it is a heavy one. There is a 
 veritable network of medical charities in every large city, including 
 dispensaries, hospitals, special clinics, convalescent homes, and 
 agencies for nursing-care in the home. In a single year in twenty- 
 seven representative hospital social service departments in the state, 
 more than 37,000 families were treated. The situation in Philadel- 
 phia is typical. In the "Reference Book of Social Agencies'" which 
 does not claim to be complete, there are listed the names of ten gen- 
 eral dispensaries, in addition to the dispensaries and clinics for 
 special kinds of treatment, and thirty-two general, and thirty special 
 hospitals of various kinds, which contain free beds and in most cases 
 
 (•)See Table XII at end of this section. 
 
 (2)Pnl>lishea by The Miwifilpal Court, Phllaaelphla, 1916. 
 
107 
 
 dispensary facilities. The Visiting Nurse Society of Philadelphia 
 alone spent in 1917 over |41,800/ receiving but $9,648.09 from pati- 
 ents in fees, leaving more than 77 per cent, of its budget as contribu- 
 tions from private charity. This percentage is over 75 in the budgets 
 of the private dispensaries studied. In no case did the receipts from 
 patients equal one-fourth of the total dispensary expenditures for 
 one year. • 
 
 At the present time there is no way of estimating the probable 
 cost to physicians of medical care given by them either at reduced 
 rates or wholly free, but we know that the proportion of charity 
 practice among physicians is very large. 
 
 The problem of estimating the proportions of the budgets of gen- 
 eral relief agencies expended because of sickness is even more difflcult 
 and subtle. The interplay of various factors, such as bad housing, 
 low wages, undernourishment, unemployment and ill health, often 
 creates a state of dependency, in which it is impossible to single out 
 any one as the principle cause. Social workers generally agree, how- 
 ever, that illness is the greatest single handicap in the families with 
 whom they come in contact ; and some go so far as to name the dif- 
 fejtent portions of their budgets expended primarily on this account. 
 For example, one relief agency states that nine-tenths of the sum 
 expended for relief in 1917 was spent on account of sickness. Other 
 societies claim lower proportions. A study of the yearly budgets of 
 one large relief society in Philadelphia, which analyses its expend- 
 itures according to the primary causes of dependency and the nature 
 of relief given, shows that more than 55 per cent, of the actual ex- 
 penditures during the last five years have teen 'because of illness, and 
 57 per cent, of this amount iecause of tuberculosis. 
 
 1913-14, 
 19U-15, 
 1915-16, 
 1916-17, 
 1917-18, 
 
 Tear. 
 
 S5 
 
 hs 
 
 °>f 
 
 
 ■"V 
 
 g+3 
 
 §1 
 
 S a> 
 
 I'S 
 
 
 
 
 a0 
 
 -M 
 
 K'Oio' 
 
 " ' i 
 
 §|g 
 
 ■at!' a 
 
 feSi 
 
 O 
 
 fii 
 
 Total for five year period. 
 
 $17,912 69 
 22,934 35 
 23,877 98 
 83,836 00- 
 23,539 SI 
 
 $112,100,23 
 
 60 
 60 
 
 67% 
 
 o a 
 ■W.S 
 
 •sa 
 
 49 
 49 
 
 er 
 
 61 
 66 
 
 55% 
 
 (MTlUa is eliminating the cost of nursing service to the policy-holders of the Metibpolitan Life 
 Insurance Company, which is paid by the company and amounted m lun to ^iy,m.ou. 
 
 it is because sickness plays such a large part in puUing down into 
 dependency the family which can only be self-supporting while moder- 
 
108 
 
 ately healthy, that we haV6 disctissed sickness in its relation to family 
 income at such length, in the section following. 
 
 The cost of sickness to society is well illustrated by the case of 
 Mr. Callahan. Mr. Callahan was a tailor, who had worked for a- 
 prominent Philadelphia firm for several years. He was the father 
 of four small children.'- Living up to the level of his income^ with 
 small savings, he felt he could not afford to be sick. He contracted 
 tuberculosis, due undoubtedly in part to the industrial conditions in 
 which he worked. He denied that he was sick and .dosed himself 
 continually with a patent medicine, warranted to "cure all ills." 
 Finally, after a bad hemorrhage, he gave up, and when examined he 
 was diagnosed an advanced case of tuberculosis. The family, up to 
 this time always self-supporting, became dependent upon charity. 
 One of his former employers gave |1.00 as matter of charity; the 
 others gave nothing. The children were all young, and Mrs. Callahan 
 could not leave them to go out to work. Two of them were found 
 to be tubercular. Mr. Callahan was only thirty-eight, and the family 
 had no resources for the long future that loomed ahead. He was 
 sent to Mont Alto, where little hope is given for his recovery; ajid 
 for the past three years the family has been cared for entirely by 
 private philanthropy, at an expense of many hundreds of dollars. 
 The oldest child is now only eleven. Meantime the state supports 
 Mr. Callahan in a public sanitorium. Has this been cheap for public 
 or private funds, or for society at large? The community has lost 
 a self-supporting industrious citizen ; industry has lost the productive 
 energy of a good worker; Mr. Callahan has lf)st his earning power 
 and his home; the children have suffered; the normal family unit 
 has been permanently broken up. 
 
 The cost of adequate measures to protect health will be repaid a 
 hundred fold. Society could make no better investment. 
 
 SICKNESS AND POVERTY. 
 
 The whole problem of sickness among wage earners' families hinges 
 on the problem of poverty. Sickness is both a cause and a result of 
 -poverty. Too often it is at bottom the condition of poverty which 
 has caused the initial sickness ; fear of more poverty which prevents 
 prompt treatment ; continued sickness which produces more poverty, 
 and so on. Jacob Hollander has said that poverty is applied indif- 
 ferently to three distinct conditions: (1) economic inequality, (2) 
 economic insufflciency, and (3) economic dependence. "Economic 
 inequality" has little significance for our purpose; but "economic 
 insufficiency" — the problem of that group midway between those in 
 comfortable circumstances and the out-right dependent — the propor- 
 tion which is inadequately fed, clad, and sheltered — and "economic 
 dependence" both foster and are fostered by disease. 
 
109 
 
 It; is ilnpossiblfe to giy,!^ exact "causes"- for. pavepty^. Schools of 
 tiiought swing from theories of land and cayjital tq the laissez-faire 
 philospphy- of; indjvidualisni. So it is. difflciiilt to place the entire 
 resporisibiity-on thp illness of. any gi^^en; family, for usually the inter- 
 play of various factors such as bad housing, low wages, undernourish- 
 ment, unemployment and ill health, have worked together. One has 
 often caused the othfer. For instance, in an unemployment survey 
 in 1915 covering a million wage earners, 11 per cent, of the unem- 
 ployment had been caused by sickness or accident. Yet sickness 
 seems to be, without question, the principal single factor which serves 
 as the "last straw," and more often than any thing else forces the 
 ordinary wage earner's family to seek help outside his own re- 
 sources. 
 
 The story of the Murphy family well illustrates the typical course 
 of events : 
 
 The Murphy s had lived in Philadelphia for, seven teen years and there 
 were six little Murphys, all under working age. Neither Mr. nor 
 "Mrs. Murphy had ever been strong, and their constant ill health was 
 reflected in Mr. Murphy's work and Mrs. Murphy's housekeeping. 
 The children were ailing, and did not have the proper nourishment. 
 Mr. Murphy made about |20.OO a week when he could work full 
 time, and Mrs. Murphy attempted to add to this by taking in two 
 men boarders, as she could not go out for days' work, while the 
 children were so young. She was advised that she needed an opera- 
 tion badly, but she thought it best to go on working and forget she 
 felt so ill, as it would be utterly impossible for her to have this 
 medical attention. For some time they managed to get along, but 
 finally Mr. Murphy was threatened with tuberculosis and the bills 
 increased. The doctor advised a change in work, but he had been 
 with the same firm for- fourteen years, had a good work record, and 
 hoped he was near a promotion. This firm paid a sick benefit after a 
 waiting period of three days, but it was only f .40 a day, and what 
 was that with six children? As long as he co\ild possibly keep up, 
 he felt he must. Besides this, he belonged to a Fraternal paying a 
 sick benefit, but this was paid only after a waiting period of two 
 weeks, and there were many restrictive rules and assessments. They 
 were anxious to keep this membership up, however, on account of 
 the substantial death benefit. Mr. Murphy tried not to miss more 
 than a day or two at a tiine, from his work, and the family spent 
 sometimes as much as flO.OO a week on patent medicines. Things 
 seemed more expensive with the boarders, than without, and they 
 gave up this plan of eking out their income. 
 
 Then Mr. Murphy broke down, and was ill for five weeks. They 
 borrowed some money from a sister and the doctor reduced his rates. 
 Tn sTiifp of this t.hev found them selves with a rent bill of |18.00, 
 
IK) 
 
 a store bill of 1155.00, a lullk bill of |42.00, and a doctor's" bill of 
 over $70.00, and on top of this the advice that Mr. Murphy was to 
 have "fresh eggs and plenty of milk every day." 
 
 Their savings were gone, they could obtain no more credit ; rela- 
 tives were unable to help them longer, and so they sought a faoney- 
 lender, and borrowed $50.00 at 10 per cent, a month. This was only 
 a drop in the bucket, and the interest was very difficult to meet. 
 The loan agency took advantage of the situation and continued 
 charging them for three months after they had paid the money back. 
 
 Mr. Murphy went back to work, far from well; he had not been 
 able to secure the sick benefit from his lodge because he was a month 
 behind in his dues. The family could never get ahead. Mrs. Murphy 
 tried to take in extra work and do it at night after the children were 
 in bed, but could not stand the strain. Things went from bad to 
 worse, and finally Mrs. Murphy, worn out, discovered she could take 
 the baby, who was ill, to the Hospital disi)ensary and secure medical 
 advice free for the child and for herself. The doctor there realized 
 that she was in critical need of attention and that the whole family 
 ^ere suffering from a chronic stniggle with ill health and inability" 
 to secure medical care or follow a physician's orders, and conse- 
 quently referred her to a private oiganization from which she could 
 secure help.^ 
 
 The Murphys are not unlike hundreds of other families. Theirs 
 was the typical road from independence to dependence. Wages at 
 the present time, with the cost of living as it is, do not cover risks. 
 Sickness is a risk, and the average wage-earner trusts his lucky star 
 that he may escape it. The problem is largely an economic one. The 
 amount a man can save depends upon the amount of his income, far 
 more than upon his personal volition. Saving toward an emergency 
 is not only difficult, but impossible, if his income admits bare suffi- 
 ciency. On the other hand, the amount of family income determines 
 in large measure the standard of living possible, which in turn 
 directly effects the susceptibility to disease and the power of re- 
 sistance against it. "You can kill a man with a tenement as easily 
 as with an axe," Jacob Eiis says. 
 
 Over-crowding, foul air, lack of light, can but breed disease. Yet 
 how is the average wage earner in an industrial community to obtain 
 the room, light, air, and nourishing food, essential to the good health 
 which is his greatest asset? And when he once becomes ill, how can 
 he afford to obtain medical care quickly, and follow the doctor's 
 orders ? 
 
 Not only does the wage^earner himself suffer, but the family, and 
 particularly the children, bear the brunt of the strain. We know the 
 
 (^)In all cases of familites whose stories are told the names and initials are assumed. 
 
Ill 
 
 lasting effects which a period of privation has on children. Under- 
 nourishment, coming in many instances from "economic insufficiency" 
 due to a period of illness and an attempt to "make ends meet," 
 is one of the "original and basic defects" found in the examination 
 of school children. In a study of 171,691 children made in the Bor- 
 ough of Manhattan in December 1917, only ' 17.3 per cent, of these 
 children were found to be in a normal condition so far as nutrition 
 was concernedy/- Sixty-one per cent, were "borderline cases ;" 18.5 per 
 cent, were definitely undernourished and needed immediate atten- 
 tion, and 3.1 per cent, were advanced cases of undernourishment 
 needing immediate medical care. 
 
 In our own state, in Philadelphia, of 5,621 children between four- 
 teen and sixteen years of age examined for employment certificates 
 in the first six months of 1916, 20 per cent, had defects debarring 
 them from immediate certificates. 
 
 How much of this is the result of privation coming l)ecause of ill- 
 ness in the family, it is impossible to estimate. Ignorance, com- 
 munity standards, working conditions, all play a large part, but the 
 emergency of illness is one of the prime factois. Here then, is the 
 gist of the problem^there are not adequate means in this country 
 to-day, by which the wage workers can safeguard himself and his 
 family against a possible emergency, such as sickness. 
 
 A study of wage conditions shows that the great majority of wage 
 earners' families can be self supporting only so long as they are 
 moderately healthy. When sick-ness comes, they must have relief, if 
 not from one source, from another, and the more prolonged the 
 sickness, the greater the delay in securing care in the beginning, the 
 greater must be the amount of relief. 
 
 Of the thousands of families who obtain sufficient help from their 
 friends and relatives to see them through, or who live on credit or 
 their own savings during illness, we have little knowledge. Surveys 
 show that practically all families exhaust these resources before ob- 
 taining public or private aid. We do know, however, that sickness 
 drives large numbers to borrow from loan societies of various sorts, 
 and that this, as in the case of the Murphy family, is often one of the 
 first steps toward dependency. 
 
 In a study of the loans made in one year by twenty-two remedial 
 loan societies in as many different cities, an attempt was made to 
 ascertain the proportion of the loans where sickness was given as the 
 reason for borrowing.^ In two cases the societies' records were kept 
 in such a way that the actual percentage could be given— 14. per 
 cent, in one case, 37 per cent, in the other. In seventeen other cases 
 an "estimated proportion" was given, which ranged from 10 per cent. 
 
 (MThis stiifly was made available through the kindness of the Ohio Health and Old Age In- 
 surance CommlBslon. \ 
 
112 
 
 to 75 per cent. The low percentages ina<Ie because of sickness wer& 
 in cases where the number of pledge loans made by the society was 
 very large. The average percentage was apparently over 38. In one 
 of the three cases where no estimate was given, the percentage due 
 to sickness was termed "very large," in another case they reported: 
 "Scarcely a day but what a loan is made to pay the expense of an 
 operation, hospital bill, etc., and in most cases the failure to meet 
 the contract is due to sickness." Another society says "sickness is 
 the reason given for non-payment in 95 per cent, of our defaults." 
 
 The average size of the 99,555 loans made by the nineteen of these 
 societies for which figures were obtainable was only-$49.30. This is 
 considerably less than the average loan made by the Morris Plan 
 Banks, which are established in 104 cities in the United States to 
 meet the needs of the industrial worker who so seldom has banking 
 connections. In the Morris Plan Company in New York, 44,866 loans 
 were made between January 1, 1915, and June 30, 1917. Of these, 593 
 were under |25.00; 13,140 were between $25.00 and $50.00, 987 
 were between $50.00 and |75.00 and 17,367 were between $75.00 and 
 $100.00. Thus some 70 per cent, of all the loans were under $100.00 
 and 30 per cent, were under $50.00-. 
 
 The weekly income of the men and women borrowing from the 
 Morris Plan Company averaged $26.00, bespeaking a group of wage 
 earners a little above the ordinary ; the largest numbers classified by 
 occupations were clerks, salesmen, owners and partners, while fac- 
 tory hands, tailors, machinists, etc., were relatively few. From 
 January 1, 191/, to June 30, 1918, 12,300 loans had been made where 
 the reason given for borrowing was "illness and births." Seven 
 hundred and seventy more loans were made because of death in the 
 family. The "illness and births" classification outnumbered any 
 other single classification by over 4,000 and formed almost 16 per cent, 
 of the total loans made. This classification did not by any means 
 include all the loans made where illness was a factor, as other classi- 
 fications include "Eepay loan sharks," "Pawns and chattels," "Mis- 
 cellaneous debts," "Help relatives," etc., where many of the first debts 
 have doubtless been contracted because of illness. In connection 
 with this it is interesting to note a letter from one of the Morris Plan 
 Company borrowers. "A few years ago," he writes, "owing to sick- 
 ness in my family, I was compelled to go to a loan shark to borrow 
 money. From that time on things grew from bad to worse, and falling 
 behind in my payments I was subjected to such unmerciful persecu- 
 tion that I was on the verge of committing suicide." 
 
 The only Morris Plan Company in Pennsylvania is in Philadelphia, 
 and it is unfortunate that their records have not been kept in the 
 same way as those in New York. Statistics for the past nine months, 
 however, January 1, 1918, to September 30, 1918, were tabulated 
 
113 
 
 especiaily for the Commission. During 'these nine months 135 loans 
 had been made where the borrower gave illness as his reason for 
 needing the money. Five more loans were made, because of death. 
 The borrowers in 119 cases had families dependent on them ; in seven- 
 teen cases they were men or women with no dependents. The income 
 of these borrowers was known in 138 cases. Tn eighty-six cases, or 
 G4 per cent, the weekly income was between |15.00 and |25.00. In 
 forty more cases, or 30 per cent., it was between |26.00 and $40.00. 
 In only six cases was it over |40.00 a week, and in only one case was 
 it under $15.00 a week. This is an interesting contrast to the incomes 
 of the groups who have passed the stage of "borrowing" and have 
 dropped into dependency. The Company does not lend less than 
 150.00, and we find that twenty-nine of the loans were for that 
 amount. Seventy, or exactly 50 per cent, were for flOO.OO and 
 only twelve exceeded the $200.00 mark. The largest loan made be- 
 cause of illness was one for .|300.00. 
 
 So much for those who have tided over the emergency of sickness 
 by borrowing money on a personal or business basis. Much more can 
 be said of those who have passed to the next stage — that of economic 
 flependence. In how many cases of the thousands coming to the gen- 
 eral relief societies asking for help, has sickness been the determining 
 factor in the application ? 
 
 Edward T. Devine, the head of the TSTew York Charity Organiza- 
 tion Society says : 
 
 "111 health is perhaps the most constant of the attendants of pov- 
 erty. It has been customary to say that 26 per cent, of the distress 
 known to charitable societies is caused by sickness. An inquiry into 
 the physical condition of the members of the families that ask for 
 aid, without for the moment taking any other complication into ac- 
 count, clearly indicates that whether it be the first cause or merely a 
 complication from the effect of other causes, physical disability is at 
 any rate a very serious disabling condition at the time of application 
 in three-fourths — not one-fourth — of all the families that come 
 under the care of the Charity Organization Society, who are prob- 
 ably in this respect in no degree exceptional among families in need 
 of charitable aid."^ 
 
 In special studies made by the Social Insurance Commissions of 
 Calif ornia and of New Jersey, sickness was the "primary cause" of 
 the dependency in 50 per cent, of the 5,000 cases studied in California 
 and 42 per cent, of the 1,412 cases studied in New Jersey. 
 
 In a study made in 1909 of 31,481 dependent cases by the United 
 States Immigration Commission, sickness was a factor in producing 
 the dependency of over 38 per cent., whereas accident was a factor 
 in but 3.9 per cent. 
 
 (')Bdward T. Devine, Misery and its Causes, page 54. 
 
114 
 
 In our own state the same general conclusions are borne out. In 
 considering sickness as a factor in producing public dependents, it 
 is impossible even to estimate the number of almshouse inmates whose 
 entrance may be traced to such a cause. The almshouses of the state 
 do not, as a rule, however, care why their inmates have come. The 
 stewards are men who are not likely to be concerned with the econ- 
 omic and social causes underlying the applications for admission. 
 The Board of Public Charities, however, attempts to classify the 
 outdoor relief given throughout the state, by the primary cause of 
 destitution. The records for this administration of outdoor relief 
 are enlightening. Over a period of five years "temporary sickness or 
 death" has always stood first as a problem of dependency. The per 
 cent, varies in each year from 35.70 to 47.83. "Want of work" comes 
 next, accounting for from 8.70 to 25.86 per cent., and the remaining 
 cases are attribuated to old age, desertion, intemperance, insanity or 
 feeblemindedness, and miscellaneous causes.^ 
 
 If this is true of the outdoor delief, it is probably even more true 
 of almshouse inmates. 
 
 If we take the group coming to the private genej"al relief societies, 
 we find that here too, sickness has been by far the greatest single 
 factor in producing the dependency. If we reverse our point of view 
 and take the group seeking free medical aid we find that temporary 
 financial dependency is the greatest single factor in driving them 
 there. In a study made by one of the Hospital Social Service Depart- 
 ments of Philadelphia of 1,050 cases coming to them between January 
 and June, 1918, the group of those "temporarily financially depend- 
 ent" out-numbered all others by almost two to one, so that either 
 way you look at it, the statement holds good. 
 
 In a letter to the Commission, Mr. Karl de Schweinitz, the General 
 Secretary of the Philadelphia Society for Organizing Charity says: 
 
 "Sickness is the greatest single handicap affecting the families 
 under the care of the Society for Organizing Charity. Unemployment 
 may vary in amount from season to season, but year in and year out 
 ill-health continues to undermine the working efficiency of wage- 
 earners, to prevent mothers from taking proper care of home and 
 children, and to cause boys and girls to be irregular in school at- 
 tendance and inferior in capacity to learn. 
 
 "Much of this sickness is preventable. Much more could be ren- 
 dered comparatively unimportant if treatment were promptly avail- 
 able. Only too often, however, the sick throw away their chances 
 for speedy cure by continuing at work because they cannot afford to 
 lose pay by staying at home. Again and again, also, we find that 
 families have postponed sending for a doctor in the hope that the 
 patient would recover without making necessary the incurring of an 
 
 (>)See Table XII at the end of thla eectlon. 
 
115 
 
 expense which they have not the money to meet. Nothing perhaps 
 would help so much to reduce sickness among small wage-workers 
 as prompt medical treatment and cessation from work when the first 
 symptoms of disease appear." 
 
 A study of the cases coming to the United Hebrew Charities of 
 Philadelphia show that for the last five yearg, sickness has figured 
 as the main problem in each year's work. In 1913-14, these cases 
 formed 46 per cent, of the 760 cases handled ; in 1914-15, 39 per cent, 
 of the 1,189 cases ; in 1915-16, 56 per cent, of the 870 cases; in 1916-17, 
 65 per cent, of the 557 cases ; and in 1917-18, 63 per cent, of the 444 
 cases. 
 
 Even in 1914-15, the year of the unemployment panic when the 
 sickness cases dropped to 39 per cent., unemployment was given as 
 the main problem in but 22 per cent. 
 
 In the work of the Bureau for Jewish Children the illness of the 
 parents was given as the reason for application in 49 per cent, of the 
 413 applications in 1915-16, and in 51 per cent, of the 472 applications 
 in 1916-17 ; the number applying in this year because of sickness was 
 six times as great as the number applying for any other of the twenty- 
 six reasons given. 
 
 Through the kindness of the Philadelphia Bureau for Social Ee- 
 search two unpublished studies were placed at the disposal of the 
 Commission. Both studies covered the year January 1, 1916 to Janu- 
 ary 1, 1917. 
 
 The first study dealt with the condition of families coming to the 
 four largest relief societies in Philadelphia; the total number of 
 families covered by the smallest society was included, and a corres- 
 ponding number was taken from e^ch of the other three. The Bureau 
 classified these applications for help by the main problem involved, 
 and it is interesting to note the proportion for which sickness was 
 responsible in these four societies: 16.59 per cent., 29.65 per cent., 
 31.15 per cent., and 53.36 per cent. The Bureau states: "Sickness 
 is proved to be the greatest problem to be met by all of the agencies 
 * * * * That sickness is not only the largest contribution, but also 
 the problem, least easily solved, is shown by the fact that it forms 
 a larger percentage of the 'old and recurrent' cases, than it does of 
 the new applications. For instance, in one society it formed 42.28 
 per cent, of the new applications, and 64.81 per cent, of the recurrent 
 cases, during this year." 
 
 The second study of the Bureau dealt with the problem of child 
 care, when sickness in the family made outside help imperative. The 
 first section of this study covered 208 families where children under 
 sixteen were removed from home on account of illness in the family. 
 The figures given seem to indicate that by far the greatest number 
 of the children came from a normal group of rather low-wage families. 
 
116 
 
 About 70 per cent, were from homes "where there was no disturbance, 
 of marital relation. In only 27.5 per cent, of the cases was the 
 mother the main bread-winner." The families did not seem to be of 
 abnormal size, nor were they transients or recent immigrants, since 
 88 per cent, had lived in Philadelphia' three years or more. 
 
 Sixty-two per cent, of the heads of these families, however, had 
 weekly wages below the fll.OO which was the average weekly wage 
 in the manufacturing industries of the state in 1916. 
 
 Regarding the exact relation of the existing illness to the depend- 
 ency, the report states that "the temporary character of care given to 
 children removed from their homes indicates the fact that illness in 
 the cases studied was responsible for the dependency, and that a 
 feUght amount of assistance might have saved the children from re- 
 moval. In fact, in 85 per cent, of the cases the sickness of one or 
 both parents appeared as the sole cause of removal. Over a third 
 of the children were away from their homes less than an month, and 
 214 out of 255, when discharged, were given back into the custody 
 of their parents. Mne out of every ten of the children had never 
 been removed from home before. 
 
 "In nine-tenths of the families one or both parents — ^the mother 
 more often than the father — had been taken to a hospital or other 
 institution for care a very short time before the children were re- 
 moved." The report concludes that the result of the study shows, 
 beyond a doubt, the "limited resources for emergencies in families 
 both economically and socially normal." It would appear that some 
 systematic method of meeting the wage-loss of employees during ill- 
 ness and of providing medical care for them and their wives is 
 needed to prevent the breaking up of homes which illness now causes. 
 
 The second section of the study deals with 418 families suflfering 
 from illness and applying to the Society for Organizing Charity or 
 to the United Hebrew Charities "for relief in order to provide proper 
 care for the children." Here again we find a group of normal families 
 "with wages no different from the average, outside the highly skilled 
 trades." In 71 per cent of the families both parents were living 
 together; 14.6 per cent; more were families of widows or widowers, 
 and only 15.2 per cent, were cases of separation, desertion, or irregxi- 
 lar union. 
 
 Many of the men were fairly steady workers, for 53 per cent, of 
 those who were employed when disabled by illness had worked for the 
 same employer more than a year. Of the 300 persons whose usual 
 weekly income was known, the largest group, 43 per cent, received 
 between .^lO.OO and $15.00 a week. But at the time charitable relief 
 was given them, the incomes of nearly all were reduced to little or 
 nothing; only three per cent, had pver |10.00 a week and 60 per 
 cent, had $5.00 or less, 
 
]17 
 
 This bears out the truth of the fact that wages do not cover risks, 
 and that savings are too soon exhausted to be relied upon to meet 
 emergencies. 
 
 Since illness, year in and year out, forms the chief single factou^ 
 in the creation of dependency, it has seemed wise to study closely a 
 dependent group handicapped by illness. Who are the people in this 
 group ; what are their standards ; are they employees of an ordinary 
 type, or are they as often claimed, a special "pauper" class ? 
 
 Seven cities in the state, throiTgh their Associated Charities, con- 
 tributed to this study. Detailed information regarding the families 
 where illness was a problem, was secured and tabulated.^ In all, 
 1,584 families containing over 7,250 individuals were studied. This 
 does not pretend to represent the total number of families in which 
 illness was a factor in the dependent group coming to these societies. 
 They reported unanimously that illness was the greatest problem 
 with which they had to deal. In Reading this was reported as the 
 main factor in the dependency of 41 per cent, of the families; in 
 Johnstown, 54 per cent., in New Castle 44 per cent., in York 88 per 
 cent., and in Sewickley, 90 per cent. In Philadelphia more than a 
 third of the families needing help in 1914-15, were suffering from 
 illness, and some 42 per cent, in 1915-16. In 1914-15, the great year 
 of unemployment, in the 10,488 families asking aid from the Phila- 
 delphia Society for Organizing Charity, the problems of unemploy- 
 ment numbered 4,237, while the illness problems were 3,867, a dif- 
 ference of but 870. This is another instance of the fact that even in 
 panic year, where one reason for dependency asserts itself so 
 strongly, sickness is a steady factor. 
 
 As a result of the influenza epidemic 224 new families needed help 
 from the Philadelphia Society for Organizing Charity, in October 
 and November 1918. One hundred and thirty-four were widows who> 
 had lost their husbands in the epidemic. The other families had ex- 
 hausted their own resources and could not see through the sickness 
 emergency. 
 
 Epidemics are spectacular and drive home truths. Sickness, how- 
 ever, is constant. The ranks of the dependent are recruited daily 
 because of the burden imposed wholly on the individual, through it. 
 
 The group requiring charity chiefly because of sickness are in the 
 majority of cases normal families, not particularly large. But in 
 many instances the children are young and cannot work, so that if 
 the bread-winner falls ill, as soon as their resources are exhausted — a 
 longer or a shorter time according to whether they are skilled or un- 
 skilled, high paid or low paid — the almost inevitable result is desti- 
 tution and an appeal, to charity. This is particularly true if the wife 
 expects a baby and so is unable to go out to work. 
 
 (nihe families 'were those defilt -with by th? gocwties during their last flseal year. 
 
118 
 
 Much of the destitution caused by illness comes at a time when it 
 
 threatens the health not only of the present hut of future generations. 
 
 J^& all know that expectant mothers must have proper nourishment 
 
 and comparative freedom from anxiety to protect their own health 
 
 and that of their babies, and that a period' of privation cannot fail 
 
 to leave a permanent mark .on growing children. Some organised 
 
 system of matrridty benefit, providing prenatal and postnatal care 
 
 and including adequate care at conffliement fiir every iporking mother 
 
 and the trife of every employee, is needed to prevent such suffering ' 
 
 Mr. C. was a teamster, attempting to support his wife and 
 
 four young children on his weekly wage of |13.50. He was 
 
 badly poisoned and was away from work three weeks, having 
 
 some free attention frouL-a private physician. His wife who 
 
 was pregnant arid unable to go out to work, suffered a fall 
 
 which disabled her for two weeks. She had had no prenatal 
 
 care and was now attended by the district doctor while a 
 
 relief society, together with relatives, supported the family. 
 
 One or two cases of pauperized families, begging and immoral, 
 
 were found, while in a few instances the need was created by old age 
 
 rather than illness, and occasionally the wife or children might not 
 
 have needed charity when they became ill if the husband had not 
 
 deserted; but the great majority of the families were not of such 
 
 types. 
 
 Seventy and three-tenths per cent, of the Philadelphia families 
 were "normal" in the sense that either the father and mother were 
 living together and the father was the main support of the family, 
 or that adult children (over eighteen) were supporting widowed 
 parents. The latter group covered only a small number of cases, as 
 the most distinctive feature about these families, and seemingly the 
 most important in which they differed socially from a typical group 
 of wage-earners such as was covered by the Kensington Survey, was 
 the unusual proportion in which young children were found. This 
 is further illustrated by the fact that the average number of wage- 
 earners per family, 1.75, was somewhat lower than in the Kensington 
 Survey. 
 
 Certainly the families could not be considered unusually large. 
 The 1,549 families whose size was known averaged but 4.7 persons. 
 The average size of the families in the Kensington Survey was 4.-" 
 persons, and the "typical family," according to "cost of living" in- 
 vestigators, is five persons. Two hundred and ninety-one families 
 consisted of only one or two persons, and 793 of three to six, which 
 ordinarily means father, mother, and one to four children. 
 
 The following cases are typical of the many in which illness was 
 the only apparent handicap. 
 
 Two attacks of grippe, each lasting two weeks, caused Mr. 
 H. to have difficulty in meeting his family expenses. He was a 
 clerk, earning about $18.00 a week, with' a wife and six young 
 
119 
 
 children ; the oldest, twins of ten years. His wife was not able 
 to help the family by outside work, since she had a "weak 
 heart," and was soon to have a -baby. The family used their 
 savings, but those were soon exhausted, and they were obliged 
 not only to have help from relativ«s and their church, but to 
 apply to a relief agency. 
 
 Ordinarily the D. family were quite comfortably off, with the 
 father working as a fireman for flS.OO a week and the oldest 
 child a winder in a textile mill at $6.00. But when Mr. D. 
 had an attack of erysipelas and had to spend three months in 
 a hospital, the earnings of the fifteen-year old were not suffi- 
 cient to meet the needs of Mrs. D. and the three younger 
 children. The family's savings were exhausted in two months 
 and in spite of the fact that the firemen took up a collection 
 for them, they had to get help from several different chari- 
 table sources. 
 Occasionally a man or woman living alone was reduced to de- 
 pendency following an attack of sickness. 
 
 When Mrs. O. was well, she was able to support herself in- 
 dependently by doing house work. But nine weeks of disa- 
 bility caused by a broken leg rendered her dependent on 
 charity. After five weeks in a hospital it was necessary for 
 her to spend four weeks of convalescence in an almshouse 
 under the care of the district "poor doctor." 
 
 Typically, the heads of the families were employed in the heavy 
 Land work which lies at the foundation of the city's activities. In 
 Philadelphia, about 35 per cent, were engaged in some sort of fac- 
 tory work or hand trade, 25 per cent, were "laborers," and nearly 20 
 per cent. — a large proportion of Avhom were women — in "domestic 
 and personal service." There were about the same proportion of per- 
 sons in manufacturing in this group, as there were in the whole city 
 in 1910, more laborers and domestic workers and fewer in trade and 
 the professional and clerical groups— more, in short, of the less 
 skilled and more poorly paid workers. Outside Philadelphia, the 
 percentage of laborers and domestic workers was even higher— 31.7 
 per cent, and 27.2 per cent, respectively. Only ninety-three heads of 
 the families were reported as being without occupation. In 138 
 cases women were both housekeepers and family ^age earners. 
 
 With the proportion of unskilled workers in this group, it is not 
 surprising that family incomes were found to be lower than in such a 
 group as that surveyed in Kensington. The largest group of families 
 had incomes of between |12.00 and flo.OO a week ; 75.'3 per cent of the 
 856 families where income figures were obtained had less than |20.00 
 a week, while 94.3 per cent, had less than |30.00 a week. A large 
 number of the 149 families with incomes under flO.OO a week were 
 the "broken" families supported by widows or young children, but 
 comparatively high incomes in other families did not by any means 
 act as a safeguard against the need for charity. 
 
120 
 
 Although Mr. N. earned $25.00 a week as a "mechanic" 
 
 and had only two dependents, a wife and baby boy, when he 
 
 was ill with "throat trouble" for three weeks he was obliged 
 
 to secure medical attention through a dispensary and to seek 
 
 aid from his relatives and a relief society. 
 
 We have, then, a majority of cases in which the family group was 
 
 normal, and the main handicap was sickness. The families were not 
 
 particularly large but the children were generally young, and the 
 
 number of wage-earners per family, rather small. 
 
 There were 2,682 cases of illness reported in these families. Na- 
 turally enough, more often than in a sickness survey among employees 
 in general, like the one in Kensington, the illness reported was that 
 of the principal wage-earner, for in such cases wage-loss is added to 
 the expense of sickness. , Such illness was reported 1,104 times, or in 
 41 per cent, of the total number of cases. Illness of the housewife, an 
 almost equally important member of the household, was reported 761 
 times. 
 
 Yet there were cases in which the illness of dependents alone, 
 jceported in 810 cases, proved a severe strain on the family resources. 
 
 Mrs. O. supported her aged mother and three smaU children 
 by work in a hosiery mill. The family came to the attention 
 of a relief society because of the illness of the grand-mother. 
 8he had been treated by a private doctor, and the bills result- 
 ing left the family without sufficient food. 
 
 The two kinds of illnesses found in especially large numbers were 
 tuberculoses^ and childbirth. Four hundred and eighty-eight cases 
 of tuberculosis were noted, and 247 cases of disability from pregnancy 
 or child-birth. These two diseases accounted respectively for 18 
 and 10 per cent, of all the illnesses recorded. 
 
 It was tuberculosis, the "captain of the men of ^eath,'' 
 which incapacitated Mr. M. for work for three monttts, aiwJ 
 made it necessary for him to obtain help from a relief society. 
 When he was able to work he was a laborer earning |15<0,0 a 
 week. Besides his wife, his family was made up of a girl of 
 five and a boy of two. A state tuberculosis sanitarium ;ad- 
 mitted Mr. M. for treatment. Mrs. M. took in lodgers to cover 
 the rent, but was unable to keep up because of tier expected 
 confinement. A doctor gave free medical eare, relatives 
 helped and material relief was given by the charitable society. 
 
 Mr. E., a laborer whose pay averaged |18.00 a week, had a 
 wife ancj a little boy twenty-two months old. He was stricken 
 with tuberculosis, was sick and away from work for three 
 months, at the end of which time he had recovered sufftciently 
 to be able to go back to work. His wife was pregnant, and a 
 relief society was the main support of the family during his 
 illness. The Society was, obliged to secure dispensary and 
 ihospital care for him, prenatal care for his wife through a 
 .dispensary, and a visiting nurse for her at the time of her 
 (Confinement. 
 
121 
 
 Certain of the eases pointed clearly to defects in community action 
 for health or civic protection, for which individuals and the funds 
 of private charity paid the price. 
 
 Mr. Y., a laborer in the early thirties earning |16.00 a week, 
 was stricken with typhoid, which more than almost any other 
 disease, indicates a weak link in the chain of public health 
 measures. A wife and five children, the oldest ten, the young- 
 est two, were dependent on Mr. Y. He was sick nearly ten 
 weeks, receiving free care in a hospital and later dispensary 
 treatment. His wife was at first aided by friends, but was 
 later obliged to leave her young family and go out to work, and 
 also to obtain charitable help. 
 Other cases were significant of the fact that the lack of adequate 
 methods of dealing with illness may cause not only hardship to indi- 
 viduals, but may endanger the health of the general public, as when 
 wage earners continue at work with a disease in an acute communi- 
 cable stage. 
 
 Outside Philadelphia data on the full duration of the illness was 
 obtained in 386 cases. Of these 43 per cent, had lasted more than 
 six months, and 31 i)er cent, more than a year. The largest single 
 group of illness lasting less than a year were those of between one 
 and three months duration. Considering the illnesses of the wage 
 learners alone in the total group of families, 32 per cent, lasted more 
 than six months, and 19 per cent, more than one year. Twenty-eight 
 per cent, of the ill wage earners were ill between one and three 
 months. 
 
 A considerable tendency was noticeable for the time out of work 
 to be shorter than the period of illness. For instance, although 107 
 wage-earners had illnesses lasting over a year, but fifty-four were out 
 of work for this period ; while seventy-eight were ill over six months, 
 but forty-nine were away from work an equal period of time. 
 
 METHODS OF FAMILY FINANCE DURING IliLNESS. 
 The strain and stress through which these families passed is best 
 shown by considering the ways in which they maintained themselves 
 during illness, and the methods used were secured for the Philadel- 
 phia families. 
 
 In one hundred and sixty-three cases, the present or future re- 
 sources of the family were drawn on in the shape of savings, credit, 
 or insurance. Savings were used in forty-five families, but usually 
 as the illness continued, in spite of cutting expenditures to the lowest 
 point, they were exhausted and other aid became necessary. In- 
 surance although it was carried in 101 families was only paid in 
 sixty-nine cases ; five cases of accidents, and sixty-four of sickness. 
 
 In forty-nine cases, the families borrowed money, obtained credit at 
 the store, pawned their furniture, or ran into debt and were left with 
 heavy bills at the end of the illness. 
 
122 
 
 Mr. P's illness was rheumatism, from which he was ill seven 
 weeks. He was a laborer employed at a wage of about |12.o0 
 a week, and his family consisted of a wife and a baby girl. 
 While he was at the hospital, they lived on a little money he 
 had saved. Later they borrowed .|30.00 or |40.00 from 
 friends and received some help'from a relief society. They 
 owed two months' rent when Mr. P. returned to work. But 
 even then he was able to work only three or four days a week, 
 both because of his own health and because his wife then fell 
 3ick and was not able to take care of the baby. 
 
 Mr. B. was a shoemaker, who leceived little more than 
 110.00 a week to support his wife and six little children, the 
 oldest but nine years old. He was ill with an acute sickness 
 for four months, but out of work for only two weeks. To meet 
 the expenses of his illness, the family "pawned almost every- 
 thing they owned," and a relief society secured hospital care 
 for Mr. B, and gave help to tide them over. 
 
 Not his own illness, but an attack of diphtheria suffered by 
 , his youngest child, kept Mr. I. quarantined and stopped his 
 wages for nearly six weeks. He was an iron moulder, earning 
 $15.00 a week or more, with a wife and two little girls of five 
 and nine respectively. After the family had used up their 
 small savings they borrowed money and were left at the end 
 of the child's sickness with a doctor's bill of flOO.OO in addi- 
 tion. 
 
 As has been previously stated only one case was found in which 
 the wage of an employee was continued during the whole of his illness, 
 and one in which it was paid during part of the period of disability. 
 In thirty-three other cases, however, the employer gave some help 
 as a matter of charity. A number of cases of sickness were noted 
 in which, though working conditions seemed to be the direct cause 
 of the illnesses, the Employer gave little or no help. 
 
 In seventy-six instances of the illness of the head of the family, 
 the mother was obliged to go out to work. The situation where the 
 mother was unable to work because of an expected child has already 
 been discussed. It is equally unfortunate from a social point of 
 view when the mother of young children is obliged to leave them 
 without proper care and seek outside employment. 
 
 Mr. J., a laborer earning $15.00 a week, was injured in an 
 accident, suffering contusions of the hips and thighs. As the 
 accident was not in the course of employment, it did not fall 
 within the scope of the compensation law. Medical care 
 through a dispensary was provided by the relief society. Mr. 
 J. was away from work three months. During this time, the 
 family obtained help from friends, and from a relief society, 
 and Mrs. J. went to work to help support the family. She had 
 three little children, the oldest four and the youngest one, 
 and while she was at work the baby had convulsions and had 
 to be taken to a hospital. 
 
123 
 
 There were 236 eases in which other wage-earners continued work 
 during illness of the head of the family. A case where the children's 
 earnings proved insufficient follows: — 
 
 All three of the O.'s contributed a share to the support of 
 the little family. Mrs. C. and the fifteen-year old earned $8.00 
 and |6.00 respectively in the mill and the fourteen-year old 
 made $4.00 outside school hours. When Mrs. G. was disabled 
 by a broken finger for over six weeks, the wages of the children 
 became the main support of the family, and their standard of 
 . living was lowered in consequence. The income was so in- 
 adequate that the Society was called upon to help with the 
 rent and the other expenses. 
 Assistance from relatives was secured for 177 families, from 
 friends for ninety-nine, from the church for 114. The proverbial 
 generosity "of the poor to the poor" was revealed in the aid given 
 by those who had barely enough for themselves and in the collections 
 so often taken up among workers in the same shop. 
 
 .Mr. F. a boiler-maker earning |15.00 a week, was ill for 
 eight weeks with typhoid fever, which is, par excellence, the 
 socially preventable disease. He had a private doctor and went 
 to a hospital. He had some money saved and friends gave 
 money toward the food and rent for his wife and little boy. 
 A collection was also taken up among his fellow-workers. 
 
 Mr. B. was a brick-layer, whose wages averaged $15.00 a 
 week. He had a wife and five children, whose ages ranged 
 from fifteen years to twenty months. He contracted rheum- 
 atism from exposure while at work, but received no aid from 
 his employer. ' The main support of the family during this 
 time came from a fraternal organization composed of persons 
 of the same nationality as the B.'s. 
 Though benefits under Pennsylvania's compensation law are lower 
 than in many states, one can but contrast its systematic provision 
 with the suffering under individualistic methods revealed by the sick- 
 ness cases. 
 
 Mr. P.'s foot was crushed while at work, which disabled him 
 for six weeks. He was a laborer with a wife and one child; 
 he received a weekly wage of $13.00. Not understanding that 
 he would receive benefits under the workmen's compensation 
 law, he appealed to a charitable agency for help, but on ac- 
 count of the benefits to which the law entitled him, it was not 
 necessa^■y to give financial relief. The requirements of the 
 law, moreover, insured him free treatment by the factory 
 doctor. 
 This group of families brought to dependency by manifold causes, 
 
 but chiefly because of a problem of illness, is not as a whole, very 
 different from any group of ordinary wage earners' families. It is 
 ^ the group between the self-supporting and the totally dependent alms- 
 house family; the group which had not been able to meet alone the 
 emergency, which has touched it. The "down and out pauper's fam- 
 ily" is hard to find. Such families figure largely in our ideas and 
 
124 
 
 conversations about "dependency," but even in the almshouses where; 
 one might perhaps expect to find them, they are relatively few. The 
 Old Age Pensions' Commission has made an intensive study of the 
 inmates of our almshouses. Their conclusions confirm ours — ^the 
 great majority of the dependent families to-day are simply those 
 normal families who have not been able to weather the rising cost 
 of living and increase their savings, and so, for a combination of 
 reasons, have been resourceless when illness or the disability of old 
 age dropped upon them. The Board of Public Charities states that 
 "Persons in receipt of out-door relief for the most part are the de- 
 serving poor, or those who became destitute through old age or 
 misfortune." There may always be a few individuals who will be 
 chronic paupers, but dependency, as it is known to-day, can be in 
 large measure eventually abolished. It is a social disease whick 
 is nine-tenths preventable; it is caused by maladjustments which 
 should rightly.be the concern of the new social order; disease is: 
 foremost among these causes. How, then, can we prevent the disease.' 
 wherever possible and adequately meet the losses from that portion 
 whijjh cannot be prevented ? 
 
 Sidney and Beatrice Webb have very clearly summed up the haz- 
 ards; which are constantly at work, undermining independence, and 
 recruiting new soldiers for the army of the destitute. They say : 
 
 j'.^As. a; matter of fact, we find five well-trodden paths along one or 
 the other of which the vapt majority— we might almost say all — of 
 the three or four millions have gone down into the morass of destitu- 
 tion. At least one-third of them are sick or prematurely broken 
 down in strength, and would not be destitute but for their sickness 
 or infirmity. Then we have the army of widows with young children 
 on their hands, who have been suddenly plunged into destitution by 
 the premature death of the breadwinner. Of the total, indeed, one- 
 third are infants and children, who are destitute not on account of 
 any characteristic of their own, but merely because their parents 
 are dead, or for one reason or other unable or unwilling to fulfill 
 their parental obligations. A large contingent have fallen into desti- 
 tution merely as the result of the infirmities of old age; whilst an- 
 other large contingent are in the same condition plainly because of 
 their inbecility, lunacy, or congenital feeble-mindedness. Finally, we 
 have to recognize the able-bodied person whose destitution comes 
 obviously from his prolonged inability — ^it may be incapacity or un- 
 willingness — to find sufficient employment at a sufficient rate to pay 
 to provide him and his dependents with the necessaries of life. All 
 these roads run in and out of each other, creating what we may ac- 
 curately describe as a vicious circle round about the morass of 
 destitution — parents are led .more and more to neglect their chil- 
 dren's needs if they have neither work nor wages ; it is the neglected 
 
125 
 
 child which becomes the 'unemployable' man ; the qjiite unnecessary, 
 preventable sickness to which the wage-earners are now exposed 
 withdraws even the skilled industrious worker from his job, or de- 
 prives the wife and children of their breadwinner; whilst mental 
 defectiveness complicates the problem by a subtle deterioration of 
 the population as a whole. And the four millions in the morass are 
 not permanently the same individuals. Some, let us hope, escape and 
 rise, to reach again the firm ground of adequate self-support. Many 
 — possibly four or five per cent. — die in the course of a year. Yet the 
 total remains at pretty nearly the same figure. It is plain, therefore, 
 that there is a constant recruitment. Every year sees two or three 
 hundred thousand separate individuals— perhaps more — pressed down 
 into the morass of destitution, along one or other of these roads, for 
 the first time. This, it is clear, is what we have to prevent.'" 
 
 It is to find methods of preventing this constant recruitment that 
 is our problem. Poverty cannot easily be cured, but can rapidly 
 be prevented, once the supply of these new Tecruits is cut off. Since 
 sickness is more than any other single thing a forerunner of poverty, 
 how then can we prevent sickness, and justly distribute the sickness 
 burden ? 
 
 No scheme of health insurance can be expected to cure existing 
 poverty. Health insurance is not a "cure-all" for dependency which 
 has been already created. Its purpose is to prevent employees from 
 becoming dependent; to cut oft a large proportion of those who 
 constantly fall into the dependent group. Mr. McFadden, speaking 
 before the National Fraternal Congress of America said, "Pauperism 
 ,has been reduced by life insurance 33 per cent., and saves, through 
 its forms, the nation in its effort to maintain the poor, about |30,- 
 000,000 a year."^ 
 
 In a special study made for the Commission of 110 families now 
 under the care of the Mother's Assistance Fund in Lancaster and 
 Lackawanna Counties, 102 were foiind to have been self-supporting 
 before^the father was taken' ill. 
 
 Of 1,200 families of dependent widows with children studied in 
 1916 by this same organization, it was found that before the illness 
 which caused the death of the father, 947, or 79 per cent., of the 
 families had been wholly self-supporting. Only 253, or 21 per cent., 
 were in some way dependent, and but 15 per cent, were in receipt of 
 what was termed "charity." During the illness of the father, the 
 number in some way dependent upon outside resources increased to 
 35 per cent., and after the father's death it more than doubled, placing 
 78 per cent, of the families in a group where self-support was im- 
 possible. Thus at the beginning of the illness almost four-fifths were 
 
 (») Sidney and Beatrice Webb, The Prevention of Destitution, pages 6-8. 
 
 P)!*. T. McFadden, Proceedings National Fraternal Congress of America, 1917, page 106. 
 
126 
 
 independent; after the death of the father almost four-fifths were 
 forced into the dependent group. 
 
 In the report of the Mother's Assistance Fund/ it is -stated that 
 the two great causes of dependency in the families under their care 
 are: (1) the untimely deaths of the fathers, due in large part to 
 preventable accident and disease, and (2) the father's inability to 
 safeguard his family against the death hazard on account of low 
 wages, and the lack of provisions by the state of any form of social 
 insurance. 
 
 On the whole conditions in Pennsylvania correspond only too well 
 to the description of Warren H. Pillsbury of the California Indus- 
 lrial Accident Commission: — 
 
 "The present method of handling illness of wage-earners is as fol- 
 lows: The workman becoming ill, struggles to remain at work as 
 long as possible to avoid loss of wages, and refuses to go to a physi- 
 cian until the last moment because of feao* of expense, thus prevent- 
 ing treatment at the time it is most effective, the early stages of 
 the illness. When finally obliged to leave work, the income of him- 
 self and his. family is ended. His savings will seldom last for more 
 than a week or two of idleness. He then becomes a charge upon 
 relatives, friends, and public charity. Worry over his financial con- 
 dition prolongs his illness. Inability to procure necessary medical 
 and surgical appliances or to take proper rest or sanitorium treat- 
 ment delays recovery. The children are taken frbm school prema- 
 turely and put to work without adequate preparation or allowed to 
 go upon the" streets. Eventually he may go to the county hospital 
 for a long period of time, and his wife will be taken care of by the 
 Associated Charities^ or will undertake work beyond her strength 
 and become ill. The employer has to break a new man into the work. 
 The community, friends or relatives have to support the family, and 
 the man is inefficiently and haphazardly taken care of because of 
 lack of organized social endeavor to meet the problem presented."^ 
 
 (') Report of the Mother's Assistant Fund, 1918, page 38 
 
 (')Transactions of the Common-wealth Club of Oalitornla, June, 1917, page 173. 
 
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 Part II. — Section II. — Table II. — Average Annual Wage. Principal 
 Manufacturing Groups 1914. (') 
 
 
 
 ^. 
 
 
 a 
 
 «D 
 
 
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 1 
 
 1 
 
 1 
 
 1 
 
 
 g 
 
 
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 Horticultural and floricultural products. 
 
 Engineering and laboratory service, 
 
 Building trades, 
 
 Chemicals and allied products, 
 
 Clay, glass and stone products, 
 
 Clothing manufactures, 
 
 Pood and kindred products, 
 
 Leather and rubber goods, - 
 
 Laquors and beverages, 
 
 Lumber and its remanufacture, 
 
 Paper and paper products, 
 
 Printing trades, 
 
 Textiles, <- 
 
 Miscellaneous products, : 
 
 Laundries, 
 
 Metals and metal products, 
 
 Mines and quarries. 
 
 Tobacco and its products. 
 
 Total, 
 
 20,571 establishments. 
 
 $602 
 
 $425 
 
 $157 
 
 $100 
 
 323 
 
 540 
 
 60 
 
 
 621 
 
 448 
 
 141 
 
 100 
 
 im 
 
 362 
 
 137 
 
 19S 
 
 625 
 
 338 
 
 2sr 
 
 193 
 
 688 
 
 338 
 
 211 
 
 178 
 
 712 
 
 303 
 
 222 
 
 193 
 
 679 
 
 277 
 
 247 
 
 228 
 
 1,002 
 
 166 
 
 157 
 
 20O 
 
 627 
 
 336 
 
 206 
 
 155 
 
 Tie 
 
 320 
 
 21S 
 
 191 
 
 f65 
 
 389 
 
 178 
 
 186 
 
 610 
 
 332 
 
 212 
 
 189 
 
 719 
 
 337 
 
 258 
 
 246 
 
 736 
 
 341 
 
 206 
 
 216 
 
 776 
 
 358 
 
 267 
 
 233 
 
 469 
 
 378 
 
 374 
 
 286 
 
 512 
 
 311 
 
 205 
 
 183 
 
 $720 
 
 ■$335 
 
 $224 
 
 $191 
 
 1,343 
 1,262 
 1,330 
 1,336 
 
 887 
 1,086 
 1,397 
 1,693 
 1,178 
 1,383 
 1,042 
 1,282 
 1,409 
 
 865 
 1,26B 
 1,102 
 1,089 
 
 SI, 207 
 
 (1) Compiled from Production Report of the Department of Labor and Industry for lffl4. 
 90-91. 
 
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132 
 
 Part II 
 
 — Section II. — Table IV. — Comparative Wages — Surveys, 
 
 
 
 EeD^ington 
 
 Visiting Nurse 
 
 Sickness and 
 
 Working Women's 
 
 
 Survey. 
 
 Study. 
 
 Dependency. 
 
 BecorasO). 
 
 Family Income 
 
 
 
 
 
 
 
 
 
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 ■M 
 
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 1 
 
 
 i 
 
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 $20-$25. 
 
 $25^30^ 
 
 Over $80, .. 
 
 Total, 
 
 143 
 
 11* 
 
 271 
 
 23.4 
 
 IS.S- 
 
 . 44.6 
 
 1 
 
 33,5 
 28-.9 
 1ft 2 
 
 19:4 
 
 644 
 
 "5! 
 49 
 
 75-.8 
 
 13.1 
 
 5.9 
 
 5.7 
 
 423 
 
 28 
 
 9 
 
 92.1 
 
 6.0 
 
 ('')1.9 
 
 
 
 606 
 
 lOO.O 
 
 438 
 
 100.0 
 
 856 
 
 100.0 
 
 46* 
 
 100.0 
 
 (^)Based on wages of individual Wtimen, not families. 
 (2) "^25 and over." 
 
 Part II.— Section II. — T?a8le V. — Per Cent, of Increase in fietail Prices in Be- 
 cember, 1915, 1916 and' 1917, and August, 1918, above the prices in December, 
 1914. (") 
 
 Philadelphia District, White Families.' 
 
 Items of Expenditure. 
 
 Per cent, of toereasS in retail pflces 
 in December. 1915, 1916, and 1917, 
 and in August^ l!ai8, ,above the 
 prites in Decem]>er, 1914. 
 
 
 December 
 1915. 
 
 December 
 Ifflie. 
 
 Decembec 
 1917. 
 
 August 
 1918. 
 
 Clothing: 
 
 Male. 
 
 3.30 
 3.94 
 
 16.15 
 15.90 
 
 64.11 
 49.12 
 
 
 
 106 73 
 
 
 
 Total, 
 
 3.60 
 
 16.0S 
 
 51.33 
 
 I0S.12 
 
 Furniture and furnishings _,j 
 
 6.94 
 
 .34 
 
 (2). 29 
 
 (2).81 
 
 1.19 
 
 19.87 
 18.921 
 0.72 
 5.37 
 14.65 
 
 49.84 
 54.41 
 2.60 
 21.34 
 43.81 
 
 lOg.TS 
 08.09 
 
 3l' M 
 
 
 Housing, 
 
 Fuel and light, 
 
 Miscellaneous, - 
 
 e7.ffl 
 
 
 All items, — - 
 
 1.19 
 
 14.65 
 
 43.81 
 
 eV.i? 
 
 (') Bureau of Labor Statistic!* Moilthly Rcvie*, October, 1918. 
 C) Decrease. 
 
133 
 
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 OH) 
 
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 00 I 
 
 
 
 
 
 
 
 
 »*& 
 
 ^ 
 
 iT^SiT 
 
 
 
 <» 
 
 j 1 
 
 1 
 
 lit'! 
 
 
 
 
 
 SS 
 
 S 
 
 g 11 
 
 1 
 
 
 
 
 
 rHoT 
 
 s 
 
 ®Sm 
 
 1 
 
 
 
 
 
 on 
 
 +■ 
 
 11^ 
 
 [ 
 
 Z-< 
 
 ° 
 
 
 1 
 
 j 
 
 i ip; 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 t>. 
 
 ii^s '>: 
 
 
 ■s 
 
 ■S-g^h^ 
 
 S8 
 
 ■y 
 
 •S-B'3-S 
 
 ■s 
 
 Wf. 
 
 a 
 
 ss 
 
 & 
 
 p^ t^ 
 
 
 
 
 §§ 
 
 S 
 
 
 
 
 00 
 
 s 
 
 3" OS 
 
 ma Hi 
 
 o o a a o 
 
 sasfeS 
 
 V 
 
 in 
 a 
 
 .9 m 2 to 
 S p E3 gf 
 
 !.9«o 
 
 u 
 
 S; 
 
 ■S 5 
 
135 
 
 Part II.— Section II.— Table VI— B.— Dental Fee Schedule.*i 
 
 "Bv the hoiir. -— 
 
 $S-»5 
 1— 8 
 2—10 
 1- 2 
 1— 2 
 8—15 
 
 Plates, 
 
 $12— $2S 
 
 Amalgam flUlng, 
 
 (jold, 
 
 
 
 8— 12 
 
 Gold plates (per tooth) 
 
 50—200 
 
 
 
 Kemoving pulp and filling canals, 
 
 3— 10 
 
 TreatEQents 
 
 
 
 
 
 
 •Dr. Alexander H. Reynolds, 
 (1) "Approximate. " 
 
 Secretary ol State Board of Dental Examiners. 
 
 
 Part II.— Section II.— Table VI— C— Nurses' Fee Schedules. 
 
 Sounse of 
 Information. 
 
 I<emale 
 
 Male 
 
 OontaglouE 
 
 Nurses. 
 
 Nurses. 
 
 and 
 
 Ordinary 
 
 Ordinary 
 
 Nervous 
 
 Oases. 
 
 Oases. 
 
 Diseases. 
 
 
 ji 
 
 
 Ji 
 
 
 M 
 
 a 
 
 S 
 
 6 
 
 
 fi 
 
 S 
 
 S 
 
 ^ 
 
 a 
 
 ^ 
 
 -B 
 
 ^ 
 
 
 
 York Hospital, 
 York, 
 
 BobCTt Packer 
 Hospital, Sayre, 
 
 State Hospital, 
 Scranton, 
 
 Mercy Hospital, 
 Pittsburgh, 
 
 Pennsylvania Hos- 
 pital. Philadel- 
 phia. 
 
 $25- 
 
 $86 
 
 $25- 
 
 per weak 
 
 per week 
 
 per week 
 
 $30 
 per week 
 
 Do not 
 take 
 
 Do not 
 take 
 
 per week 
 
 •None available. 
 
 TABLE VI — D. — Hospital Fees. 
 
 
 
 OS 
 
 a 
 
 Include 
 
 o 
 
 
 
 
 
 
 
 Name of Hospital. 
 
 S 
 
 .§ 
 
 
 
 § 
 
 
 
 
 09 
 
 s 
 
 03 
 1 
 
 ! 
 
 i 
 
 il 
 
 O 0) 
 
 03 a 
 
 6° 
 
 7 
 
 State Hospital, Scran- 
 ton, 
 
 Bobert Packer Hos- 
 pital, Sayre 
 
 York Hospital, York, 
 
 Mercy Hospital, PStts 
 . burgh 
 
 Pennsylvania Hospi- 
 tal. Philadelphia 
 
 $2 per day 
 
 $2 per day 
 $1* per week 
 
 $1.50 per day 
 $10.50 per week 
 
 $10-12 per week 
 $"1 per day 
 
 $3.50-4.50 per 
 day 
 
 $21-42 per week 
 $S-5 per day 
 $20-75 per week 
 $3-6 per day 
 
 Yes 
 Yes 
 Yes 
 No 
 No 
 
 Ordinary 
 
 Yes 
 
 Yes 
 
 Yes 
 
 Yes 
 
 Yes 
 
 Yes 
 
 Yes 
 
 Yes 
 
 No 
 
 $5 ward 
 $10priv8teroom 
 
 $5 room 
 
 $5 anaesthetic 
 
 $5-10 
 
l36 
 
 Part II. — Section II. — Table VII. — Expenditures for Sickness Care. 
 
 
 «ost of Living Studies, United States 
 
 Cost of living Study, Hill* 
 
 
 Bureau ol Labor Statistics. 
 
 
 delphia Bureau of Munici- 
 pal Besearch. 
 
 
 Fhiladtlpliia. 
 
 Chester 
 
 
 
 
 
 , 
 
 Dollars. 
 
 
 
 
 i 
 
 ■3 
 
 
 +» IB 
 
 
 i 
 
 ■i 
 
 
 ^• 
 
 "S 
 
 
 
 
 
 S 
 
 o 
 
 1 
 
 
 1 
 
 i 
 
 1 
 
 1 
 
 sa 
 
 
 7 
 16 
 25 
 49 
 60 
 26 
 4 
 3 
 1 
 
 89 
 42 
 23 
 23 
 11 
 3 
 1 
 
 4 
 
 8 
 
 22 
 
 45 
 
 59 
 
 42 
 
 6 
 
 4 
 
 1 
 
 10 
 7 
 9 
 
 11 
 
 1 
 1 
 
 14 
 15 
 1 
 6 
 3 
 1 
 
 7 
 4 
 10 
 13 
 4 
 1 
 
 4 
 
 52 
 
 28 
 
 76 
 
 77 
 
 17 
 
 3 
 
 1 
 
 1 
 
 127 
 59 
 22 
 37 
 '9 
 S 
 
 1 
 
 2 
 35 
 25 
 74 
 85 
 30 
 6 
 1 
 
 76 
 
 Less than 6, 
 
 6- 10, -_- 
 
 11- 25 .TTn 
 
 143 
 
 22 
 11 
 
 26- 60 
 
 8 
 
 51-MO. 
 
 
 101-150 
 
 
 151-290, 
 
 
 201-'225 
 
 
 
 
 
 212.60, 
 
 
 
 
 1 
 
 
 252.00, 
 
 1 
 
 
 1 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 413 00 
 
 
 
 
 
 1 
 
 
 
 
 
 450.00. 
 
 
 
 
 
 
 1 
 
 
 
 
 463.00 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 Total. — — - 
 
 192 
 
 192 
 
 192 
 
 40 
 
 40 
 
 40 
 
 260 
 
 260 
 
 260 
 
 260 
 
 (1) Included in "medical.' 
 
 Part II. — Section II. — ^Table VIII. — Cost of State Hospitals for Miners.i 
 
 
 Year End- 
 ing May 
 31, 1912. 
 
 Year Bind- 
 ing May 
 31, 1913. 
 
 Year End- 
 ing May 
 31, 1914. 
 
 Year End- 
 ing May 
 31, 1915. 
 
 Tear End- 
 ing May 
 31, 1916. 
 
 Number of hospitals, 
 
 Receipts from patients and 
 
 friends of patients, 
 
 Prom State 
 
 Expenditui"^ 
 
 8 
 
 $27,735.92 
 
 254,199.71 
 
 287,990.^ 
 
 646 
 
 8,481 
 
 7,559 
 
 380 
 
 ft7,303 
 
 10 
 
 $36,364.99 
 
 286,774.87 
 
 372,525.41 
 
 791 
 
 11,«W 
 
 9,688 
 
 256 
 
 227,895 
 
 10 
 
 $46,912.10 
 
 337,662.29 
 
 429,781.64 
 
 789 
 
 12,143 
 
 10,552 
 
 640 
 
 262,371 
 
 10 
 
 $54,071.86 
 
 349,256.63 
 
 433,243.92 
 
 855 
 
 14,567 
 
 12,150 
 
 1,175 
 
 261,688 
 
 10 
 
 $64,553.01 
 369,456.25 
 439,428.92 
 
 Total number of beds, 
 
 Total number patients, . 
 Number free in-patients, 
 
 821 
 
 Total number days 
 
 280,785 
 
 
 
 Total cost free days. 
 
 $266,283.19 
 
 $335,362.45 
 
 $381,165.38 
 
 $373,914.80 
 
 $366,965.60 
 
 (1) Taken from Reports of State Board of Public Charities. 
 
137 
 
 Part Il.-Section II—Table IX.^Statistics of Hogpitals Reporting to State 
 
 Board of Chsrities.i 
 
 Nilijiber of hospitals coTeted 
 
 Total received for mainte- 
 
 Dgace, 
 
 Projn patients and friends of 
 
 patients, 
 
 IVom the, State, -- 
 
 Prom donations, 
 
 Total expenses, 
 
 Number hospitals having de- 
 ficit, 
 
 Total deficit, 
 
 Total number of beds, 
 
 Total numlaer in-patients 
 
 treated, 
 
 NumlDer treated free, 
 
 Ifumbers treated parti; free,-. 
 Total number free hospital 
 
 days, , 
 
 Number of dispensary p.8- 
 
 tie^its,, 
 
 Received from dispensary pa- 
 
 tjients, 
 
 Fixed indebtedness, 
 
 Tear 
 
 Ending May 
 
 81, 1912. 
 
 *169 
 3,555,562 52 
 
 2,203,891 71 
 
 1,977,400 73 
 
 ?370,764 08 
 
 9,686,819 SB 
 
 103 
 
 $665,505 97 
 15,244 
 
 181,854 
 97,723 
 34,838 
 
 1,918,000 
 408,009 
 
 $9,471 71 
 $4,3172,220 90 
 
 Tear 
 
 Ending May 
 
 31, 1918. 
 
 ties 
 
 $7,204,611 49 
 
 $2,727,091 20 
 
 $8,172,727 03 
 
 $414,499 84 
 
 $7,196,081 66 
 
 68 
 
 $203,456 85 
 
 15,547 
 
 204,310 
 103,895 
 -42,900 
 
 2,012,572 
 797,958 
 
 $67,015 74 
 $4,620,754 34 
 
 Tear 
 
 Ending May 
 
 M, 1914. 
 
 $7,186,463 37 
 
 2,900,744 11 
 2, 304^800 14 
 .$270,048 60 
 7,414,694 90 
 
 85 
 
 $435,814 51 
 
 205,116 
 
 103,987 
 
 48,713 
 
 2,138,996 
 
 $87,439 71 
 ,522,304 51 
 
 Tear 
 
 Ending May 
 
 31, 1^6. 
 
 n69 
 
 $6,964,112 57 
 
 $2,929,314 58 
 
 2,36e,30S50 
 
 $118,519 01 
 
 7,418,244 88 
 
 130 
 
 $622,516 60 
 15,603 
 
 166,428 
 
 118,538 
 
 45,918 
 
 2,i28,7er 
 
 882,204 
 
 $64,737 84 
 $4,482,620 35 
 
 Tear 
 
 Ending May 
 
 31, 1916. 
 
 176 
 
 ■,306,726 42 
 
 r,268,287 16 
 !,319,a88 96 
 
 17,937,055 10 
 
 102 
 
 $734,486 49 
 
 16,351 
 
 219,834 
 127,678 
 
 1,627,846 
 868,171 
 
 $88,727 81 
 ,548,649 52 
 
 Part II.- 
 
 -Seetion II. — Table X. — Statistics of Sanatoria Reporting to State 
 Board of Charities. 
 
 Number of sanitoria covered, 
 Total, received for mainte- 
 nance, 
 
 From patients and friends of 
 
 patients, 
 
 From the State, 
 
 Prom donations, 
 
 Total expenses. 
 
 Number sanitoria having de- 
 ficit, 
 
 Fixed indebtedness, . 
 
 Total number of beds for pa- 
 tients, 
 
 Total number in-patients 
 
 - treated, 
 
 Number treated free, 
 
 Number treated partly free, 
 Total number free days, — 
 Number of dispensary pa- 
 tients, 
 
 Beceived from dispensary pa- 
 tients, ,. 
 
 Tear 
 
 Ending May 
 
 31, 1912. 
 
 $256,255 20 
 
 $99,343 68 
 
 $38,111 90 
 
 $64,885 09 
 
 $222,386 00 
 
 S 
 
 471 
 
 i,63r 
 
 479 
 
 831 
 
 67,516 
 
 e,SS7 
 $209 10 
 
 Tear 
 
 Ending May 
 
 31, 1913. 
 
 8 
 $275,357 96 
 
 $106,484 06 
 $45,120 44 
 $74,874 02 
 
 $2g«,516 63 
 
 3 
 
 $13,000 00 
 
 14,608 
 
 Tear 
 
 Ending May 
 
 SI, 1914. 
 
 $338, SS6 60 
 
 $142: 
 $322 
 
 $37 
 
 ,404 00 
 ,665 60 
 ,225 91 
 ,980 65 
 
 2 
 
 ,000 00 
 
 618 
 
 2,093 
 
 1,093 
 
 431 
 
 92,945 
 
 11,554 
 ,930 43 
 
 Tear 
 
 Ending May 
 
 31, 1915 
 
 1,449 09 
 
 9,377 39 
 2,877 70 
 3,185 88 
 
 $27,000 OO 
 
 1,867 
 
 970 
 
 80O 
 
 125,741 
 
 23,134 
 
 $118 49 
 
 Tear 
 
 Ending May 
 
 81, 1916. 
 
 $42,531 34 
 $60,500 00 
 
 ~$2634oi"ii 
 
 $27,000 00 
 481 
 
 1,098 
 649 
 
 67,734 
 6,273 
 
 (1) "State Hospital" not included after 1911. 
 
 • Sixteen of these received no State aid. 
 
 t Seventeen of these received no State aid. 
 
 {No information about number not receivmg State aid. 
 
138 
 
 Part II. — Section II. — ^Table XI. — Certain Statistics of. Hospitals Reporting 
 State Board of Charities for Fiscal Years 1916 and 1917. 
 
 to 
 
 Item. 
 
 Teai Ending 
 May 31, 1916. 
 
 iTear Ending 
 May 31, 1917. 
 
 Total receipts, 
 
 Total expenditures. 
 Apparent deficit. 
 
 Number ot tree Inpatients, 
 
 Number ol pay patients, 
 
 Number of free days, 
 
 Average per capita ol patients,* 
 
 $7,306,726 42 
 
 7,937,065 10 
 
 63D,32S68 
 
 127,678 
 
 98,156 
 
 1,627,348 
 
 ♦$1 98 
 
 $8,708,846 S7 
 
 9,526,061 27 
 
 817,214 90 
 
 154,216 
 
 92,7!'3 
 
 1,680,728 
 
 «$2 28 
 
 'Average not weighted by number of beds per hospital. 
 
 Part II. — Section II. — Table XII. — Number of Cases of Out-door Relief in Alms- 
 house Districts as Reported to the State Board of Charities. 
 
 Cause of Destitution. 
 
 Tear End- 
 ing Dee. 
 31, 1912. 
 
 Tear End- 
 ing Dec. 
 31, 1913. 
 
 Tear End- 
 ing Dec. 
 31, 1914. 
 
 Tear End- 
 ing Dec. 
 31, 1915. 
 
 Tear End- 
 ing Dec. 
 31,' 19M. 
 
 Old age or permanent disability, 
 
 Temporary sickness or death, 
 
 Want of work . 
 
 Desertion or absence of heads of 
 families, — ". 
 
 Intemperance, 
 
 Insanity, idiocy or feeble-minded. 
 Other, 
 
 Total, 
 
 
 5,287 
 
 15.88% 
 
 15,414 
 
 46.87% 
 
 5,157 
 
 15.48% 
 
 5,635 
 
 16.91% 
 
 997 
 
 2.99% 
 
 847 
 
 2.47% 
 
 33,311 
 
 6,499 
 
 19.30% 
 
 15,455 
 
 45.90% 
 
 4,6S9 
 
 13.98% 
 
 5,256 
 
 IS.61% 
 
 1,110 
 
 3.30% 
 
 693 
 
 1.96% 
 
 7,821 
 
 16.84% 
 
 19,883 
 
 38.71% 
 
 13,289 
 
 25.89% 
 
 7,334 
 
 14.30% 
 
 2,178 
 
 4.26% 
 
 688 
 
 1.30% 
 
 178 
 
 0.34% 
 
 61,311 
 
 6,060 
 
 14.06% 
 
 16,387 
 
 35.70% 
 
 10,766 
 
 35.02% 
 
 7,882 
 
 17.89% 
 
 2,398 
 
 5.57% 
 
 nz 
 
 1.79% 
 
 43,035 
 
 7,631 
 20.86% 
 
 vr.oss 
 
 3,213 
 8.90% 
 
 6,877 
 16.22% 
 
 1,692 
 4.68% 
 
 -718 
 1.97% 
 
 36,118 
 
 100.00% 
 
PART II. 
 SECTION III. ^ 
 
 The Adequacy of Present Methods of Care. 
 
 (139) 
 
(140) 
 
141 
 
 PHYSICIANS IN PENNSYLVANIA. 
 
 The number of physicians in the state at the present time, because 
 of the demands of the army for medical service, is of course in no way 
 representative or normal conditions. ^ 
 
 According to the report of the Social Insurance Committee of the 
 American Medical Association, however, there were in 1916, 11,502 
 legally qiialifled physicians in Pennsylvania,^ or an average of one 
 physician for each 729 persons. This corresponds fairly well to the 
 standard of one physician for each 700 persons, considered adequate 
 by the Committee, but gives no idea of the unevenness of distribu- 
 tion. It is interesting to find that while Philadelphia, Pittsburgh, 
 and Scranton have one physician for each 431,516, and 663 persons 
 respectively, Hazelton and Shenandoah, both important mining com- 
 munities, have 848 and 1,031 persons respectively, for each physician. 
 The contrast between urban and rural communities is even more 
 marked, for in the latter the number of persons per physician is 1,297 
 as compared with 524 in cities of 25,000 and over. Among the most 
 important reasons for this are the economic conditions in the varioiis 
 communities, which determine their ability to offer fair or poor re- 
 muneration for medical work. 
 
 HOSPITAL FACILITIES IN PENNSYLVANIA. 
 From the medical directory issued annually by the American 
 Medical Association, a list furnished by the Modern Hospital maga- 
 zine, and the directory of the B.oard of Public Charities, the number 
 of beds in public hospitals, special and general, in each county of the 
 state was computed for the year 1916. This of course, is an over- 
 estimate of the facilities available to the average employee, for it in- 
 cludes a number of beds in private rooins, which are far beyond his 
 n-.eans. No data is available, however, by which these can be de- 
 ducted. There were a total of 20,-118 beds in the public general hos- 
 pitals of the state in 1916. Various classes of public special hos- 
 pitals including those for epilepsy, tuberculosis, contagious diseases, 
 cancer, maternity, surgical work, children's diseases, and eye and ear 
 cases contained an additional 6,603 beds, and insane asylums con- 
 tained 11,843. Exclusive of these asylums the total number of beds 
 in public hospitals was 26,721, or 3.4 beds per 1,000 persons on the 
 basis of the population of the state in 1910. On the basis of the esti- 
 mated population in 1916 (8,522,017) the number of beds per 1,000 
 population is 3.1. Either estimate is far below the five beds per 1,000 
 population which authorities tell us are necessary for adequate hos- 
 pital accommodation. 
 
 (^)Statistics Regarding the Medical Profession, Social Insurance Series, Pamphlet VII, American 
 Medical Association. 
 
142 
 
 Sixteen of the sixty-seven counties in Pennsylvania, some of them 
 at considerable distances from better- supplied areas, have no hospital 
 beds whatever, and nine other counties have less than one per 1,000 
 persons.^ 
 
 A division of the state into sections, as shown by the appended 
 map,^ illustsates the inadequacy of existing hospital facilities. 
 
 The nineteen counties included in Section I represent the bitumi- 
 ious coal region of Pennsylvania, and in 1916 produced 162,010,334 
 tons of coal, or more than 95 per cent, of the entire bituminous out- 
 put of the state. This district with a population of 2,636,026 persons 
 or 34.38 per cent, of the total state population, has 8,276 hospital 
 beds, or an average of 3.1 beds per 1,000 persons. More than two- 
 thirds of these beds are located in Allegheny County, which has only 
 38.6 per cent, of the population of the entire district, and is not 
 readily accessible to the most remote and most poorly equipped 
 counties. Exclusive of Allegheny County^ the average numher of 
 beds per 1,000 population for the district is only .14- Because of 
 the highly industrial character of the population and the health and 
 accident hazards involved in mining, this provision is shockingly 
 inadequate. Two counties, neither of which is within easy reach of a 
 well-supplied area, have no beds at all, and six have less than one 
 bed per 1,000 persons. 
 
 Section II, the anthracite coal district, comprises eleven counties 
 with a population of 1,132,035 or 14.76 per cent, of the total popula- 
 tion of Pennsylvania. The 1916 coal production of these counties was 
 87,680,198 tons, or more than 98 per cent, of the anthracite output 
 of the state. In this whole section there are only 1,872 beds or 1.65 
 per 1,000 persons, and the distribution is still more uneven and un- 
 satisfactory than in the bituminous district. Four of the eleven 
 counties have no hospital beds, and are not accessible to adequately 
 supplied districts. 
 
 Section III, which includes the northern and north central coun- 
 ties, thirteen in all, has an average if 2.72 beds per 1,000, or 1,792 
 for the population of 656,698. The distribution, exclusive of Erie 
 County, which has almost one-third the total number of beds, is more 
 even than in the anthracite and bituminous districts, although Cam- 
 eron and Forest Counties are entirely lacking in hospital facilities. 
 Forest lies next to Clarion County, one of the two bituminous coun- 
 ties which have no beds. 
 
 The twenty-three remaining counties of the state make up Section 
 IV, which has 42.29 per cent, of the total state population. This 
 section, in comparison with the other three, stands slightly higher 
 in the number (>f beds, having 12,545 for the population of 3,240,353 
 or 3.87 per 1,000. But, exclusive of Philadelphia County with 9,659 
 
 (')See Table II at end o( this section. 
 (')See Table I at end o( this section. 
 
143 
 
 beds or 6.2 per 1,000, the average for the district is only .88, while 
 eight counties have no beds at all. Of these eight counties, four,. 
 Union, Snyder, Juniata and Perry are adjacent. Perry is next to 
 Cumberland with an average of only .90 beds per 1,000 and south of 
 Cumberland is Adams County, with no beds. Fulton with no beds 
 joins Franklin with only 1.0 per 1,000, and Bedford, one of the bitu- 
 minous counties with no hospital facilities. 
 
 This concentration of existing hospitals in the two large cities of 
 the state is not surprising, and there is no evidence to show that 
 these cities are over-supplied with hospital accommodations. The 
 problem is not so much one of poor distribution as of inadequate 
 supply. 
 
 But even if accommodations were adequate, it would not be pos- 
 sible to look with satisfaction on the hcspital situation of the state. 
 When the cost of 'ward ieds is heyond the means of proiaMy half 
 the employees of the state; when in a single year, nearly 2,000,000 
 days of free hospital trcatm.ent are given and almost 000,000 persons 
 patronize charity dispensaries, some change in method is called for 
 wMch will make medical care a/ooMahle to the avrerage employee as a 
 .matter of right, not charity. 
 
 MEDICAL CARE BECEIVED BY EMPLOYEES AND THEIR FAMILIES.i 
 The sickness surveys show a considerable number of sick persons 
 who receive no medical attention at all, or receive it too late to 
 prevent the illness from becoming serious. In Pittsburg and West- 
 ern Pennsylvania, 25.4 per cent, of the illnesses, including 49.4 per 
 cent of the persons sick but able to work, and 24.2 per cent of those 
 aptually disabled, had no medical care. In the Philadelphia Survey 
 21.7 per cent, of the 514 cases of illness wer^ treated only by patent 
 medicines and home remedies. In an additional 16.3 per cent, the 
 kind of treatment was "unknown," and it is probable that the major- 
 ity of these received no care. A physician had been consulted in only 
 60 per cent, of the total number of 'cases. Among the Kensington 
 families, no care at all was received in 154 cases and home treatment 
 or patent medicine only in an additional 144 cases, making a total 
 of 14.9 per cent, of the 1,994 illnesses foujid in the survey. 
 
 The use of patent medicines, which was more fully discussed in the 
 section on "The Cost of Medical Care," is a striking feature in every 
 group. Of 348 girls in the study of Working Women who had ex- 
 penditures for medical care, 39.9 had medicine only. Although 97.5 
 per cent, of the 1,360 cases of illness in the Visting Nurse Study 
 were said to have had medical care, 11.4 per cent, of these had had 
 only patent medicine. The nurses who made this study were 
 impressed with the inadequate character of the care generally 
 received. 
 
 (>)Sce Table III at the end of this eectlon. 
 
 10 
 
144 
 
 In cases where medical care was reported, a private physician had 
 most often been consulted. This was true in 86.6 per cent, of the 
 treated illnesses in Pittsburgh and Western Pennsylvania, 48.9 per 
 cent, of those ia.the Visiting Nurse group, 37.1 per cent, of those in 
 Kensington, and 57J per cent, of the working women who had expen- 
 ditures for medical care. In all except the Sickness and Dependency 
 Study, the use of the "district doctor," dispensary, hospital «r ■con- 
 valescent home was infrequent, tuberculosis, accidents and mental 
 diseases being the usual cause of institutional care. Nursing care 
 was reported in less than 10 per cent, of the cases. This figure was 
 highest in the Visiting Nurse Society Study, where it was recorded 
 for 11.1 per cent, of the cases under treatment. About 10 per cent, 
 of the nurses were described as "practical nurses." 
 
 The amount of free treatment cannot be accurately estimated, but 
 there were many instances in which the fact of medical charity was 
 beyond dispute. For instance in the Sickness and Dependency 
 Study, the Poor Boards' "district doctor" was called in 119 times 
 and a dispensary was consulted 421 times. No doubt most of the 435 
 persons who went "to a sanitarium and seventy-one who went to a 
 convalescent home were also treated free of charge.^ Within the 
 Visiting Nurse group, 37.8 per cent, of the nursing care was only 
 partially paid for, and an additional 14.8 per cent, was given entirely 
 free, while in the 324 cases treated by city doctors, "practical nurses," 
 dispensaries, hospitals and convalescent homes, there were certainly 
 many instances of medical charity. 
 
 A special study of maternity care in Pennsylvania would be highly 
 desirable as certain facts on this subject which have been noted 
 indicate that mothers too frequently fail to receive proper attention 
 at this critical time. For instance the Federal Children's Bureau, in 
 its study of infant mortality in Johnstown, states that 37.9 per cent, 
 of the motlvers of children horn in 1911 in that city had only a mld- 
 ■uiife as attendant at the Mrths of their bahies, and 2.3 per cent, no 
 attendant, or neighbors, relatives or friends. Out of 1,463 of these 
 mothers, 401 took up all, and 626 others at least part, of their house- 
 hold duties in less than fourteen days after confinement. The infant 
 death-rate was considerably lower in the cases having better atten- 
 tion and the longer period of rest.^ 
 
 It is well known that every expectant mother requires special pre- 
 natal care and instruction to safeguard her own life and health and 
 that of her child. Yet the Dispensary Aid SocieV of Pittsburgh 
 reported that in the district in which they carried on intensive chtld 
 hygiene work during the year ending April 1, 1916, only ten out of 
 106 mothers had had any prenatal care.^ 
 
 (MTn miiny of the above paees of course, more than one kinfl of medical care was iised. 
 C'lOhndreuis Bureau; "Infant Mortality, Results of a Field Study in Johnstown, Pa." ■' Bureau, 
 Publication No. 9. paees 32, 3.S. 34, 45. 
 
 («)Dispensary Aid Society, Tuberculosis League of Pittsburgh. Firgt Bnrveji Report, page 52. 
 
145 
 
 The fact has been emphasized in connection with the Sickness and 
 Dependency Study that the crisis of childbirth combined with the 
 illness of the breadwinner, frequently exhausted family resources and 
 reqnired charitable aid. One or two cases were found in which the 
 husband was obliged to stay at home from work and care for his wife 
 because no other help was Available. 
 
 The difficulties of the working mother, whose income stops just at 
 the time she is most in need of it were often illustrated. 
 
 Mr. P. was a laborer, but his work was irregular, and his wife did 
 washing to help support the five children. Olga, the oldest girl, was 
 of working age but had never been able to work on account of tuber- 
 culosis, and during the time the relief society was interested in the 
 family, she went to a state tuberculosis sanitarium, where she died. 
 The record states that Mrs. P. "worked nearly up to the time of her 
 coniimement and as soon after as she could stand on her feet." She 
 had no prenatal care. 
 
 MEDICAL CARE RECEIVED BY MINERS AND THEIR FAMILIES. 
 A special effort was made by the C<j)mmission to investigate the 
 extent and nature of sickness care received by miners and their 
 families. Although conditions vary widely, the following facts are 
 generally true : 
 
 A great many companies, especially in the bituminous region, have 
 organized systems of "contract practice" under which each employee 
 pays a definite monthly sum, usually from |1.00 to |1.50 if he is mar- 
 ried, and from fifty to seventy-five cents if he is single. These sums 
 are paid by the employers to physicians who agree to care for illness 
 among the miners and their families. Operations, maternity cases 
 and long, serious illnesses are usually excluded from the list of ail- 
 ments to J?e treated, and medicines, appliances, etc. are frequently 
 charged for in addition. Although this practice seems to be proving 
 satisfactory in som€ districts, it has been abandoned by practically 
 aH the anthracite operators and by two of the largest companies in 
 the bituminous region. The objections to it seem to be the usual, 
 criticisms made of "contract" and "lodge" practice, with the addi- 
 tional complaint that in many cases too few doctors are employed. 
 One company, for instance, had one doctor and one nurse to care for 
 between 2,000 and 3,000 families living in nine different districts 
 within a radius of several miles. As no records are kept by the doc- 
 tors practicing under this contract system, it is almost impossible tp 
 get any clear idea of the extent of their work. 
 
 The state maintains ten hospitals for miners whose work is 
 descrihed in Part III, Section I of this report. In addition, a few 
 companies, mostly in the anthracite district, maintain private hos- 
 pitals where their employees and sometimes members of their 
 families, may receive practically free treatment. The foreign work- 
 ers, as a rule, appreciate the advantages of hospital care more keenly 
 
146 
 
 than the Americans and take advantage of the opportunity to secure 
 it to greater extent. In some instances, the location of the hospitals 
 makes it practically impossible for members of the family, or even-the 
 family physician, to visit the patient, in which case hospital care is 
 less often received. ' 
 
 Employees of the large number of operators who do not maintain 
 the "contract system" depend upon lodge doctors and private prac- 
 titioners for treatment. In many communities "physicians make a 
 specialty of this kind of practice and the care given is very good, 
 especially among Hungarian and Slavic families who are noted for 
 their scrupulousness about paying for treatment. In the Western 
 Pennsylvania Survey, the Metropolitan Life Insurance Company 
 found that 85.4 per cent, of the bituminous miners' illnesses and 77.4 
 per cent, of those among anthracite miners received medical care. 
 This was attributed partially to the large number of accident cases 
 included in the survey. The report states : 
 
 "It must not be inferred from the higher ratios of medical attend- 
 ance shown for the three occupational classes (anthracite and 
 bituminous miners and iron and steel workersj that these special 
 groups are better able financially to provide private medicalcare for 
 themselves.'" 
 
 As a rule, maternity cases receive less frequent and poorer treat- 
 ment than any others. Midwives, frequently untrained, are generally 
 employed, instead of physicians. Nursing care is very seldom avail- 
 able, and little is being done to encourage the improvement in sanita- 
 tion and health knowledge that would do so much to decrease the 
 amount of sickness, particularly among young children. Attempts 
 have been made by some insurance companies to provide nursing 
 service for their industrial policy-holders, but as yet this is in no way 
 adequate. One company employed before the war two nurses to care 
 for about eight thousand policy-holders living in a district with a 
 ten-mile radius. 
 
 The experience of one bituminous mining company employing about 
 2,000 men is interesting. In their "contract system" they have four 
 physicians and a visiting nurse, as well as facilities for giving 
 instructions in hygiene, prenatal and infant care. They consider 
 that the cost of maintaining this care is more than met by the 
 improvement in the health and efficiency of their employees. This 
 seems to have been the experience of the mining companies generally, 
 so far as accidents are concerned, for most of them carry their own 
 compensation insurance and provide immediate and adequate care 
 for industrial accident cases. The health conditions, especially 
 among the families of these miners, would seenf to make imperative 
 some similar provision for sickness care. 
 
 (*) sickness Survey of Principal Cities in Pennsylvania and West Virginia, page" ,37, 
 
147 
 
 MEDICAL CARE IN ALMSHOUSES. 
 Figures supplied to the Commission by the Board of Public 
 Charities give a fair idea of facilities for medical care in seventy- 
 nine almshouses in the state. Thirty-two of these institutibns, or 40 
 per cent., contain no hospitals facilities whatever, and there are 
 such great differences between the so called "hospitals" in the others 
 that.it i» impossible to consider many of them adequate. Over half 
 the institutions have no hospital equipment or it is described as 
 "poor." Only twenty-five have nurses in iattendance, although 
 practically all have "matrons" and "attendants." In fifty-six cases, 
 a physician is said to be in charge, but as this is very often known to 
 be the County Doctor who qp^n be called, it is doubtful whether many 
 places have a resident physician. No records are available showing 
 the number of almshouse inmates who are ill during the year, the 
 number of visits made by the attending pTiysicians or the nature or 
 length of the illnesses. The fact that so little is known by the Board 
 of Public Charities, which has charge of the seventy-nine institutions, 
 about the type of medical care given, is evidence of its casual and 
 inadequate character. 
 
 EXISTING HEALTH INSURANCE IN PENNSYLVANIA. 
 The carriers of Health Insurance at the present time in Pennsyl- 
 vania may be roughly classified as commercial insurance companies, 
 trade unions, fraternal orders, and estaMishment funds covering 
 employees of individual establishments. 
 
 Commercial Insurance Companies Carrying Health Insurance. 
 
 In the absence of any social organization by the state, certain 
 commercial insurance companies have entered into competition with 
 Trade unions, fraternal orders, and establishment funds covering 
 sickness insurance for wage earners. The reports from these com- 
 panies are difficult to secure and do not classify their policy-holders 
 so that the number of employees among them can be ascertained. 
 The better paid, skilled employees may be able to pay for a fair 
 amount of accident and sickness insurance, but the rates are pro- 
 hibitive for the majority. It is only because the need for insurance 
 is so widely felt and protection against sickness so necessary, that 
 the business of these companies is growing. Most of them began 
 by offering accident insurance, 6ut the demand for sickness insur- 
 ance became so great that this was included. 
 
 In the latest report of the Pennsylvania State Insurance Depart- 
 ment, 1916, figures for sixteen Commercial insurance companies are 
 given. These companies paid during that year, 4,924 claims for acci- 
 dents and illnesses, amounting to $84,725.59.^ 
 
 (i)See Table IV at end of this section. 
 
148 
 
 The larger part of this, in all probability, went to employers and 
 professional men, rather than to the rank and file of employees; 
 
 To appreciate the slight extent to which cSmmercial insurance com- 
 panies have developed a health insurance business among the 
 employees of the state, a comparison may be made between the 
 |84jT25.58 paid out for 4,924 health insurance and accident claims 
 in 1916 by sixteen of these companies, with the business done by the 
 three principal companies doing an industrial life insurance business. 
 It will be found that the great majority of employees are insured 
 in this way for sums of from flOO.OO to $500.00, the premiums for 
 which are paid weekly to agents making door- to door collections. 
 In the Kensington Survey, 77.4 per cent. 0i the 3,198 persons covered 
 and 53.3 per cent, of the wage-earners, carried such insurance^ prac- 
 tically all with the commercial companies. The sickness survey 
 of Western Pennsylvania "was made among such industrial policy- 
 holders. This industrial life insurance is to guard against the 
 dreaded Potter's Field and to provide for decent "burial. 
 
 In 1916 these three companies, according to the annual report of 
 the State Department of Insurance, issued 5,640,000 policies. The 
 number of policies lapsing was nearly half as many, or 2^^70,000. 
 The total premiums paid these companies in 1916 amounted to 
 •1256,000,00. They paid out |7^,000,000 in claims and their 
 excess of income over expenditures was reported to be more than 
 .^7,000,000.00.^ 
 
 Of these 5,640,000 policies 669,998 were issued in Pennsylvania for 
 industrial life yisurance. Premiiims paid for these during the year 
 amounted to $22,526 043.05. More than twelve times as many poli- 
 cies were issued in the industrial branches as were issued in the 
 "ordinary branches," although the amount of policies in the "ordi- 
 nary branches" was 65 per cent, of the amount of the industrial 
 policies. The industrial policies which ceased to be in force during 
 1916 number over 400,000, leaving in foi"ce Dec. 31, 1916 in the indus- 
 trial branches of these three companies, 5,326,107 policies, amounting 
 to $678,956,915.00. More than 59,000 industrial policies had been 
 settled during the year, the settlements amounting to almost 
 $7,000,000.00.1 
 
 The $84,725.58' paid out by commercial companies for siclmess and 
 accident claims in Pennsylvania is small indeed in comparison with 
 these sums. It is frequently estimated 'by advocates of compulsory 
 health insurance that the average employee, for the same sum he 
 now pays for burial insurance, could receive, under a properly 
 oganized system of universal health insurance, adequate protection 
 against sickness as well as a modest funeral benefit. 
 
 The purpose of commercial insurance companies, from the stand- 
 point of the directors and stockholders, is profit, and the social pur- 
 
 (»)See Table V and VI St the end ol this section. 
 
149 
 
 pose is secondary. As a result there is much room for mismanage- 
 ment in writing sickness insurance and common complaints that the 
 contracts "are narrow, and the settlements uncertain. Many com- 
 panies insure only diseases which rarely occur and many of the most 
 common are excluded; or the technical clauses modifying the agree- 
 ment are so many that apparently more is promised than paid. 
 At any rate it is too often true of this type of carrier that the 
 insured fails to receive his benefit when he most needs.it. 
 
 Mr. H. who was a barber with a wife and five children between 
 five and fifteen years of age, feU ill with tuberculosis. During his 
 illness the family expenses were met by the irregular earnings of his 
 two oldest children, but it was also necessary to obtain some help 
 from a relief society. Mr.H. is not known to have received any 
 medical care at all. He was insured against sickness in a commer- 
 cial company, and was entitled to sick benefits of flO.OO a week for ' 
 six weeks, but the company claimed that Mr. H. had chronic bron- 
 chitis, and had been ill with it when he took out his policy, and they 
 refused to pay any benefits. 
 
 Abuses to which health insurance by commercial companies has 
 lent itself are indicated by the state law regulating such com- 
 panies.^ 
 
 The law expressly excludes "assessment associations," fraternal 
 societies and establishment funds which are non-commercial_. But 
 casualty companies insuring against sickness and accident are not 
 allowed to issue policies until thirty days after their rates are filed 
 with 'the Insurance Commissioner. All benefits payable and the dates 
 at which the policy comes into force and expires are to be named. 
 The minimum size of the printing is specified. All exceptions must 
 be printed with the same prominence as the benfits, and any pro- 
 visions for the reduction of benefits in certain cases, with greater 
 prominence. Ite practices which these clauses are intended to pre- 
 vent are cybvious. 
 
 Fraternals Carrying Health Insurance. 
 
 By far the largest class of health insurance carriers in the state 
 are the fraternals. Facts regarding health insurance carried by 
 fraternal orders have been compiled from the Report of the State 
 Department of Insurance,^ and from a study of sixty-eight of the 
 most prominent and representative fraternals operating in Pennsyl- 
 vania. Forty-three of these were maintaining sick benefit funds, 
 about which detailed information was secured. 
 
 Bach large fraternal order has a main or supreme law-making 
 body to which all its locals must apply when desirous of amending 
 a law. The local lodges are very independent, however, and are 
 usually left free to regulate the details of administration. • 
 
 "iiji^s^i^rto^^^^jisrcT'st Apx'i 6."- ill?, -ia'"^-«<''tdT^^«itA?t3i™^ *vf; 
 
 port to the State Insurance Commissioner ™a their funds "".^'^empted from State t^^^^^^ 
 
 does not apply to societies formed by churches or .co?'"™"""^ *» ^^^''1 ™'^JS^ 
 
 emplojS'ees can helong, or to the secret beneflcial societies not accepting the provisions of the act. 
 
150 
 
 There is marked similarity between these fraternal societies and 
 the friendly societies of Great Britain which operate under the 
 compulsory health insurance law established there in 1911, but unlike 
 these friendly societies the membership of the fratemals in this 
 country is not at all confined to the so-called working class. The 
 Catholic orders in all probability are composed in large measure of 
 wage earners, Ijut as a general rule with the exception of these and 
 certain of the foreign societies, unskilled and low paid working- 
 men do not constitute any large part of the membership; for the 
 most part the fratemals are made up of the skilled workmen and 
 professional groups. 
 
 There are two general types into which the fraternal orders are 
 divided — the social, or purely fraternal order, and the insurance 
 fraternal. In the former, small irregular sick benefit provisions are 
 made, largely by the local bodies, with slight minimum require- 
 ments from the main order. In the latter, more explicit regulations 
 for the sick benefit funds are enforced, but the sick benefit is a mat- 
 ter of secondary importance, for the real" offering of the insurance 
 fratemals is life insurance. 
 
 In all fratemals much "brotherly assistance" is rendered which 
 cannot be reported in statistical tables, or prescribed in the laws. 
 Much of this is done as a matter of charity. Some fratemals have 
 established old-age ^pensions, and it is not unusual to find that large 
 homes are maintained for the aged members and for orphaned' chil- 
 dren. 
 
 The fratemals are organized on a basis of nationality, religion, 
 '5r general fraternal rites. The fratemals of various nationalities, 
 Lithuanian, Ukranian, Slavonic, exist in large numbers in the min- 
 ing regions of the state, where the foreign element in the population 
 is large. 
 
 There are usually many membership qaualifications. As a usual 
 thing the members are restricted to an age group of from sixteen 
 to fifty years. Occasionally others are admitted as "honorary or 
 social" members, but are not eligible to the sick or death benefits. 
 In addition to the age restrictions, approximately half the fratemals 
 require a medical examination and a certificate signed by a physi- 
 cian ; in other cases the member himself swears that he is physically 
 sound, and not suffering from any chronic ailment. Many specific 
 diseases, varying with the requirements of the different fratemals, 
 exclude applicants from membership. In almost every case venereal 
 diseases, tuberculosis and any chronic trouble are excluded as well 
 as men working in occupations in which there are special health 
 hazards; consequently the group covered by such insurance as the 
 fiaternals oflfer is restricted to those who are comparatively 
 physically fit and -not subject to recognized occupational hazards, 
 
151 
 
 Weekly lodge dues are paid in most cases, although some few 
 orders have quarterly or, as was found in one instance, yearly dues. 
 These dues are generally divided into four parts — one portion goes 
 to the main body, one to the maintenance expenses of the local 
 lodge, one to the funeral benefit fund and one to the sick benefit 
 fund. In the case of these fratei"nals which have centralized sick 
 benefit funds, of which there are very few, the sick benefit tax is 
 paid by the local to the main body. 
 
 The eligibility to sick benefit depends first on the member's stand- 
 ing. If he is behind in his dues, he cannot receive his benefit. Sec- 
 ond, if he has not belonged to the fraternal a certain length of time, 
 he is. not eligible. The probation period is usually either six months 
 or a year. Third, his illness must be of sufficient length to cover 
 the waiting period, usually one or two weeks. In other words, no 
 benefit is paid until the man is sick two weeks, if the waiting period 
 is one week — or sick three weeks, if the waiting period is two weeks. 
 In only one case was it found that benefits were paid by the day; 
 other fraternals paid by the week, disregarding any fraction of a 
 week. In an order where the waiting period is seven days, and a 
 member is ill for but thirteen days, he receives nothing — if he is 
 ill for twenty-seven days he receives two weeks' benefits. 
 
 Only three of the fraternal orders studied had sick benefits which 
 were extended to the dependents of a lodge member. These were 
 medical, not cash benefits, and in two instances were for maternity 
 care only. Many fraternals give a funeral benefit on the death of a 
 member's wife, and the system of funeral benefits is much more com- 
 prehensive than any system of sick benefits. 
 
 The possible sick benefits are of two kinds— cash and medical. 
 Four-fifths of the lodges have cash benefits only. Three fraternals 
 had regular "lodge doctors" in every local. Others reported that 
 the matter of a physician rested entirely with the local bodies— in 
 one case 50 per cent, of these local bodies had their doctors,— in 
 another case 25 per cent.— and so on. The doctor is hired on a per 
 capita basis. He usually receives $1.00 a year per member, and is 
 then responsible for all illness except operations, maternity care, 
 and certain "serious diseases" which vary in the different fraternals. 
 In one instance an arrangement existed with a "lodge druggist" sim- 
 ilar to the arrangement with the lodge doctor. Several lodges paid 
 for nursing care upon occasion, but practically always as a matter 
 of charity. 
 
 The prevailing cash benefit is |5.00 a- week for thirteen weeks in 
 any given year, after a waiting period of one week. Some few fra- 
 ternals have a graded scale, and pay benefits after thirteen^weeks, 
 occasionally for the duration of the illness. Two fraternals reported 
 a scale of graded membership, according to the amount of sick 
 
i52 
 
 benefit desired, and the occupation of the member. The largest 
 weekly benefit was for $10.00. This was paid for only ten weeks in 
 one year, after a probation period of twelve months and a waiting 
 period of seven days. 
 
 Long waitiilg periods and special qualifications as to age and 
 physical ability are necessary in order to fix risks. One large fra- 
 ternal order in Pennsylvania has recently centralized its Sick Benefit 
 Fund in order to distribute more evenly the sickness burden. 
 Before this centralization the cost per member in the local lodges 
 varied from $5.88 to |.08 according to the ages and number of mem- 
 bers, and the general condition of the local. Now, with a centralized 
 system, a flat rate of |1.80 per year per member maintains the sick 
 benefit fund and allows a surplus in the treasury as a guard against 
 insolvency. In 1917, 938 members drew 4,613 weeks of skk benefits 
 from this fund. This was about six per cent, of the membership. 
 The average duration of sickness was five weeks, but 184 6t the 938 
 drew benefits for ten weeks, the maximum allowed in this fund. Of 
 the many sicknesses of under two weeks' or over ten weeks' duration, 
 we know nothing. 
 
 Isolating three of the sick benefit funds whose reports were fullest 
 and whose waiting period was one week, we find that 830 out of 5^857 
 members were ill during one year, or approximately one out of every 
 seven. The average length of the illness was five and, a half weeks. 
 
 So far as wage earners are concerned this type of health insurance 
 has several limitations. First, it reaches comparatively few in the 
 wage-earning group. Second, it is bound by many restrictive rules. 
 Third, the benefits are usually inadequate, and seldom include medi- 
 cal care. Fourth, the lack of centralization and the age differences 
 in the locals make the benefit funds often financially unsound. 
 
 Trade Union Funds Carrying Health Insurance. 
 
 Trade Union Sick Benefit Funds afford as a rule even less protec- 
 tion than the funds of the fraternals. In both types of insurance the 
 sick benefit is secondary to the death benefit. For the most part the 
 establishment of sick benefit funds is left entirely with the local 
 unions, although nineteen of the international unions are known to 
 have sick benefit systems. Based upon studies of union sick benefit 
 funds in five industrial centers, made in 1917 by the Bureau of Labor 
 Statistics of the United States Department of Labor, it would seem 
 that about one fourth of the local unions in existence have some 
 scheme for the payment of sick benefits. 
 
 Practically all trade union funds limit the eligibility to sick bene- 
 fits to pembers in good standing who have passed a probation period, 
 usually of six months, and whose disability is not due to intemper- 
 ance, dfebauchery, or other immoral conduct. 
 
153 
 
 As a rule, the i^umber of days of sickness which must elapse before 
 the payment of cash benefits, is seven. In six of the large inter- 
 national Unions it is fourteen. More than three-fourths of the funds 
 Studied ptovide a sick benefit of |5.00 a week, payable, in the majority 
 of cases, for thirteen weeks in a single year. The following table 
 shows the waiting period, the maximum benefit period, the amount 
 of the weekly benefit given, and the average annual number of days of 
 disability per member, in sixteen of the . international funds.^ 
 These regulations are typical of all the existing trade union funds. 
 
 
 
 
 Average An- 
 
 
 
 
 nual No. 
 
 
 MaxiiDum 
 
 Weekly 
 
 Disability 
 
 Waitinff Period— (days) . 
 
 Benefit 
 
 Benefit 
 
 Days Per 
 
 
 Period (days). 
 
 (in dollars). 
 
 Member 
 (all dis- 
 abilities) . 
 
 ^ 
 
 78 
 
 Jia 00 
 
 4.6 
 
 7 (2), 
 
 183 
 
 10 oo 
 
 4.6 
 
 7, _. 
 
 112 
 
 91 
 
 700 
 
 700 
 
 5 40* 
 
 6 GO 
 
 3.S 
 
 7, ' _ 
 
 m 
 
 
 m 
 
 7* 
 
 81 
 
 600 
 
 3.7 
 
 ^ 
 
 m. 
 
 5 OO 
 
 (8) 
 
 7, _ . 
 
 91 
 42 
 73 
 91 
 70 
 
 5 00 
 6.0O (♦) 
 5.0O 
 5 00 
 5 00 
 
 3.6 
 
 7, ._ .. .. 
 
 1.1 
 
 7, 
 
 (=) 
 
 14 __ 
 
 3.1 
 
 14, _ _- 
 
 2.0 
 
 
 118 
 
 5 OO 
 
 2.S 
 
 14 
 
 84 
 
 600 
 
 1.7 
 
 14, .__ 
 
 91 
 91 
 
 4 OO 
 30O 
 
 2.(r 
 
 14, . 
 
 (.') 
 
 
 
 (2) No waiting period in cases of disability due to accidents. 
 
 (*) No reeoM. 
 
 (*) Three dollars per week for female members. 
 
 *THis organization is now paying a weekly benefit of $7.60. 
 
 The average number of days of disability varied from 4.5 to 1.1, 
 and in the majority of cases was about three days. It must be 
 remembered in considering these figures that the group is a selected 
 one, and that only disabilities for which benefits were paid are 
 included. Of the many illnesses lasting less than the waiting period 
 or more than the maximum time for which benefits are paid, we know 
 nothing. 
 
 Very few of the funds furnish their disabled members with any 
 medical care or supplies. Occasionally a union like the International 
 Typographical Union, maintains a sanitorium for its sick members, 
 but in almost all cases the fund limits its benefits to small cash 
 payments. 
 
 ^Monthly Reriew, United States Bureau of Labor Stattsties, August, 1917, page 29. 
 
154 
 
 Establishment Funds Carrying Health Insurance. 
 
 The most complete protection seems to be that provided by some of 
 the funds maintained within individual factories or establishments. 
 These are of several kinds : 
 
 1. Funds financed and managed entirely by the employees. 
 
 2. Funds managed by the employees, \o which the employer 
 
 makes occasional gifts. 
 
 3. Funds financed jointly by employer and employees, and 
 
 managed jointly or controlled entirely by the employer. 
 4.' Funds financed wholly by the employer. 
 
 In the last two types membership in the fund is frequently a com- 
 pulsory condition of employment. — 
 
 It has been impossible to make a thorough study of all establish- 
 ment funds in the state, but the experience of five representative 
 funds in Philadelphia for a period of from three to five years was 
 sxamined, and figures covering twenty Pennsylvania funds were 
 taken from the Establishment Fund Study made by the United Stal;es 
 Bureau of Labor Statistics. According to this Bureau, among the 
 t)71 establishments in the state employing more than 100 persons 
 each, there were in December, 1916, seventy-two establishment funds. 
 
 The dues in these funds usually range between ten cents and a 
 dollar per week, some funds having several membership classes in 
 which both dues and benefits are graded according to the wage 
 received. In many cases the employer's contribution takes the form 
 of paying the cost of administration, including necessary salaries. 
 In about one-half the funds studied by the Bureau of Labor Statistics, 
 the employers made contributions toward maintenance, but in two- 
 thirds of the cases, this contribution was less than 50 per cent, of the 
 cost. 
 
 The "period before eligibility to benefits" is non-existent in some 
 funds, but in others may be as long as three or four months, in order 
 to exclude the casual employee and the malingerer. These long 
 periods are often prescribed even in funds where membership is com- 
 pulsory. 
 
 Benefits begin after waiting periods of from three days to a week, 
 and usually consist only of cash benefits amounting to from |3.00 to 
 fl5.00 per week and payable for from five to thirteen weeks in each 
 year. Some funds pay benefits at reduced rates from the end 
 of the regular benefit period, during a longer specified period or as 
 long as the illness lasts. Seventeen of the twenty Pennsylvania funds 
 in the Bureau of Labor Statistics Study had the seven day waiting 
 period, which predominated among all the funds. Only three of the 
 Pennsylvania funds, or 15 per cent., and about 20 per cent, of all the 
 funds, supplied medical treatment. In all but some five per cent, of 
 the funds throughout the Country, moreover, medical care as reported 
 
155 
 
 was confined to minor surgical operations, supplies and a single visit 
 from the physician. The average weekly cash benefit paid by the 
 Pennsylvania funds was |8.32. Death benefits of from $75.00 to 
 1500.00 are usually paid. 
 
 This type of insurance, as would naturally be expected, is most 
 often found in the larger, more progressive establishments, especially 
 the railroads, telephone companies, department stores and steel mills. 
 One large group of workers, the miners, seem to be almost entirely 
 untouched by it, only one company having been found to be main- 
 taining such a fund, and one other company having taken out a 
 group policy with a commercial company. 
 
 The members of the employee's family are rarely if ever included in 
 such a fund, although occasionally medical and nursing care are sup- 
 I)lied to them at reduced rates. 
 
 In comparison with trade union, fraternal, and commercial health 
 insurance, the establishment fund gives more adequate and certain 
 cash benefits and is more simple in fidministration. Its weakness is 
 its usual lack of provision for medical care and its common restriction 
 to employees in the better managed establishments. 
 
 Results of the surveys show conclusively the limitations of existing 
 health insurance facilities. 
 
 A study of the existing insurance shows that it is carried mainly 
 by the wage-earners of the family, that insurance in fraternals is 
 most popular, and that most of it provides only a small weekly cash 
 benefit, medical treatment being seldom supplied. 
 
 The tendency to insure only wage-earners is illustrated by the fact 
 that in western Pennsylvania and West Virginia, while 40.6 per cent, 
 of the iron and steel employees and about 30 per cent, of the anthra- 
 cite and bituminous miners were insured, only 17 per cent, of the 
 bituminous miners' families were insured and 12 per cent, of the 
 anthracite miners' families. 
 
 In the Kensington Survey, while 34 per cent, of the wage-earners 
 were insured against "sickness and death," only 17.4 per cent, of the 
 total number of persons covered were protected in that way. Twelve 
 dependents, as against ninety-two wage-earners, carried sickness 
 insurance in the 893 Sickness and Dependency families. 
 
 An analysis of the benefits provided by health insurance in the 
 Sickness and Dependency Study shows that a cash benefit of $5.00, 
 16.00 or $7.00 a week was the usual return. The maximum period 
 during which benefits were payable was between six and thirteen, and 
 between thirteen and twenty-six weeks a year, in about an equal num- 
 ber of cases. Although the importance of adequate medical care in 
 shortening the period of illness and improving health is universally 
 recognized, medical benefits were pro^'ided bj oiily a fifth of the 
 
156 
 
 policies. Except one establishment fund, which gave sanitarium 
 treatment when needed, this took the form, in all cases, of medical 
 treatment by the factory or "lodge" doctpr. 
 
 The cost of insurance in this study was known in only thirty-one 
 families. Although this number is too small for definite conclusions, 
 it may "be mentioned that in fifteen cases it was between ten and 
 twenty-five cents a week, in nine, between twenty-five and fifty cents, 
 and in five, between fifty and seventy-five cents. It would seem that 
 by their unaided voluntary efforts, Pennsylvania employees are not 
 at present able to purchase health insurance having adequate braiefits. 
 
 Another serious limitation of health insurance as it exists in Penn- 
 sylvania today is found in the restrictive rules of many benefit 
 societies, which often prevent the receipt of benefits in time of need. 
 It is noteworthy that in the Sickness and Dependency Study, 
 although some form of health insurance was carried in 101 families, 
 only sixty-nine were in actual receipt of benefits. One woman was 
 even refused benefits, though unable to work, because she went to the 
 hospital to have her tubercular glands dressed, and was therefore 
 "not confined to the house." Other and more legitimate reasons for 
 refusal were arrears of dues, the initial waiting-period, and the 
 alleged existence of the disease at the time of joining the society. 
 
 Mr. B., a structural iron worker whose wage was f 5.00 a day but 
 whose work was irregular, was ill and out of work for four months 
 on account of sciatica-. The family soon exhausted their own 
 resources. They then received help from a national society and from 
 a relief agency, which secured free hospital care for Mr. B. and aided 
 in the support of the family. Mr. B. belonged to a fraternal sick 
 benefit society, to which he paid flO.OO a year, but he could obtain 
 no benefits as he'had fallen somewhat behind in dues. 
 
 In the study of the 110 Mothers' Assistance Fund Families, 
 although there were thirty-two policies calling for health insurance 
 during the father's illness, the benefits had been paid in but twenty 
 cases. Because the others were behind in their dues, or had excluded 
 diseases, or had violated some rule of the insurance organization, 
 benefits had been refused. 
 
 Extent of Health Insurance in Pennsylvania. 
 
 Sickness surveys show that while a. coiunderaMe minority of wage- 
 earners have already turned to health insurance as a means of pro- 
 tection from, the effects of sickness, it has developed least mnong 
 those who need it m-ost. They show also that existing health insur- 
 ance pays hut small benefits and is limited in usefulness hy the many 
 restrictive rules which have heen discussed. 
 
 The percentage of persons protected by some form of health insur- 
 ance was considerably higher in the Kensington and the Western 
 Pennsylvania Survey^ than in the other Surveys. 
 
157 
 
 In Western Pennsylvania and West Virginia, 30.7 per cent, of the 
 males fifteen years of age and over were in receipt of some form of 
 sick benefits.^ In Pittsburgh the figure was 29.4 per cent. How- 
 ever benefits paid under the Workmen's Compensation law as well as 
 under voluntary health insurance are included in these figures. 
 Since disability from accident was very prevalent among the Western 
 Penjisylvania workmen, to find the real extent of health insurance a 
 considerable deduction from these figures should in all probability 
 be made. In the Kensington district of Philadelphia, however, no 
 less than 34.9 per cent, of all the wage-earners covered carried some 
 form of insurance against sickness. 
 
 In the study of Mothers' Assistance Fund' Families 29 per cent, of 
 the fathers carried some form of health insurance, in the Visiting 
 Nurse Study, 18 per cent, of the families had this protection ; in the 
 Working Women's Study but 12 per cent, of the women carried 
 health insurance. 
 
 In contrast to the extent of insurance among ordinary groups of 
 employees, is the fact that of the 893 Philadelphia families in the 
 Sickness and Dependency Study, of which an extensive study was 
 made in the previous section, only. 11 per cent, carried health insur- 
 ance of any kind ; only ninety-two of the wage-earners were insured, 
 while by no means all of the persons insured actually received insur- 
 ance benefits. Among the 418 charity illness cases studied by the 
 Bureau of Social Research, insurance was found in only 19 per cent. 
 ~of the 300 about which the fact was ascertained. Moreover, health 
 insurance was least often carried by the wage-earners having low 
 incomes, who are most likely to need additional resources in time of 
 illness. While the numbers involved are small, so that conclusions 
 should be guarded, the difference is striking. In thirty-seven families 
 with incomes of over |15.00 a week, insurance was carried in eleven, 
 or 30 per cent. In 179 receiving less than |15.00 a week, insurance 
 was carried in only twenty-two or 12 per cent. It has been pointed 
 out in discussing sickness as a factor in destitution, that the majority 
 of these families, containing a high proportion of young children and 
 fewer wage-earners than the average, are living through the time 
 when the strain on family expenses is heaviest and the fewest 
 resou^s exist. In view of this fact and the small percentage of 
 insurance among the low wage group, it can rightly be said that 
 imder present voluntary methods, those who most need liealth insur- 
 ance are least likely to carry it. 
 
 The predominance of lodge and fraternal societies as the carriers 
 of health insurance among employees was clear in each study. In 
 Western Pennsylvania 52 per cent, of the^ insurance was of that 
 variety, in Pittsburgh alone, 53 per cent, and in the Kensington Sur- 
 
 (I) statistics for Westers Pennsylvania' alon? are not given. 
 
158 
 
 vey no less than 73 per cent. Sixty-seven of the 103 policies found in 
 the 893 dependent families were with fraternals, and thirty-nine of 
 fifty-four policies in the families studied by the Bureau of Social 
 Research. In the study of working women forty out of forty-eight 
 policies were with fraternals, and in the Mothers' Assistance Fund 
 Study over 50 per cent, were held in these lodges. Doctors and 
 employers in the mining districts reported that from 50 to 90 per 
 cent, of the miners were carrying fraternal* health insurance. 
 Besides this type of carrier the number of trade union funds and 
 other carriers found, is insignificant. 
 
 Taking the figures found in the Western Pennsylvania Survey as 
 the most representative for the state as a whole, we find that of the 
 685 cases in receipt of sick benefits, 365, or 52 per cent., were being paid 
 by fraternal societies or lodges. Establishment funds, or employers 
 directly, were paying sick benefits in 11.4 per cent, of the cases; 
 commercial insurance companies in 8.0 per cent, and trade unions in 
 8.6 per cent. Miscellaneous groups of other agencies, including 
 Workmen's Compensation, provided for 20.5 per cent, of the total 
 number of persons in receipt of any kind of benefit.^ 
 
 It can 1)6 concluded that not more than 30 per cent, of the wage 
 earners carry any insurance protection against the sickness risk; 
 that more than half the insurance carried is of the fraternal type; 
 that trade union funds, commercial insurance com,panies, establish- 
 ment funds and miscellaneous agencies account for the remaining 
 half ; that the insurance is carried by the better-paid and more highhi 
 skilled workmen, is seldom extended to dependents, and rarely affords 
 either medical card or adequate cash benefits. 
 
 (MTable — at end cf section contrasts types of benefit received in tlie various surveys. 
 
TABLE I. 
 
169 
 
 Part II, Section III, Table II. 
 HOSPITAL BED ACCOMODATION. 
 
 County. 
 
 Beds in Public Hospitaix. 
 
 General. 
 
 Special. 
 
 Total. 
 
 Beds Per 
 
 1,000 
 
 Population. 
 
 «r. 
 
 Adams, 
 
 Allegheny, 
 
 Armstrong, 
 
 Beaver, 
 
 Bedford, 
 
 Berks, 
 
 Blair, — - 
 
 Bradlord, 
 
 Bucks, 
 
 Butler, 
 
 Cambria, 
 
 Carbon, 
 
 Cameron, 
 
 Centre, 
 
 Oliester, 
 
 Clarion, 
 
 Clinton, 
 
 Columbia, 
 
 Crawford, 
 
 Cumberland, — 
 
 Dauphin, 
 
 Delaware, 
 
 Elk, 
 
 Erie 
 
 Fayette, 
 
 Forest, 
 
 Franklin, 
 
 Fulton, — ' 
 
 (rreene, 
 
 Huntingdon^ — 
 
 Indiana, 
 
 Jefferson — 
 
 Juniata, 
 
 Lackawanna , 
 
 Lancaster, 
 
 Lawrence, 
 
 Lebanon, 
 
 Lehigh, 
 
 Luzerne, 
 
 Lycoming, 
 
 McEean, 
 
 Mercer, 
 
 Mifflin, 
 
 Montgomery, 
 
 Montour, 
 
 Monroe, 
 
 Northampton, — 
 Northumberland , 
 
 Perry, 
 
 Philadelphia , 
 
 Pike, 
 
 Potter, 
 
 Schuylkill, 
 
 Snyder, 
 
 Somerset, 
 
 Sullivan, 
 
 Susquehanna, — 
 
 Tioga, 
 
 Union, 
 
 Venango, 
 
 Warren, 
 
 Washington, — 
 
 Wayne, 
 
 Westmoreland, . 
 
 Wyoming, 
 
 York, 
 
 Olearfleld, 
 
 Total, 
 
 24 
 171 
 
 
 360 
 34$ 
 155 
 
 
 55 
 S57 
 
 
 
 
 
 
 80 
 110 
 185 
 
 40 
 
 440 
 
 188 
 
 
 
 eo 
 
 
 20 
 BZ 
 50 
 110 
 
 453 
 710 
 143 
 lOO 
 
 214 
 
 179 
 
 79 
 
 44 
 
 261 
 
 75 
 
 30 
 
 215 
 
 112 
 
 
 
 (,857 
 
 
 
 41 
 
 363 
 
 
 
 40 
 
 
 
 19 
 
 45 
 
 
 
 ■ 90 
 
 171 
 
 228 
 
 
 
 195 
 
 b 
 
 124 
 
 120 
 
 20,118 
 
 
 
 1,199 
 
 
 
 141 
 
 
 910 
 
 
 
 
 
 419 
 
 
 
 
 820 
 
 
 
 
 
 1,486 
 
 760 
 
 
 
 87 
 
 
 
 
 
 1,040 
 
 
 
 
 
 
 
 
 
 
 
 
 
 OS 
 
 
 
 
 
 
 
 1,000 
 
 33 
 
 
 
 sr 
 
 
 
 2,73(/ 
 1,450 
 
 
 
 
 2,80B 
 
 
 
 
 
 
 
 
 
 
 
 600 
 
 
 
 
 
 18,449 
 
 
 
 6,058 
 
 24 
 
 W! 
 
 
 
 i,»ro 
 
 345 
 
 155 
 
 65 
 
 er6 
 
 
 
 
 
 88 
 
 1,105 
 
 
 
 80 
 
 110 
 
 IftS 
 
 49 
 
 l,69r 
 
 1,OCO 
 
 40 
 
 627 
 
 188 
 
 
 
 1,100 
 
 • 
 
 20 
 
 52 
 
 50 
 
 110 
 
 
 
 621 
 
 710 
 
 143 
 
 lOO 
 
 1,227 
 
 W2 
 
 214 
 
 216 
 
 79 
 
 44 
 
 2,991 
 
 1,625 
 
 30 
 
 215 
 
 112 
 
 
 
 9,669 
 
 
 
 41 
 
 363 
 
 
 
 40 
 
 
 
 19 
 
 45 
 
 
 
 1,7^ 
 
 1,458 
 
 228 
 
 600 
 
 195 
 
 
 
 124 
 
 120 
 
 38,584 
 
 .0 
 5.9 
 
 .0 
 1.9 
 3.1 
 2.8 
 
 .0 
 
 .75 
 4.6 (1.7) 
 
 .0 
 
 .0 
 2.0 
 2.6 
 
 .0 
 2.6 
 2.2 
 2.0 
 
 .90 
 4.8 (1.2) 
 2.1 
 1.1 
 4.5 
 l.I 
 
 J> 
 18.3 (1.0) 
 
 .0 
 
 .69 
 1.3 
 
 .75 
 1.7 
 
 .0 
 2.07 
 4.2 
 2.0 
 1.6 
 1.0 
 1.9 
 
 z.a 
 
 4.5 
 1.0 
 1.6 
 1.6 
 5.04 
 1.3 
 1.7 
 1.0 
 
 
 6.2 
 
 .0 
 1.3 
 1.7 
 
 .0 
 
 .69 
 
 .0 
 
 .60 
 1.05 
 
 .0 
 1.7 
 4.3 
 1.6 
 
 .0 
 
 .84 
 
 .0 
 
 .91 
 1.2 
 
 3.4 
 
 "Special" and "Total" include State insane hospitals I°a»°f hospitals are not included In 
 "number beds per 1,000 population." Figures in parenthesis indicate number of beds per 1,000 
 excllisive of State tuberculosis sanatoria. ^ . ^ ^ ^ x i~ 
 
 ft°we consider the population of Pennsylvania in 1918 as 8,991,176 number of beds taken 
 from 1917-18 directories! we may consider the present number per 1,000 population as S.9. 
 Total Hospital beds not including Insane,' 28,721. 
 
 11 - 
 
160 
 
 i'art 
 
 II. — Section III. — Table III. — Kinds of Medical Care Received in Sickness 
 Cases Covered by Various Pennsylvania Surveys.^ 
 
 Kinds ol Treatment. 
 
 Western 
 Pennsyl- 
 vania 
 Survey. 2 
 
 Pittsburgh 
 Sickness 
 Survey. 
 
 Philadelphia 
 Survey. 
 
 Kensington 
 Survey. 
 
 Sickness 
 
 and 
 
 Dependency 
 
 Study. 
 
 
 
 
 93 
 
 48 
 154 
 
 28 
 116 
 
 ers 
 
 85 
 58 
 15 
 
 
 
 1,389 
 
 452 
 
 24 
 
 
 23 
 
 89 
 
 236 
 
 22 
 
 48 
 
 
 Home treatment 
 
 
 
 
 Private physician, _ 
 
 3,445 
 
 629 
 
 59 
 
 292 
 
 1,208 
 
 200 
 
 9 
 
 94 
 
 337 
 
 Hospital or sanitarium, 
 
 435 
 421 
 
 Nurses (visiting) 
 
 87 
 
 Midwife 
 
 3 
 
 13 
 
 Dentist 
 
 
 
 180 
 
 9 
 
 11 
 
 15 
 
 
 District doctor. 
 
 
 
 
 119 
 
 Lodge doctor, 
 
 
 
 
 12 
 
 
 
 
 
 71 
 
 
 
 
 
 9 
 
 Drug store, doctor, 
 
 
 
 
 18 
 
 
 Factory doctor, 
 
 
 
 
 13 
 
 
 
 
 
 
 
 Part I'l. — Section III. — Table IV-A. — Number and Amount of Sickness Claims Paid 
 by Fraternal and Commercial Insurance Companies Supervised by the State 
 Insurance Department, 1916. 
 
 ASSESSMENT SICK BENEFIT AND ACCIDENT ASSOCIATIONS OF 
 OTHER STATES OPERATING IN PENNSYLVANIA. 
 
 Name of Company. 
 
 Claims 
 
 Paid, 
 
 1916. 
 
 Amounts. 
 
 
 121 
 151 
 729 
 153 
 
 12 
 
 246 
 
 3 
 
 8 
 
 184 
 
 2,447 
 
 1.51 
 
 93 
 
 76 
 143 
 337 
 
 70 
 
 $1,388 C9 
 2,825 47 
 
 27,000 62 
 
 3,069 71 
 
 164 32 
 
 3,715 20 
 
 10,500 OO 
 
 351 85 
 
 5,040 69 
 
 15,813 02 
 3,079 46 
 522 OO 
 1,219 77 
 2,366 00 
 6,734 23 
 1,548 18 
 
 Detroit Casualty Co., - 
 
 Fraternal Protectve Association, Inc., 
 
 Fidelity Health and Accident Insurance Co., _ 
 
 
 Hoosier Casualty Co., 
 
 Inter-state Business Men's Accident Association, __ 
 
 Massachusetts Indemnity Co., 
 
 Masonic Mutual Accident Co., 
 
 National Benefit Association, 
 
 National Accident Society, 
 
 Royal Mutual Aid Beneficial Association, — : 
 
 St. Lawrence Life Association, _ . 
 
 United States Indemnity Society, 
 
 Union Casualty Co., —. . 
 
 Wisconsin Casualty Association, 
 
 
 
 4,924 
 
 $84,725 59 
 
 1 In some cases, more than one kind of medical care. was received. 
 ' White persons only. 
 
161 
 
 PART II.— SECTION III.— TABLE IV-B. 
 
 FRATERNAL, BENEFICIAL AND RELIEF SOCIETIES OF 
 
 PENNSYLVANIA. 
 
 Name of Oompany. 
 
 Olaima 
 Paid, 
 1916. 
 
 Amounts. 
 
 American Oheckweiglit and Voluntary Relief Association, — 
 
 Btst Hungarian Reformed Sielc Benefit Society, 
 
 Fraternal Mystic Oirel«"(Sul)r'eme' Ruling)-, ;_ ^^- 
 
 Serman Roman Catholic Knights of St. George, 
 
 Independent- Order of Puritans, 
 
 Litljuanian Alliance of America, 
 
 Lithuanian Roman Catholic Alliance of America, ^.__ 
 
 Kational Croatian Society of the United States of America, 
 
 SlfflTonie Eyangelical Union of America, ,- 
 
 Verhovay Aid Association, 
 
 208 
 3,182 
 107 
 408 
 136 
 10« 
 20 
 266 
 
 
 4,416 
 
 548 GO 
 756 00 
 489 52 
 633 60 
 096 70 
 919 11 
 ,660 60 
 ,688 00 
 451 96 
 ,242 OO 
 
 5119,665 29 
 
 PART II.— SECTION III.— TABLE IV-C. 
 SECRET FRATERNAL BENEFICIAL SOCIETIES 
 
 Name of Company. 
 
 .Educator,'!' Beneficial Association, 
 
 Tort Pitt Mutual Life Insurance Co., 
 
 Gterman Beneficial Union, 
 
 The Bralnd Fraternity, ^ 
 
 Snild of the East, 
 
 i The Home Beneficial Society, 
 
 Keystone Fraternal Union, -. 
 
 National Fraternal League, 
 
 National Home Guard, 
 
 • Bbyal Fellowship, 
 
 Security Industrial Life and Benefit Association, 
 
 ■ Standard Protective Society, 
 
 'Teachers' Protectire Union, 
 
 daima 
 Paid, 
 1916. 
 
 177 
 81 
 
 524 
 
 2,644 
 
 Amounts. 
 
 5653 31 
 
 9,658 OO 
 
 3,228 78 
 
 1,839 63 
 
 151 OO 
 
 1,010 33 
 
 4,964 70 
 
 4,617 81 
 
 37 OO 
 
 6i780 00 
 
 47 40 
 
 33,331 94 
 
 $63,319 SO 
 
162 
 
 PART II.— SECTION III.— TABLE IV-D. 
 
 FRATERNAL, BENEFICIAL AND RELIEF SOCIETIES OF OTHER 
 
 STATES OPERATING IN PENNSYLVANIA. 
 
 Name of Company. 
 
 Claims 
 Paid, 
 191S. 
 
 Amounts. 
 
 Aid Association for Lutherans, 
 
 Americau Insurance Union, 
 
 The American Workmen, 
 
 BeneTOlent Order of Egyptians; 
 
 Brotherhood of American Yeomen, 
 
 Brotherhood of All Railway Employees 
 
 Catholic Fraternal League, 
 
 Catholic Belief and Beneficiary Association, 
 
 The Columbian Circle, L 
 
 Columbia Fraternal Association, 
 
 Court of Honor, 
 
 Fraternal Benefit League, 
 
 Fraternal Brotherhood (Supreme Lodge), 
 German Baptists Life Association, 
 
 Grand Camiolian Slavonian Catholic Union of U. S. A. 
 
 Independent Order of Foresters, 
 
 Independent Workmen's Circle of America, 
 
 Jewish National Worker's Alliance of America, 
 
 Loyal Mystic Legion of America, 
 
 The Maccabees, 
 
 Modem Brotherhood of America, 
 Modem Order of Praetorians, — 
 
 National Benevolent Society, 
 
 National Pralsrnal Society of the Deaf, 
 
 National Protective Union, 
 
 North American Union, 
 
 Order of the Golden Seal, 
 
 Order of United Commercial Travelers of America, 
 The Patricians, 
 
 Royal Fraternal Association, 
 
 Slovenic National Benefit Society, _.. 
 Slovenic Progressive Benefit Society, 
 
 South Slovenic Catholic Union, 
 
 ■ United Artisans, 
 
 Woman's Benefit Association of the Maccabees, 
 
 Workmen's Sick and Death Benefit Fund of U. S. A. 
 
 Workmen's Circle, 
 
 Travelers' Protective Association of America, 
 
 United Insurance Society, 
 
 6 
 
 110 
 
 (Not given 
 
 forPenna.) 
 
 56 
 
 3 
 
 i6 
 
 5 
 
 75 
 
 IS 
 
 55 
 
 447 
 
 (Not given 
 
 forPenna.) 
 
 12 
 
 (Not given 
 forPenna.) 
 1 
 •157 
 833 
 80 
 2 
 
 (Not given 
 forPenna.) 
 (Not given 
 forPenna.) 
 (Not given 
 forPtnna.) 
 5 
 13 
 510 
 (Not given 
 forPenna.) 
 399 
 123 
 (Not given 
 forPenna.) 
 (Not given 
 forPenna.) 
 1,769 
 
 (Not given 
 forPenna.) 
 2 
 1,577 
 617 
 206 
 9 
 
 $231 00 
 2,500 12 
 
 iM8 25 
 
 54 70 
 
 1,221 21 
 
 236 00 
 
 2,316 CO 
 
 7,6S1 16 
 
 653 DO 
 
 12,116 38 
 
 420 33 
 
 60 00 
 
 *3,441 31 
 
 15,188 60 
 
 1,048 00 
 
 20O 00 
 
 81 10 
 
 185 00 
 
 15,233 66 
 
 8,3Sr 41 
 8,635 43 
 
 39,837 GO 
 11,705 30 
 13,443 62 
 
 60 00 
 
 46,324 76 
 
 14,196 DO 
 
 15,544 58 
 
 ISO 00 
 
 7,990 
 
 $221,996 80 
 
 Name ol Company. 
 
 Claims 
 Paid, 
 IMS. 
 
 Amounts. 
 
 Assessment sick benefit and accident associations of other states (16), 
 Fraternal, beneficial and relief societies of Penna (10), 
 
 4,984 
 4,416 
 8,544 
 7,990 
 
 $84,725 59 
 119 665 29 
 
 Secret fraternal beneficial societies (13), 
 
 Fraternal, beneficial and relief societies of other states (40)t, 
 
 66,319 80 
 221,996 80 
 
 79 societies, t Totals, 
 
 19,874 
 
 $492,707 48 
 
 
 •Sickness and funeral claims In a lump sum. 
 tPigures for 80 only. 
 tFIgures for 89 only. 
 
163 
 
 PART II.— SECTION III.— TABLE V. 
 CERTAIN STATISTICS OF PRINCIPAL COMMERCIAL INSURANCE COM- 
 PANIES CARRYING INDUSTRIAL LIFE INSURANCE, 1916. 
 
 Name ol Oompany 
 
 John Hancock 
 
 Metropolitan 
 
 Prudential 
 
 Total 
 
 Ho. of policies issued. 
 
 No. ol policies lapsed, 
 
 -Premiums— flrst year, 
 
 Premiums— renewals, 
 
 Total premiums, 
 
 Claims paid. 
 
 Excess of income over expenditure. 
 
 562,873 
 
 261,i)46 
 
 2,198,195.80 
 
 28,649,018.40 
 
 30,847,214.20 
 
 9,981,707.91 
 
 13,358,729.72 
 
 2,ei6,062 
 
 1,059,903 
 
 10,685,770.89 
 
 114,675,546.83 
 
 125,261,317.72 
 
 39,058,657.99 
 
 64,108,518.53 
 
 2,574,587 
 1,149,373 
 6,429,697.59 
 93,660,493.90 
 99,990,191.40 
 29,739,979.40 
 42,247,637.81 
 
 6,643,472 
 2,470,822 
 19,213,664.28 
 236.886,069.13 
 266,098.723.41 
 78,780,345.30 
 119^714.886.06 
 
164 
 
 El 
 
 O 
 
 ^ 
 
 ■< 
 
 tf 
 
 P 
 
 m 
 
 •^ 
 
 M 
 
 
 M ^^ 
 
 
 OJ 
 
 
 p 
 
 <JO 
 
 
 ^rt 
 
 a2p 
 
 ^0 
 
 
 
 S^ 
 
 
 121 
 
 ?^ 
 
 12;^ 
 
 VI. 
 OAEEYI 
 
 PENNSY 
 
 <D 
 
 ?M^ 
 
 ^s" 
 
 n III, 
 
 MP AN 
 STATE 
 
 o o 
 
 ■43 OE 
 
 -M^ 
 
 ^^Nb 
 
 Hi2;§ 
 
 M<l]l-I 
 
 «rtp 
 
 S!-)@ 
 
 ^^c^ 
 
 M<^ 
 
 
 
 PS&h 
 
 
 
 '-'m 
 
 
 „o 
 
 02 S. 
 
 WO 
 
 ^H 
 
 l<</.^ 
 
 &^ 
 
 m 
 
 % 
 
 \- 
 
 < 
 
 E- 
 
 M 
 
 W 
 
 O 
 
 
 a 
 
 3 
 
 a 
 
 a 
 
 
 I 
 
 S 88i 
 
 s si 
 
 8 is^ 
 
 to Iftt- 
 
 ■* Sir- 
 
 88 
 
 
 88 
 
 IS 
 
 sfe 
 
 CO lA 
 
 8 88 
 
 
 
 6m 
 
 
 ©3 MOj 
 
 C4 coco 
 
 eg MiH 
 
 oco 
 
 cot- 
 
 S" 
 
 g 8 
 
 8S 
 
 s s? 
 
 ss 
 si 
 
 inco 
 
 88 
 
 8 8 
 
 
 g gs 
 
 
 88 
 
 feS 
 
 1.-00 
 
 
 l>00 
 inc- 
 t-CJ 
 
 88 
 
 
 
 aa a 
 ■oSrt 
 
 " a S 
 
 -".a§ 
 .aofl 
 
 •a 
 11 
 
 o 
 
 p. 
 
 o 
 
 
 ■" t t-.S 
 
 .X3 
 
 2 2 9 
 » Om 
 
 <W r] 03 
 
 .a^w 
 
 CJ M S 
 
 :q Bl+3 
 
 si" 
 
 ■a'H'S 
 aoS 
 
 Ai 
 
165 
 
 PART II.— SECTION III.— TABLE VII. 
 Kinds of Health Insurance Carried, According. to Pennsylvania Sickness Surveys. 
 
 Kinds of Insurance. 
 
 Pennsyl- 
 
 Filttsliurcli 
 
 Kensington 
 
 Sickness 
 
 Bureau for 
 
 vania. (1) 
 
 m 
 
 Survey. 
 
 and Depend- 
 ency, t 
 
 Social 
 Beseaicli. 
 
 i 
 
 
 i 
 
 
 i 
 
 
 S 
 
 
 S 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 o 
 
 
 o 
 
 
 
 
 
 
 
 a 
 
 
 
 
 
 
 G 
 
 *a 
 
 
 
 ■w 
 
 
 H-l 
 
 
 <H 
 
 g 
 
 «M 
 
 i 
 
 <*-) 
 
 nH 
 
 
 « 
 
 o 
 
 C3 
 
 o 
 
 o 
 
 
 
 w 
 
 O 
 
 a 
 
 o 
 
 a 
 
 o 
 
 v. 
 
 o» 
 
 fe 
 
 o 
 
 ss 
 
 K 
 
 Oh 
 
 K 
 
 tk 
 
 K 
 
 h 
 
 ^ 
 
 fi< 
 
 ^ 
 
 Ph 
 
 Lodges and fraternal i 
 
 eietles, 
 
 Trade unioils, 
 
 Establislwnent funds, -. 
 Commercial companies, 
 Other, 
 
 Total, 
 
 356 
 59 
 78 
 55 
 
 137 
 
 62.0 
 8.6 
 
 n.4 
 
 8.0 
 20.0 
 
 116 
 23 
 37 
 27 
 16 
 
 53.0 
 10.5 
 16.9* 
 12.3 
 7.3 
 
 452 
 50 
 96 
 18 
 
 73.3 
 8.2 
 
 15.8 
 2.9 
 
 67 
 9 
 
 14 
 8 
 
 ••5 
 
 65.0 
 8.7 
 - 13.6 
 7.8 
 4.8 
 
 39 
 
 5 
 10 
 
 *«* 
 
 
 
 
 
 
 
 
 
 685 
 
 lOO.O 
 
 219 
 
 100.0 
 
 616 
 
 lOO.O 
 
 103 
 
 100.0 
 
 54 
 
 
 
 •Including all forms of assistance from employers. 
 **Klnd unknown. 
 •••Numbers too small to compute percentage. 
 
 tFigures for Bhiladelphia. 
 '(i)Plgures for males, fifteen years and over. 
 
(166) 
 
PART II. 
 SECTION IV. 
 
 Influence of Working Conditions on Health. 
 
 (167) 
 
(168) 
 
169 
 
 INFLUENCE pF WORKING CONDITIONS ON HEALTH. 
 Dr. Alice Hamilton, of the United States Bureau of Labor Sta- 
 tistics, has written for the Commission a report on the principal 
 Pennsylvania industries in which abnormal hazards to health are 
 present. The value of this work from so authoritative a source can 
 hardly be over-emphasized, especially^ as existing material on local 
 conditions is very scant, and time and money for first-hand investi- 
 gations are lacking. 
 
 In addition to this study, which deals with the relation between 
 specific industrial processes and certain definitely recognized occu- 
 pational diseases, other facts have toeen collected which show the 
 influence that conditions of occupation may and often do have 
 upon the general health of the workers. Aside from the dangers 
 presented by industrial poisons, there are innumerable other factors 
 connected often with the place of employment and the methods of 
 work, but not necessarily inherent in the industrial process, — among 
 them, ventilation, sanitation, temperature, posture, illumination, 
 fatigue — over which the employee has little if any control, but which 
 affect him in- varying degrees, according to the nature of his occu- 
 pation and the surroundings in which he works and lives. "The 
 wage-earner sells to his employer, not merely so much muscular 
 energy, or mechanical ingenuity, but practically his whole existence 
 during the working day. An overcrowded or badly ventilated work- 
 shop may exhaust his energies, sewer gas or poisonous material may 
 undermine his health, a badly constructed plant or imperfect machin- 
 ery may maim him or even cut short his days ; coarsening surround- 
 ings may brutalize his life and degrade his character; yet, when he 
 accepts employment, he tacitly uncfertakes to mind whatever machin- 
 ery, use whatever materials, breathe whatever atmosphere, and endure 
 whatever sights, sounds and smells, he may find in the employer's 
 workshop, however inimical they may be to health and safety."^ 
 
 "Aside from family ways of living and toad places to live in, there 
 are many conditions of labor which reduce the health and weaken 
 the resistance of the individual, making him susceptible to infection 
 and making him and liis descendents less likely and able to bring 
 into the world and rear liealthy, robust children. The true signifi- 
 cance of many bad conditions of labor relates to the demoraliza- 
 tion of the health, morals and social status of the individual and to 
 home conditions from inadequate wages."^ 
 
 The effects of many such harmful conditions of employment are 
 not generally appreciated or understood. In the absence of any sud- 
 den or spectacular illness, the slow development of premature old 
 age. blindness, rheumatism, and degenerative diseases of the lungs. 
 
 Report of Commissioner of Heslth of Penna., 1914, page 147. 
 
170 , . 
 
 heart and kidneys may proceed without the attempt being made to 
 seek their cause in the factory or workshop. In Pennsylvania, in 
 1916, of 58,703 deaths of persons of working age, between 20 and 70 
 years, 46,714, or 79.5 per cent., were from causes which, according 
 to Dr. iEmery R. Hayhurst of the Ohio State Board of Health, "would 
 not bear scrutiny as either timely or justifiable," and which in his 
 study of Industrial Health Hazards in Ohio he considers to a certain 
 extent indicative of the effects of occupation. 
 
 PENNSYLVANIA, 1916, DEATHS FROM CERTAIN CAUSES OF PERSONS 
 BETWEEN 20 AND 70 YEARS OP AGE. 
 
 Cause ol Deaths. 
 
 Number 
 
 of 
 Deaths. 
 
 Tetanus, 
 
 Tuberculosis (total), 
 
 Cancer, 
 
 Bheumatism, -_- - 
 
 Anemia, -"_ 
 
 Alcoholism , : 
 
 Nervous diseases, 
 
 Organic heart disease 
 
 other circulatory diseases, 
 
 Lung diseases (other than tuberculosis) , 
 
 Bright's disease, 
 
 Skin diseases, 
 
 External causes, 
 
 55 
 
 8,641 
 
 4,791 
 
 277 
 
 359 
 
 485 
 
 5,480 
 
 6,899 
 
 1,933 
 
 5,536 
 
 5,285 
 
 172 
 
 6,801 
 
 One-sixth of these deaths were due to diseases of the circulatory 
 system, and one-eighth to organic heart disease alone. All diseases 
 of the circulatory system, and particularly organic heart disease, are 
 in the majority of cases preventable and worthy of investigation as 
 to cause when found in persons below seventy years of age; and yet 
 nearly one-third the total number of persons who died from these 
 two causes in the state in 1916 were between twenty and fifty, and 
 more than 60 per cent, of them were under seventy years of age. 
 Moreover, the increase in the state death rate from all causes 
 between 1913 and 1916 was only 4.5 per cent., as ^compared with 
 an increase of 10.5 per cent, from organic heart disease. This dis- 
 ease is known to have a high rate among lead, iron and steel, tobacco 
 and leather workers, of whom Pennsylvania has a very large number. 
 
 Both because of their own injurious effects and because of the 
 encouragement which they afford to the growth of definite occupa- 
 tional diseases, a few of the more common health hazards in industry 
 are being made the subject of investigation and attack by health 
 departments and sanitarians. One of these is the problem of eye- 
 strain, due to inadequate illumination, overworTs or faulty posture. 
 
 "I know of no one factor that affects the earning capacity of the 
 laboring classes to such an extent as eye-strain. '"^ 
 
 {^)Dr, B. B. Alger, In an address before the Second National Conference on Industrial diseases. 
 Atlantic City, June, 1912. 
 
171 
 
 "The importance of adequate lighting in industrial establishments 
 is obvious, as a matter of fact, especially where dangerous processes 
 are carried on, as bearing on health in many ways, directly or indi- 
 rectly, and as a condition of efficient work. On the health side, it 
 is hardly necessary to point out that inefficient illumination entails 
 risk, strain and ultimate danger to the sight, even apart from inter- 
 ference with work, that it tends to the neglect of cleanliness and 
 adds to the risk of working in poisonous materials. 
 
 "Prom the standpoint of health, faulty illumination soon exerts 
 damaging effects upon vision, by reason of varying intensities of 
 Ijght which produce sharp contrasts, glares and shadows." 
 
 "Sewing, engraving and printing, textile work, and watch-making 
 frequently induce excessive strain to eyes. Objects close by are seen 
 only by muscular effort. The constant effort to maintain distinct 
 vision causes fatigue of the muscles, spasm of the ciliary muscle and 
 deficient convergence, from which result headache, defective vision, 
 nervous exhaustion and various neuroses. Eventually, under these 
 deleterious influences, the eye passes into -a condition of myopia or 
 chronic nearsightedness, which is a distant occupational disease due 
 to eyestrain. This disease runs a progressive course, the vision grad- 
 ually fails, the eye is exceedingly prone to acquire all kinds of inflam- 
 mations, and total blindness often results."^ 
 
 InJlustrial fatigue is another danger which has been especially 
 noticeable in the war industries of Pennsylvania. After two years 
 experience with "speeding-up" devices and over-time work, the 
 British Home Office issued in August 1916 a report on an investi- 
 gation of industrial fatigue by ' physiological methods. The investi- 
 gation covered two factories, one making surgical. dressings and the 
 other an engineering works, and concludes : 
 
 "Overtime invariably produces the lowest output, and this may 
 be traced to fatigue. When once an individual has through labor 
 during ordinary hours, reached a certain degree of fatigue, and pro- 
 ceeds to further labor (overtime) without taking the repose nec- 
 essary to dissipate the fatigue already produced, this further labor 
 has a greater physiological effect and exhausts the organism more 
 than would a similar amount of labor performed when fatigue was 
 absent. This is a well-known fact in physiology ; it is also a matter 
 of ordinary experience. It is of importance in the present connection 
 because it indicates that overtime labor is more harmful to the 
 worker than labor performed during ordinary hours. It is therefore 
 physiologically extravagant." 
 
 "Overtime," however, is not the only cause of industrial fatigue 
 which is so commonly observed, especially among boot and shoe, 
 textile, cannery, iron and steel, tobacco and laundry workers, and 
 
 ~nmoiithIy Bulletin. Pennsylranla Department of Labor and Industry, November, 1916, pages 5-6. 
 
172 
 
 which is the result of laborious work, long hours, piece-work, speed- 
 ing up, monotony, constant standing, constant strain, chairs or stools 
 without backs, faulty postyres, jarring processes, pressing or holding 
 objects against the body, eyestrain, loud noises, irregular hours for 
 sleep, and the absence of work variation or periods of relaxation 
 and recreation, which, in the case of women workers, means also 
 rest rooms. Such fatigue not only reduces efficiency; but opens the 
 way for the development of many chronic, degenerative diseases, 
 especially among women, and increases the hazard of industrial 
 accidents. '^Fatigue delays work, diminishes output, spoils goods, 
 causes accidents and sickness, keei)s workers at home, and in a,ll 
 these ways is an obstacle to efficiency. How fatigue can 'be kept 
 down to its lowest reasonable limit, how the Avorking power of the 
 individual can be maintained from day to day and from week to 
 week and be made to yield a maximum output without detriment Lo 
 itself and to others — constitutes one of the great industrial problems 
 of theday."(/) 
 
 The smoke-laden atmosphere in which thousand of employees not 
 only work but live is believed also to have a serious effect upon their 
 health. The Mellon Institute of Industrial Eesearch of the Univer- 
 sity of Pittsburgh, as the result of extensive research in the Pitts- 
 burgh district, states: 
 
 "It does not seem an exaggeration to say that more persons are 
 devitalized, disabled and poisoned by the impurities contained in 
 smoke-polluted air, than toy the noxious ingredients in food and 
 water. Not only do the solid and" vaporous ingredients of smoke- 
 begrimed air, the noxious compounds of carbon, sulphur, nitrogen, 
 chlorine, and arsenic — irritate the sensitive membranes of the eyes, 
 nose, throat and lungs, and thus aggravate or cause inflammatory 
 diseases of these organs or produce collapse of their sensitive tis- 
 sues, or increase their susceptibility to such specific diseases as 
 bronchitis, pneumonia and subacute forms of phthisis; but the 
 poisonous compounds also enter the gastro-intestinal tract and this 
 causes nausea, vomiting, diarrhea and systemic poisoning. 
 
 "In Pittsburgh a recent investigation by Dr. W. C. White shows 
 that pneumonia increases with the density of population or of 
 poverty. In late years pneumonia has assumed a -very acute and 
 fatal form in Pittsburgh."- 
 
 Faulty posture and strain due to improperly arranged chairs, 
 stools or machinery may be responsible for serious physical harm 
 to the worker. The Journal of the American Medical Association 
 contains an account of how Dr. Latta, of the Pennsylvania Kailroad 
 Relief Association found that a surprisingly large number of loco- 
 
 (MUnitea States Public Health Reports, Volume 33, No. 2, January 11, 3918, page 30. 
 (2) "Psychological Aspect of the Problem of Atmcspherlc Smoke Pollution" — J. B. Wallace Wallin, 
 Ph. D., Director of Psychological Clinic, University of Pittsburgh. 
 
173 
 
 motive engineers were suffering from sciatica of the right leg, due to 
 sitting on their benches sidewise, with the weight of the body resting 
 on the right hip, while subjected to constant jolting. When the ends 
 of the bendhes were cut off to enable the men to sit squarely while 
 fncing forward, further cases ceased to develop.^ A telephone 
 . Company in Philadelphia had constant trouble with back-ache among 
 its switchboard operators until it was discovered that by changing 
 the form of the switchboards the injuriously long reaches could be 
 eliminated. Sedentary workers and all those whose work involves 
 repetition and close application are particularly exposed to this - 
 hazard. 
 
 Specific dangers to the health of a large group of women workers 
 were brought out in an investigation made during the summer of 
 1.918 by the Women's Committee of the Council of National Defense 
 and covering 100 factories and other establishments employing about 
 9,000 women in Pittsburgh. Five hotels and four cigar factories 
 were included in the survey, which covered also a large number of 
 plants engaged in the manufacture of war materials. Women were 
 employed at a wide variety of operations, including office work, 
 elevator operating, riveting, inspecting, assembling, operating power- 
 machines, press feeding, wire stitching, etc. The wages paid for the 
 different operations were, recorded in 144 instances, and over 70 per 
 cent, of them were between $5.00 and |15.00 per week. While this 
 cannot be taken as an exact indication of the proportion of employees 
 to be found in this wage group, the number of women employed at 
 the more skilled and more highly paid types of work did not exceed 
 one-fourth the total number. In only two instances was a wage of 
 125.00 per week or more mentioned and to thirty-three different 
 groups of women less than $10.00 per week was paid. 
 
 In addition to data on the general sanitation of the establishments 
 visited, special facts were obtained for the Commission on the facili- 
 ties for the protection of the health of the workers, the equipment 
 for the treatment of the sick, and the extent to which sick benefit 
 or establishment funds were being maintained. More than one- third 
 of the places of employment were found to be deficient in ventilation, 
 light or general cleanliness, more than half of them had inadequate 
 toilet facilities, and over two-thirds had no rest rooms. Only twelve 
 "establishirents had hospitals or infirmaries, thirty-five had first-aid 
 equipment only, and thirty-seven had made no provision for medical 
 care whatever. 
 
 Conditions in hot-els, printing establishments and cigar factories 
 were particularly bad, and in twenty-three cases the investigator 
 advised against placing women with the concerns visted. In one 
 large machine shop, women were required to repeatedly lift weights 
 of forty or fifty pounds. Tweiity-five pounds is set as the maximum 
 
 (i)"The Occupational Diseases," W. G. Thompson, M. D., page 548. 
 
174 
 
 weight which women should be required to repeatedly lift, by the 
 Women in Industry Section of the United States Department of 
 Labor. In another plant, a foreman testified that "the labor turn- 
 over was 100 per cent. Men and women were sick all the time, due 
 to overwork and strain. Much of the work that was not heavy was 
 continuous, affording no chance to rest fatigued or untrained 
 muscles." In one hotel, the chamber maids were constantly ill with 
 strained and aching backs because too few girls were employed to 
 care for the rooms. The housekeeper in this place had been dismissed 
 just prior to the investigator's visit, because she complained of 
 immoral conditions. Dangers to morals were mentioned in every 
 hotel and restaurant visited. In a number of establishments the 
 work was described as sufflciently noisy to have an effect on hear- 
 ing. In one factory it was the practice of the women to lick the 
 labels placed on large numbers of products every day. In an egg- 
 candling plant, the work was done entirely in a damp, dark cellar, 
 and the manager stated that men employed at this kind of work 
 almost invariably drink heavily. 
 
 Few of the dangers to health mentioned in this study were inherent 
 
 in the nature of the work to be performed. Most of them could be 
 
 attributed to a lack of knowledge of health principles on the part 
 
 -of the employer, or of realization that the health of his employees 
 
 bore a significant relation to his own success. 
 
 Several investigations made by the Pennsylvania Department of 
 Labor and Industry reveal health-hazards due to conditions of work 
 which do no.t seem necessary to the carrying on of the particular 
 processes involved. 
 
 During the summer of 1918 the Division of Industrial Hygiene 
 and Engineering made a study of the seven factories in the State, 
 engaged in making felt hats.^ The chief health-dangers found 
 there were the presence of nitrate of mercury particles and fumes 
 in the air of the carroting rooms ; particles of fur and dust constantly 
 flying about where fur was being sorted and cleaned ; and steam and 
 vapor in the sizing and dyeing rooms. All of these factors are dan- 
 gerous in varying degrees to the health of the exposed workers, and 
 could be corrected, in the opinion of the inspectors, by installing 
 proper methods of ventilation, sweeping and cleaning. In several 
 cases the floors were described as "filthy," and in some instances 
 lack of drainage was responsible for several inches of water in 
 which the men were obliged to stand while at work. "These health 
 hazards are not myths * • • several of eur largest insurance 
 companies refuse to insure fur cutters, makers, starters and sizers 
 at any premium, and workers in other departments are charged an 
 o^tra heavy premium on ordinary policies."^ 
 
 (^)Thp TopiiUa of this study were made available to the Commission by Dr. Francis D. Patter- 
 son. Chief of the Division. ; 
 
 f2) "Sanitary Rtanda'ds for the Felt Hatting Industry," Special Beport by New Jersey Depart- 
 ment of Labor, 1915, page 45. 
 
176 
 
 The principal investigation of health in relation to employment 
 made by the Departmeiit in recent years deals with two groups of 
 tobacco workers. Those employed in this industry in the state in 
 1914 numbered 37,000, and included a large proportion of women. 
 In both groups studied certain physical defects due to occupation 
 were found; The first investigation made in 1914 covered 111 fac- 
 tories and over 33,000 employees in Philadelphia, Pittsbugh and else- 
 where. 
 
 In most of the factories dirt, tobacco dust and poor ventilation 
 were noticed. Many employees were under-nourished, pale and stoop- 
 shouldered. Dirty and decayed teeth were frequent. At least a 
 part of the "tendency to ill health" was ascribed to the custom of 
 "biting out" the ends of the cigars and licking the wrappers. But 
 the most serious menace to health appeared to be the dust and waste 
 which covered the floors and was stirred by "every movement of the 
 workers." This was ibelieved to be the source of the excessive death 
 rate from tuberculosis found in the trade. Comparatively few chil- 
 dren under sixteen were found, but these were in bad condition, pale, 
 stooped and overtired. The investigators felt that these younger 
 employees were most susceptible to the adverse conditions na^ed, 
 and that the employment of all persons under sixteen should be 
 forbidden. 
 
 The second investigation, made in 1917 in cooperation with the 
 University of Pennsylvania Clinic, covered a smaller number of 
 workers, ninety-eight males and 302 females in seven factories, but 
 gave somewhat more exact information on the relation between the 
 occupation and the diseased conditions found. Congestion of the 
 pharynx and of the lining of the eyelid were abnormally frequent, 
 and were held to be "at least in some measure due to the dust and 
 fumes of the tobacco." The wearing away of the teeth noticed was 
 caused by "biting out". the ends of the cigars, the gritty material 
 acting like emery dust on the teeth. Other disabilities resulting 
 from the occupation were a large amount of constipation, caused by 
 lack of exercise and faulty posture while at work, and many head- 
 aches which were accounted for by eye-strain among the packers and 
 by poor ventilation in other departments. 
 
 The most complete evidence as to health conditions among iron 
 and steel workers is contained in a study made in 1908 by Mr. John 
 A. Fitch, who after ten months of intensive investigation in the 
 Pittsburgh district, felt that the industry contained hazards to 
 health. These included dust,.. great noise, nervous strain, extreme 
 heat, and the twelve-hour day., A fine diist is always present in the 
 air of a steel-mill, wWb .steel. workers declare gives rise to throat 
 troubles Due to the noise of the mills, a slight deafness is common 
 among the em|)loyces,^ Tlie noise^ the vibration of the machinery, 
 
176 
 
 tremendous physical strain in some cases, and in others great respon- 
 sibility for dangerous machinery combined to make excessive demands 
 on nervous energy. The extreme heat in which many men were 
 obliged to work was also considered a special health hazard, while 
 the twelve-hour day, Mr. Fitch believed, intensified all the other 
 hazards and xmade the men "chronically tired." 
 
 It is worthy of note that the standard American text on industrial 
 hygiene^ devotes a chapter, to the iron and steel industrj among 
 the "occupations involving exposure to conditions injurious to 
 health." Sir Thomas Oliver, the English authority on industrial 
 hygiene, reports that English iron and steel workers, though the 
 eight-hour day is much more common there than in the United 
 States, have a death-rate 37 per cent, above the standard for occu- 
 pied males. 
 
 COA.L MINING IN PENNSYLVANIA. 
 
 Pennsylvania produces practically all the anthracite and by far 
 the largest portion of the bituminous coal mined in the United States 
 and employs one-third the coal miners of the country. The number 
 of employees in and about the mines in 1916 was 333,473 and the 
 total coal produced amounted to 256,804,012 tons. Because of the 
 tremendous part which coal mining plays in the industrial life of the 
 state, it was decided to devote special attention to its effect on 
 health. 
 
 Health hazards involved in coal mining are briefly discussed in 
 Dr. Hamilton's study, special emphasis being laid on the high-death 
 rate among miners from non-tuberculous diseases of the lungs, flj^s 
 fact is confirmed by the results of the Western Pennsylvania Survey, 
 which, besides finding that the total sickness rate among miners 
 was eight per cent, higher than the general rate for white adult 
 males, states that "It is probable that the true rate for miners' 
 asthma involving disability for work is not less than 400 per 100,000 
 exposed among anthracite and not less than 175 per 100,000 among 
 bituminous miners. These figures for anthracite and for bituminous 
 miners measure within certain limits of error, the incidence of 
 anthracosis among the coal miners in the two groups, asthma being 
 the most prominent symptom, to the lay mind at least, of that con- 
 dition."^ 
 
 Special permission was obtained from Dr. Emery E. Hayhurst, 
 of the Ohio State Board of Health to quote from a study of health 
 dangers among coal miners in Illinois which he made for the 
 Illinois Health Insurance Commission during the summer of 1918. 
 Extracts from this report follow, and show to a certain extent condi- 
 tions in Pennsylvania coal mines": 
 
 (')Kober and Hanson's "Diseases of OccuDation and Vocational Hygiene." 
 (=)Sicline8S Survey of Principal Cities In Pennsylvania and West Virginia, page 53. 
 
177 
 
 THE CONDITIONS UNDER WHICH MINERS WORK. 
 
 "Coal Seams. — For convenience, coal seams, in mining parlance, 
 are numbered upward from No. 1, or that at the lowest level (and 
 therefore the earliest geologically) to that which constitutes the most 
 recent deposit. Hence many seams are present in most districts, 
 superimposed one above the other, often with hundreds of feet of 
 rock strata separating them; but, because of upheavals, glacial ac- 
 tion, erosions, etc., even the deepest seam, No. 1, may lie at the sur- 
 face (or indeed be-'in the sky' — when there is, therefore, no coal to 
 be found in that place). From a health point of view the particular 
 seam has some significance as to whether (1) it is 'low coal,' thereby 
 necessitating a great deal of^ kneeling at work; (2) whether it con- 
 tains much sulphur and other impurities, especially tending to 'dust ;' 
 (3) whether the strata next above and below the coal are dust pro- 
 ducting, and (4) whether mine gases are apt to be encountered. The 
 same seam in different localities often varies, however, in these 
 factors. In but a few instances in the state is more than one seam 
 worked at a single mine. Working two seams means working at two 
 or more levels, unless seams are very close together. 
 
 "The work of the miner has gradually changed, -through the in- 
 troduction of machines and the use of powder, from that of pick 
 work on the solid face of coal to that of breaking up large chunks 
 of coal and loading them into the mine cars. Hence,, workers 'at 
 the face' have come to be called 'miners,' 'machine men,' 'loaders,' 
 'shot-firers,' etc., according to the nature of their duties. This is 
 important to note since it means that many of the afflictions prev- 
 iously attributed to 'miners' have become relatively scarce or are no 
 longer existent because of these changes in work methods. 
 
 "Blasting Substances. — Throughout the entire mining field, with 
 the exception of long-wall mining, black powder is the explosive 
 , used. 
 
 "The time of use of blasting substances may constitute a serious 
 menace to the health of coal miners. The principal point is whether 
 'shooting' is done during work hours so that the powder fumes and 
 smoke are present during work hours. 
 
 "Mine Gases. — The gases encountered in coal mines are of three 
 types— 'natural' gas or methane, black damp or carbon dioxide, and 
 white damp or carbon monoxide. Very exceptionally, hydrogen sul- 
 phide may be detected from old timbers, gob pile refuse and animal 
 deposits. 
 
 "Of these three gases the one which the miner fears the most is 
 methane (marsh gas, CHA) because it is so easily exploded when 
 lights come in contact with it. Methane gas is practically half the 
 weight of air and hence tends to accumulate about the roof. It is 
 especially to be feared in dry mines and in the vicinity of faults in 
 the coal seam. Certain coal strata or seams are well known to be 
 associated with it. For our purpose, however, it may be dismissed 
 as it has a very limited, if any, influence upon health, at least in the 
 amounts to which it accumulates in mines. It is the most common 
 gas encountered in mines and is called 'natural gas' because it oc- 
 curs naturally, i. e., comes out of the coal and rock strata. It is 
 identified by the miner with his naked (carbide) lamp, which it 
 causes to flame up brighter than usual and perhaps to pop in mm- 
 
ITS 
 
 ature explosions (the lighting of small pockets of gas). When seek- 
 ing for minute traces of it the miner holds his lamp along the pockets 
 in the roof. It has neither odor nor any sensible effect upon the 
 liuman being. 
 
 "Black damp, or carbon dioxide, does not occur naturally in mines 
 as a rule. There are some evidences that carbonaceous rock may 
 disintegrate to an extent great enough to produce the gas, par- 
 ticularly if it is associated with sulphurous waters. In old mines, 
 as in any deep pits, it accumulates because of the lack of ventilation 
 and the tendency of this heavy gas to seek low levels. In poorly 
 ventilated mines it accumulates to an extent to be noticeable upon 
 the respiration, and more especially in the case of certain individuals 
 suffering from acidosis from any cause (heart, kidney, or arterial 
 diseases in particular). This gas is nearly half again the weigM 
 of air and accumulates, at first, along the floor of entryways and 
 rooms. Its usual origin in mines is from old workings which have 
 been shut off from the general ventilation scheme of the mine but 
 in which the battices or stoppings are leaky and the gas comes up 
 through the nooks and crevices of its own pressure. It is also espe- 
 cially to be feared in the case of mine fires, because the regular 
 ventilation does not remove the products of combustion fast enough 
 It is the typical asphyxiating gas and usually gives plenty^ of warning 
 that it is accumujating, in the way of increased breathing, easy 
 fatigue, headache and a heightened or dusky color of the face. It 
 affects the miner's lamps, "causing them to smoke and the flame to 
 become rather bluish. It readily affects bird life, so that the canary 
 is sometimes used in its detection. Should anything happen to the 
 ventilating fan or other ventilation apparatus, it. accumulates 
 rapidly in the mine, and necessitates withdrawal of the miners at 
 once. When necessary to enter strata of this gas, helmets with 
 oxygen tanks are used. 
 
 "White damp, or carbon monoxide, is of very rare occurrence in 
 mines and is always an accidental aJft'air. It occurs principally from 
 incomplete combustion of powder explosions, when it may pervade 
 a considerable area of the mine before it is thinned out by the forced 
 ventilation. It also occurs in the case of fires, through incomplete 
 combustion, and may leak into workings from fires which are sealed 
 off in sections of the mine. Carbon monoxide is a gas slightly lighter 
 than the air and, therefore, tends to accumulate in the upper half 
 of the stratum of air, although it is quite evenly distributed if there 
 is much moving to and fro, or agitation of the air by mine car 
 trains. It is called 'white damp' apparently for two reasons : One, 
 because it causes the flame of the miner's lamp to burn up more 
 brightly, and secondly, because it is usually associated with a flue 
 vapor, the remnants perhaps of powder smoke; In mines where 
 shooting is done in work hours it often produces its characteristic 
 symptoms which the miners call the 'thumps,' due to the type of 
 headache experienced. Cases of acute poisonings leading to death 
 rarely occur among miners. It is probable that chronic or low grade 
 poisonings are frequent where shooting is allowed during work 
 hours. 
 
 "The hygienist has but to witness the operation of gasoline motors 
 in a mine either at the bottom of the hoisting shaft or in the main 
 entries, to become suspicious of their effects upon the mine air. 
 
179 
 
 particularly at the bottom where a certain small percentage of 
 miners must work all day. Motors running overly rich and discharg- 
 ing smoke and very perceptible' gasoline exhaust fumes, were wit- 
 nessed. There was no reason to be surprised at complaints of 
 miners in regard to these features. It is probably but a question of 
 time before all gasoline motors will be done away with in the few 
 mines in which they are now found. The question of investment 
 seems to be the chief reason for their continuance at the present 
 time. The liklihood of carbon monoxide and other exhaust fumes, 
 which in degrees of poisoning may amount to anything from the 
 sudden acute cases to the slow cltronic effects, are the chief dangers. 
 Furthermore, smoke from defective motors is often so pronounced 
 as to obstruct vision and noise is so loud, in the absence of mufiSers, 
 as to interfere with signals and perhaps cause some permanent inter- 
 ference with hearing from the reverberations which take place in the 
 entryways. In the mines where they are used, the hoisting shaft 
 constitutes the 'upcast' for the air current. Hence these motor fumes 
 do not affect the workers at the face but they travel with the air 
 current from the face to the foot of the hoisting shaft, always in- 
 creasing in concentration, also in velocity of movement. Hence the 
 workers who run the cars on and ofE the cages are the ones chiefly 
 affected by the fumes. 
 
 "Temperature. — The temperature of a coal mine is quite constant 
 throughout all seasons of the year, usually varying not more than 
 ten degrees after proceeding a few hundred feet from the foot of a 
 shaft. Even at, the foot of the downcast the air brought in on a 
 hot day is generally reduced in temperature through its passage 
 down the wet and dripping shaft. After the air has traveled a few 
 hundred feet it has gained, the 'temperature of the mine,' which it 
 holds more or less constantly until it is returned to the upcast and 
 out. Within the mine a number of factors tend to increase the 
 temperature somewhat, such as the heat coming from the miners' 
 bodies, from the animals, from the motor cars, from shooting, from 
 the decomposition of timbers, etc. 
 
 "The temperature of mines vary, however, according to their 
 depth. As a rule shallow mines are the coolest, due to the fact that 
 they are usually wet mines, which, in turn, is due to their proximity 
 to the ground waters which leak into them'. In Illinois such mines 
 run from fifty to sixty degrees in temperature. Mines which are 
 from 300 to 600 feet deep have temperatures ranging from sixty to 
 seventy degrees. Mines from 600 to 1,000 feet deep have tempera- 
 tures which range from seventy to eighty degrees. Men working in 
 the deeper mines often strip to the waist because of the effects of 
 this higher temperature. , 
 
 "Miners, therefore, as a group work under more admirable temper- 
 ature conditions than practically any other class of workmen. In 
 the hot seasons of the year they have a temperature which is cool, 
 exhilarating and energizing ^and admirably adapted for the heavy 
 work involved. In the frigid seasons their quarters are relatively 
 nice and warm. When air-circulation is also satisfactory, ventila- 
 tion conditions approach the ideal, except for one element, dust. 
 
 "Humidity.— The amount^ of water vapor in the air of cool mines 
 varies directly according to the wet or dry condition of the mine. 
 About the shafts it is probably near the point of saturation. Since 
 
180 
 
 evaporation is excessive at these points, however, the temperature 
 is kept low and the total condition is therefore good for the type of 
 active work performed. Within the interior of dry mines the 
 dehydrating properties of the dry coal and coal dust are such as to 
 render the air excessively dry. Dry air, itself, is irritating to the 
 skin and mucous membranes and when combined with dust is apt 
 to become much more so. This latter will depend upon whether 
 activity is great enough to produce plenty of perspiration and 
 secretion. 
 
 "Dust. — Because of the darkness and the lack of reflecting sur- 
 faces, one is easily misled as to the quanitity of dust in the working 
 atmosphere of a coal mine. In fact, one, at first, has the impression 
 that there is very little. But, except where the coal dust is wet 
 when mined, and this is very rarely the case, dust is present in larg^ 
 amounts, particularly in the work rooms, and about mining machines 
 and also in the entries where rapidly moving mine trains keep it 
 in the air. Naturally, in damp and dripping mines dust will be 
 much reduced, but such conditions are usually limited to the pas- 
 sage ways rather than to the work rooms. Where mines are char- 
 acterized by the dry type of workroom, the chief defect in the work- 
 ing atmosphere is not a chemical one (of the amount of oxygen and 
 carbon dioxide, or one of temperature extremes) but is this purely 
 physical one of an excessive amount of dust particles. 
 
 "Where the rock, clay or earthy matter which occurs in connec- 
 tion with mining coal does not pulverize, it is of little health 
 significance. Where, however, it tends to dust, its harmful char- 
 acteristics are to be regarded as in proportion to its hardness or 
 gritty character. For instance, sandstone and fiint dusts are con- 
 sidered much more harmful than clay or soapstone dusts. Where 
 irritating sulphur dusts occur with any frequency, this is to be con- 
 sidered, probably, the worst dust. Of the dangerous dusts in con- 
 nection with coal mining, their harmful nature may be stated in 
 descending order as follows: coal, clay, soapstone, shale, slate, sand- 
 stone, granite and sulphur. 
 
 "Absenteeism. — Absences from all causes were at ten per cent, each 
 day throughout the coal fields as a whole, with this percentage about 
 doubled for a day or two following paydays, which occurred twice 
 per month. 
 
 "An inquiry, at the mines as to how much of the absenteeism was 
 due to sickness failed to reveal any definite information. The usual 
 replies were that 'there is no way of finding out;' 'they just want a 
 day off;' 'most of the absences are due to drunkenness;' 'no records 
 are kept nor has a practical way been devised for keeping such.' 
 Certain large corporations were, however, beginning a study of this 
 subject. 
 
 SUMMARY OF HEALTH HAZARDS, IN MINES. 
 
 "For the principal operations in mines, the following may be given 
 as a summary of the chief health hazards: 
 
 "Cagers. — These men push the cars on and off the hoising shaft. 
 They are doing active work. Those at the bottom are in a strong 
 draft of moving air, since the hoisting shaft is usually the upcast for 
 the air leaving the mine. Hence the entire mine air which is col- 
 lected by the return entries constitutes their working and breathing 
 atmosphere. It contains a certain amount of fine dust, practically 
 
181 
 
 ijnperceptible to the naked eye, which is the result of the activities 
 within. Where the air contains smoke or gasoline motor fumes, these 
 workers are especially concerned. Their work is laborious but, for 
 selected men, not overly hazardous. They usually have little time 
 for sitting around, so that the cool, damp, rapidly moving air should 
 be no hazard. Those men who work in the tipples at the top of the 
 hoisting shaft are usually within buildings partially protected from 
 the weather and high up in the air, where, however, the air within 
 is loaded with coal dust or whatever dirt is brought out of the mine. 
 A considerable number of laborers are employed about the foot of 
 the hoisting shaft and the tipple, where they have the same hazards 
 as just described. 
 
 "Drivers. — Using this term to include motormen, trip-riders and 
 mule-drivers, we And here processes concerned with more or less 
 rapid transit through entryways, usually in strong drafts, and a 
 considerable amount of dust produced from the coal carried and 
 from the surroundings where these are not moist or wet. In addi- 
 tion, long rides seated on cars constitute a hazard for many. Con- 
 sequently, the effects of cool, damp drafts have opportunity to be 
 considerable. Boys or youths usually make up this class. 
 
 "Laborers. — Laborers are scattered about morej)r less all over 
 the mine, depending upon the type of mine and the character of 
 work. Their hazards are the same as those of the workers in whose 
 vicinities they are, except that they are more apt to be changing 
 from place to place; consequently, health hazards are less in dura- 
 tion, although more in number. 
 
 "Loaders.^Loaders work in the rooms, torealdng up the coal and 
 loading it into mine cars after machines and shootings have dis- 
 lodged it from the face. They are subject to the total dust hazards 
 of the mine, principally coal dust. Also, to the full extent of any 
 bad ventilation or accumulation of black damp which may occur. 
 Their work is laborious, all piece-work type and rather monotonous. 
 They, however, have the advantage of considerable change in posture. 
 When work is slack, or empty cars do not come frequently enough 
 they are apt to sit around in cool damp places and thus expose them- 
 selves. 
 
 "Machine Men. — Probably the dustiest job in the mine is that 
 carried on by the machine men. One of them is employed most 
 of the time in shoveling back the fine dust (bug dust) created by the 
 machine which is undercutting the coal seam and, many times, 
 scouring the clay bottom or other substances beneath the seam. The 
 shoveler works with his face about two feet from the dust heap and 
 liis exposure is inordinate. However, the other men in and about 
 machines have but little less exposure, since the air of the work space 
 is heavy with dust. Machine men are usually big, powerfully built in- 
 dividuals. About every ten to twenty minutes they are concerned in 
 moving the machine along, which is very laborious and straining 
 work. As with all men at the face, they have the same atmospheric 
 hazards so far as ventilation is concerned. 
 
 "Miners. — In old days coal was mined directly off the face by pick, 
 s]edge, wedge and drill. With the introduction of powder, much of 
 this slow, hard work disappeared. Miners are employed where ma- 
 chines are absent. After shooting down the coal more or less per- 
 fectly, thev break it up with picks and sledges and load it into cars. 
 
182 
 
 The dust hazard for them is great and naturally is worse where other 
 substances than pure coal are encountered in the course of their 
 work. They have the same ventilation hazards as for all workers at 
 the face. While their work is laborious, and all piece-work and 
 rather monotonous, with considerable jar and vibrations from tools 
 used, there is the advantage of a standard work day of eight hours 
 which they very rarely ever exceed. Throughout the entire coal 
 mining district the eight-hour day prevails and covers the vast 
 majority of workers. Occasionally 'spurt' work prevails for both 
 loaders and miners and others at the face. Here there is a shortage 
 of mine cars and when a car is obtained, the man or men concerned 
 work strenuously for twenty minutes or so in filling in, then wait 
 for the next 'empty' to come along. In most mines there is enough 
 'dead work' to keep them occupied in the interval, which may last 
 upwards of a half-hour or so. In many instances, however, they sit 
 around in the cool atmosphere with sweat-soaked clothing and per- 
 haps lunch a bit from their buckets. Undue exposures and liability 
 to chilling naturally occur. 
 
 "Shot-Firers. — In bigger mines a few men are employed toward 
 the quitting hour of the day to shoot down thai coal for the next day's 
 work. The powder or shot has usually been placed for them with 
 fuse attached, so that their duty doilsists of shooting oflf the 'shoots.' 
 They are employed for a couple of hours and their chief hazard is 
 work in powder smoke and incompletely combusted powder gases 
 which fill the sections of the mine during this procedure. They 
 usually go from place to place in a logical order calculated to keep 
 them in the freshest air, but the force of the exposions disarranges 
 the ventilation to some extent during this process. Breathing of 
 ^vhite damp (GO) as well as black damp (002) constitutes their 
 chief health hazard. Dust is naturally a bad feature also. 
 
 "Timbermen. — These workers are employed mostly at the breast 
 of the mine in and about the rooms -and the terminal entries, and 
 have dust and ventilation hazards as their chief concern. Wet road- 
 ways' and other places involve them probably more than others in 
 the mine. 
 
 "Trappers. — Trappers are usually boys or youths, sometimes* old 
 men, who stay at switch junctions or at doors and save the time of 
 mine train drivers or motormen by operating switches or opening 
 doors. They usually have a manhole or niche in the wall where they 
 may sit between activities. A bench is almost always provided for 
 them. They are naturally in good draft, breathe the entryway dusts 
 and, because of long workless intervals, are subject to the hazard 
 of chilling. There is often some strain in connection with their 
 work as when assisting in the steering of cars across rough and un- 
 certain switches. 
 
 "Tipple Men.— The chief hazards of the workmen in the coal 
 tipple are the breathing of an excessive amount of dust, mostly coal 
 dust, which arises in connection with the dumping and screening 
 and, perhaps, crushing of coal in the vicinity. While more or less 
 within doors, tipples are usually not protected much against the low 
 temperatures of winter, and being high in the air, are cold 
 places to work. The weighmen are usually located in a part of the 
 tipple more or less partitioned oft" and nearly always provided with 
 
183 
 
 some form of heating appliance in the winter time. There are al- 
 ways two of them, except in the smallest mines, one of whom is the 
 company weighman and the other the check weighman who rep- 
 resents the miners. 
 
 "Track Men. — Track men move, or assist in moving, the railroad 
 cars slowly along as the coal chutes fill them. Their work is vei-y 
 dusty and they have full weather exposure. They assist somewhat, 
 also, in shoving the lumps of coal about when they tend to flow 
 over the top of the cars. Some of them, also, keep the ground clean. 
 
 "Hoisting Engineers.-— Where steam hoists are used, investigations 
 of engine rooms showed that the hoisting engineer often worked 
 under an unusual temperature exposure (110 to 140F.). While 
 buildings for hoisting-engines varied at different mines, the engineer 
 was usually placed between two steam engines with steam pipes un- 
 der foot and perhaps overhead. To a large extent, windows were 
 depended upon for ventilation. Of all the men at the mine, he is 
 the one required to be the most mentally alert, since he must be 
 constantly watching the indicators on the dials to keep informed of 
 the height and speed of the rapidly moving cages loaded with coal 
 or men, which cages he controls with his hand-levers. He must also 
 be mindful of whistle or bell signals by which he starts his levers. 
 
 "Coal Washers. — In the present great demand for coal, coal wash- 
 ers have largely been allowed to stand idle. However, at a con- 
 siderable number of mines this process is still carried on and re- 
 quires the presence of some ten to twenty men. As the term implies, 
 the screened coal is washed with water, which frees it from much 
 impurity, particularly of sulphur deposits and the finer dusts. The 
 atmosphere about all coal washers is exceedingly dusty, due, princi- 
 pally, to the crashing process preceding the washing. While the 
 process is within enclosures, there is no special protection from cold 
 weather. The men have frequent periods of inactivity, and are, 
 therefore, liable to chilling. Noise is also a marked feature. 
 
 "Housing Conditions. — The. hygiene and sanitation of housing is 
 important since it involves about one-third of the normal day for 
 the worker and most of the time for his family. The typical mine 
 town consists of rows of dingy houses, all built after one or two pat- 
 terns, often located on hillsides, with rows of privies located close to 
 jyells or draining toward the wells on the next street. Rarely any 
 attempt at garbage collection exists. Often small ditches of water 
 act as open sewers. Screens for the houses are usually provided by 
 the occupant if present at all. Many mining towns are unincorpo- 
 rated. There is often no local health officer. The board of health con- 
 sists of the mayor and two or more members of the council in the 
 larger towns. . In some places only the township supervisor arrange- 
 ment prevails. Very often the health officer is not a physician and 
 is entirely unskilled in matters of hygiene and sanitation. Very 
 often he belongs to the old type of health officer, who lays great 
 stress on garbage collection and ashes, and pays little attention to 
 wells, outhouses, screening or milk supply." ^ » ,«•• 
 
 According to the report of the Pennsylvania Department of Mines 
 for 1916 "the mines of Illinois and Ohio cannot be compared with 
 those of Pennsylvania for gas and dust." "During the past nineteen 
 years the worst accidents have been due to gas and dust and could 
 have been prevented toy proper operation of the mines. In 191b, 
 
184 
 
 these two causes accounted for 8.74 per cent of the fatal accidents in 
 bituminous mines and 8.65 per cent, of those in anthracite mines. 
 "Mining is now more difficult and hazardous than ever before. The 
 miners are no longer the early type of trained British workers, but 
 are largely agricultural laborers from Southern Europe, and re- 
 cently negroes from the South are migrating to the Pittsburg dis- 
 trict in large numbers." "Moreover, housing conditions are generally 
 poor. Little has been done to improve the houses built years ago, 
 which in many cases are now most inconvenient and unsanitary. 
 
 "Greater attention is given to approved methods of mining, safety 
 appliances, sanitary conditions and the general welfare of the miner 
 while at work, but not so much to the home or social life of the 
 communitv."^ . . 
 
 Inquiries were made by the Commission of physicians practismg 
 in the anthracite and bituminous regions and of representative em- 
 ployers, to ascertain as far as possible general health conditions 
 among miners and their families. The evidence gathered supports 
 the findings of the Western Pennsylvania Survey. While the miners 
 themselves do not seem to be a particularly unhealthy class of men, 
 the high rate of non-tuberculous respiratory diseases among them 
 probably raises their sickness rate slightly above that of the rest 
 of the community. Among 1,208 families included in the report of 
 the Mothers' Assistance Fund for 1916, the death of the principal 
 wage earner in 286 cases had been due to his occupation; although 
 only 19 per cent of the total number of men had been miners, min- 
 ing was responsible for 45 per cent of the deaths which were at- 
 tributed to occupation. In a. study of 110 families made for the 
 Commission by the Mothers' Assistance Fund in 1918, it was found 
 that 91 per cent of the men were under forty years of age at the time 
 of death, and that among seventy-threp men who died in Lackawanna 
 county, twenty-one had pneumonia, nine had tuberculosis, and ten 
 were victims of industrial accidents. 
 
 Inquiry into conditions in the families of miners tells a far more 
 striking story. Practically every physician consulted stated that the 
 sickness rate, especially among children, was noticeably higher than 
 among other families in the community. As it is necessary for the 
 miners to live in the immediate vicinity of the mines, the occupation 
 may be said to have as close a relation to the health of their families 
 as to their own health. Insanitary, frequently filthy, housing, the 
 almost total absence of pre-natal or maternity care, the use of 
 untrained midwives in confinement cases, the inaccessibility of many 
 mining communities, the lack of facilities for public health education, 
 have combined with the ignorance of the miners and their wives to 
 produce a state of affairs that is often shocking. One physician 
 practising in the bituminous district stated that th^ infant mortality 
 among miners' children was fully 50 per cent, higher than in the 
 community as a whole. In fact, he considered it a question of the 
 "survival of the fittest," and thought that the deaths of the weaker 
 children might account for the comparative ruggedness of the adults ! 
 
 (')Repoit of Department of Mines, 1916. 
 
185 
 
 Unfortunately the disregard for health, which many mining com- 
 panies showed when they built for their employees crowded rows of 
 fcur-room houses, frequently full in the smoke and gas from the coke- 
 ovens, and always without plumbing, is only too indicative of general 
 housing conditions among wage-earners in many communities where 
 industry is directly responsible for living conditions, and yet, 
 "standards of health in industry cannot be effective unless decent 
 living quarters are provided. Any benefit accruing from carefully 
 eq^ipped shops may be entirely dissipated by the workers' unwhole- 
 some environment in leisure hours — all investigation and experience 
 tend to show a constant relationship between mortality, morbidity, 
 and living conditions.''^ The extensive experiments made in indus- 
 trial housing on a large scale by many employers during the war is a 
 recognition of the importance of the problem and a step toward its 
 solution. 
 
 Aside from the prevalence, of health hazards in various occupations, 
 another important feature in the relationship between work and 
 disease is the problem of the worker himself. Some employees are 
 very much more susceptible to certain hazards than others, so much 
 so that hygienic as some industrial processes can possibly be made, 
 still there are certain classes of persons who should not engage in 
 them. While this is often settled by natural selection, such chance 
 cannot always be relied upon, especially in the case of older workers 
 who have been following hazardous occupations for years and who, 
 although weakened, still endeavor to continue. An increasing num- 
 ber of employers are instituting physical examinations. for applicants 
 for employment as a means of meeting this difficulty. Among thirty- 
 seven industrial plants in Pennsylvania studied by the United States 
 Public Health Service in April and May, 1918, seventeen required 
 applicants to submit to physical examination. In only four estab- 
 lishments, however, was the examination used as a basis for deter- 
 mining the exact nature of work to which the applicant should be 
 assigned. In most cases, the examination was very superficial, com- 
 municable diseases and obvious defects being the only causes for 
 rejection. 
 
 The United States Bureau of Labor Statistics has partially com- 
 pleted a study of forty years' experience of the "Workmen's Sick and 
 Death Benefit Fund of America." This study covers approximately 
 47,000 persons of all ages engaged in over 100 different occupations. 
 As the fund has no waiting period, the benefit periods are an accurate 
 measure of sickness among the members. The data for the five year 
 period, 1912 to 1916, has been compiled and made available for the 
 use of the Commission, by Dr. Eoyal Meeker, Chief of the Bureau. 
 As shown in Table I the occupations have been classified into forty- 
 
 OJohn A. Lapp, Annals of the American Academy of Political and Social Science, January 
 1919, page 132. 
 
186 
 
 two groups, within which the proportion of members ill per year 
 ranged from 12.2 per cent, for professional workers, including 
 musicians, draftsmen, chemists, opticians, physicians, dentists, art- 
 ists, writers, reporters, teachers, lawyers and nurses, to 31.40 per 
 cent, for miners. Ten of the forty-two occupational groups, miners, 
 drivers, liquor manufacturing employees, "laborers," freight handlers, 
 molders, tobacco and cigar workers, railway employees, tanners, and 
 blacksmiths, had over 25 per cent, of their members ill annually, and 
 in only nine groups was the percentage less than 20 per cent.; in 54 
 per cent, of the occupations the reports showed that on an average 
 from 20 per cent, to 25 per cent, of the members were ill each year. 
 
 The foregoing facts indicate that, aside from specific occupational 
 diseases, serious health hazards exist in industry today and make 
 industry in large measure responsible for illness among employees 
 and their families. Great improvement could be made by the 
 universal institution of proper methods of work and the standardiza- 
 tion of working conditions. The Industrial Board of Pennsylvania 
 has taken a step in this direction by establishing the lighting code of 
 1916, to regulate factory illumination. Following a two years' sur- 
 vey of the effect of industry on health, the Ohio State Board of Health 
 declared that "until some direct incentive to improve factory sani- 
 tation is offered, little real progress can be hoped for." Any plan 
 TO raise health standards among wage earners must provide this 
 much needed stimulus. 
 
 OCCUPATIONAL DISEASES IN PENNSYLVANIA. 
 By Alice Hamilton, M. D.. Bureau of Labor Statistics, Washington, D. C. 
 
 Pennsylvania is probably the most important industrial state in 
 the Union. Certainly to the student of occupational diseases, it is 
 much the most important. No state has so wide a variety of those 
 industrial processes which carry with them danger to the workers 
 either because of poison in the form of fumes, liquids, or dusts, or 
 because of mechanically irritating dusts which injure the throat and 
 lungs. 
 
 It would be impossible to describe in detail all the dangerous 
 trades of Pennsylvania, impossible to more than mention those that 
 are not classed as dangerous but that are known to have a sickness 
 rate higher than the average for industry. Lead poisoning usually 
 comes first in order, since it is considered by far the most important 
 of the industrial poisons. 
 
 LEAD POISONING. 
 
 A great deal of lead work is done in Pennsylvania. In the Pitts- 
 burgh region much molten lead is used in making machine parts and 
 castings, plumbers' goods, in tempering steel, in manufacturing lead 
 pipe, sheet lead and wire; lead compounds are used in enameling 
 sanitary ware, and in grinding paint; white lead is corroded and 
 
187 
 
 oxides are roasted. The Philadelphia region has even larger white 
 lead works and oxide roasters, and paint factories. Lead oxides are 
 used in large quantities in the manufacture of storage batteries in 
 Philadelphia, and the shipyards use great quantities of white lead 
 and red lead paint. In several parts of the state, tile works use a 
 lead glaze, and there are many brass foundries and factories in which 
 lead poisoning occurs because of the presence of lead as an impurity 
 in the brass. There are also factories in which molten lead is used, 
 type metal, solder, babbitt. Rubber works use lead salts in com- 
 pounding, small refineries work up lead scrap, dross, and lead refuse 
 of all kinds. 
 
 ^ No figures are available in Pennsylvania, or for that matter in 
 any state, to show how much lead poisoning occurs in any of these 
 industries. Studies made for the Federal Bureau of Labor Statistics 
 have provided us with information concerning the chief lead indus- 
 tries throughout the country and at the time they were made the 
 Pennsylvania plants did not differ in any important respect from 
 those in the other states included in the investigations, nor was there 
 any reason to suppose that there was less lead poisoning in them than 
 in those of other states. The publications of the Bureau show that 
 in 1910-11 the white lead industry had a rate of about 18 per cent, 
 yearly^ of lead poisoning. In enameling sanitary ware, the yearly 
 rate in 1911 was 21.4 per cent., and in glazing tiles the rate during 
 the same year was 13.9 per cent. In the smelting and refining of 
 lead there was a little over 22 per cent, of lead poisoning in 1912. 
 Making storage batteries caused lead poisoning in almost 18 per cent, 
 of all those employed in 1913. 
 
 Since these figures were compiled, certain of the lead industries 
 in Pennsylvania, notably the making of white lead and of lead oxides 
 and the making of storage batteries, have improved very greatly and 
 undoubtedly have a much lower; rate of poisoning now. Not so much 
 improvement has taken place in other lead trades, indeed it is doubt- 
 ' f ul whether there is much less plumbism in the smaller refineries and 
 in the establishments using solder and casting lead than there was 
 before general attention was called to this kind of danger to work- 
 men. The notoriously dangerous lead trades have been made much 
 safer, the less dangerous ones have hardly changed at all, and hospital 
 records that used to tarry many cases from white lead works and 
 storage battery works, get the greater number of their cases from 
 among solderers, lead burners, type-founders and makers of tin cans. 
 
 Printers and painters are too numerous for any complete investiga- 
 tion concerning their rate of lead poisoning. Both are notoriously 
 unhealthy lead trades, the latter much more so than the former. The 
 printing trade has always had more than its share of ill health, but 
 it is impossible to be sure just how much is due to the presence of 
 
188 
 
 lead and how much to the fact that it is an indoor trade involving 
 little muscular effort and much nervous strain. In the course of an 
 investigation made for the Bureau of Labor Statistics, it was found 
 that out of 200 working printers, 100 in Chicago and 100 in Boston, 
 18 or 19 per cent, had lead poisoning. It is not clearly defined lead 
 poisoning, however, that causes most of the ill health among printers ; 
 rather the lead acts in lowering the resistance to tuberculosis and in 
 encouraging the progress of the so-called "old age" or degenerative 
 diseases, Bright's, heart disease, general' arteriosclerosis. Of late 
 years the printers have succeeded in lowering their tuberculosis rate 
 and in adding to the average duration of life, but an increasingly 
 large number are now suffering from old age diseases during the^ 
 middle years of life. 
 
 The most severe and crippling forms of lead poisoning are found 
 among painters, for this is a skilled industry and men do not drop it 
 easily even if they know it is ruining their health. The examination 
 of a hundred painters in Chicago in 1913 showed that no less than 59 
 of them were suffering from some form of plumbism. If the same 
 proportion holds good among the 14000 journeyman painters in the 
 state of Pennsylvania, there must be some 8000 whose health is some- 
 what impaired as a result of their work. Lead poisoned painters 
 often have very serious forms of plumbism. Among 100 lead poisoned 
 painters in Chicago, there were 42 cases of palsy, 9 cases of brain dis- 
 ease, 11 cases of impaired sight and 11 of general hardening of the 
 arteries. Painters are exposed to other injurious substances besides 
 lead, to the benzine or naptha in quick-drying paints, to benzol in 
 coal tar paints, to turpentine, wood alcohol, carbon tetrachloride and 
 to carbon monoxide gas which rises from the charcoal stoves placed 
 in new buildings to dry out the walls. 
 
 Painting in factories is either much less dangerous than house and 
 ship painting or rather more so. Instances of the safe branches are 
 the painting of machinery and vehicles with leadless paints by 
 dipping them in vats of paint. Instances of the dangerous forms are 
 the painting and sandpapering of wheels and bodies of automobiles 
 and carriages where a paint rich in lead is used. The most danger- 
 ous work for the journeyman painters is interior decorating of 
 houses, requiring many coats of white lead paint which must be 
 sanded down, and ship painting where great quantities of white and 
 red lead paints are used. Ship painting employs a large number of 
 painters in Pennsylvania. 
 
 Prom records of hospitals in Philadelphia and Pittsburgh the fol- 
 lowing industries were shown to have caused lead poisoning severe 
 enough to require hospital treatment. The well known lead indus- 
 tries are not included here : 
 
189 
 
 Grinding lead enamel for sanitary ware. 
 
 Sanitary ware enamelling. 
 
 Lead tempering. ' 
 
 Lead casting. 
 
 Sweeping up scrap and dross from lead casting. 
 
 Unloading lead bullion from cars. 
 
 Plumbing trade. 
 
 Making lead stoppers and perforated filters for washstands. 
 
 Pouring brass. 
 
 Polishing brass. 
 
 Making tin ware. 
 
 Soldering tin cans. 
 
 Chipping off old red lead paint. 
 
 CARBON MONOXIDE. 
 This is probably the closest rival of lead as an occupational poison. 
 Carbon monoxide poisoning is yearly on the increase as the use of 
 producer gas for heat and power increases and as the automobile 
 industry increases. All incomplete combustion of gas is accompanied 
 by the production of carbon monoxide, but the gas is found more 
 especially in the steel foundries, in smelters, brick kilns, enamelling 
 furnacies, bakeries, laundries, and in coke by-products works. In 
 testing automobiles many cases of carbon monoxide poisoning have 
 occurred through the escape of exhaust gases which are composed 
 largely of this compound. Acute carbon monoxide poisoning is far 
 from rare in the great steel mills of the Pittsburgh region. It causes 
 symptoms of dizziness, weakness, confusion or rapid loss of con- 
 sciousness which may end in death in a very short time. If the man 
 recovers from this attack there may be a more or less permanent loss 
 of memory and mental powers, or pneumonia may develop, very likely 
 to be fatal. Chronic carbon monoxide poisoning is found in steel 
 workers and also in pressers in tailor shops and tailors who work in 
 the same room with them, in printers working in shops where gas is 
 used to Tieep lead melted and there are no pipes to carry off the 
 fumes, in bakers who are exposed to gas fumes and in solderers of 
 cans who use the heat of naked gas jets. This chronic poisoning 
 causes an increasing anaemia with all its consequences, loss of nutri- 
 tion, loss of strength, nervousness, indigestion, and a tendency to 
 infectious disease, especially tuberculosis. 
 
 BRASS. 
 The metallic poisons which are used in Pennsylvania industries 
 are brass— an alloy of copper and zinc— mercury, arsenic and anti- 
 mony. Brass poisoning as often described is really lead poisoning, 
 for brass polishers and buffers do not become poisoned by the solid 
 brass, if they are poisoned it is from the lead so often present in the 
 alloy. Real brass poisoning is met with in brass founding or pour- 
 ing, when the thick white fumes given off are allowed to escape and 
 contaminate the air of the room. The sublimed zinc oxide is the 
 
190 
 
 element in these fumes that gives trouble, not any form of copper, 
 and zinc smelters suffer from the same kind of symptoms as do zinc 
 welders. Brass founders' ague, as it is called is not considered a 
 serious affection by either physicians or the workmen themselves. It 
 resembles a short attack of chills and fever, but clears up rapidly. 
 Nevertheless, brass workers do not have as good health as the average 
 of men employed in manual work. Probably this is the result of 
 exposure not only to brass, but to lead and sometimes arsenic, to 
 heat and abrupt changes of temperature and heavy work, and to car- 
 bon monoxide from the furnaces. 
 
 • 
 
 MERCURY. ' 
 
 Mercury is used chiefly in the making of felt hats, a fairly large 
 industry in this state. The rabbit fur used for felting is treated with 
 nitrate of mercury and all who handle it after this preliminary "car- 
 rotting" are liable to mercurial poisoning. This is a notoriously 
 vinhealthful industry all over the civilized world. In addition to the 
 presence of so powerful a poison as mercury there is the irritating 
 effect on the lungs of the particuleg_ of fur in the air, the atmosphere 
 of steam in certain departments, and the wood alcohol used in shel- 
 lacking the felt. The felt hat industry has had more cases of indus- 
 trial wood alcohol poisoning than has any other trade. 
 
 ARSENIC. 
 Arsenic ;s present as an impurity in much iron zinc and lead ore 
 and also in much of the muriatic acid and sulphuric acid used in 
 industry, When such an acid is brought in contact with such a 
 metal, arsenic in the form of arseniurretted hydrogen is given off and 
 poisons the workman. Lead burners get it from the hydrogen which 
 they use for their oxy-hydrogen flame and which they make from 
 muriatic acid and zinc ; makers of toy balloons get it from the hydro- 
 gen used to fill the balloons. Such cases are seldom rightly 
 diagnosed, for there is nothing in the industry to suggest arsenic to 
 the physician. The making of arsenical insecticides is not carried on 
 in Pennsylvania. 
 
 VARIOUS INDUSTRIAL GASES. 
 
 Gaseous poisons less important than carbon monoxide are sulphur 
 dioxide, nitrogen oxides, chlorine, ammonia, ether. Sulphur dioxide 
 is believed by many practical men to be devoid of real danger, yet it 
 was one of the poisons that Germans selected for experiment when 
 they inaugurated gas warfare. It is given off chiefly in the making 
 of sulphuric acid and in the making of carbolic acid, both of them 
 carried on in this state. Chlorine is given off during the early stages 
 of nitric acid manufacture. It is the gas that was used almost 
 exclusively during the first year of gas warfare. Ammonia gas may 
 cause so much irritation of the respiratory, tract as to set up a fatal 
 
191 
 
 pneumonia. It is used in refrigerating plants and in the making of 
 artificial ice, and to a less extent in making ammonium nitrate for 
 the explosive industry. 
 
 Nitrogen oxides are a danger wherever nitric acid is made or used. 
 The manufacture of nitric acid has increased enormously since the 
 war and so has its use in the making of explosives all of which are 
 nitrated products. There is nothing in the making or use of nitric 
 acid that requires the escape of nitrous fumes, on the contrary, every 
 effort should be made to prevent their escape in the interests of 
 economy as well as to protect the workmen. Of recent years the 
 handling of this dangerous acid has greatly improved and there is 
 much less "fume poisoning" in nitric acid works and in the 
 making of picric acid, nitro-cotton, trinitrotoluol, and celluloid 
 than there was three years age. Nevertheless it is impossible 
 to ^altogether prevent the leaking of pipes or vats, for strong 
 nitric acid is very corrosive, and there is still some poison- 
 ing from this gas among workers in Pennsylvania acid plants 
 and in explosive manufacture. 
 
 COAL TAR PRODUCTS. 
 
 Since the beginning of the war, when supplies from Germany were 
 shut off, there has been a great increase in Pennsylvania of industries 
 involving exposure to coal tar products. Formerly a certain amount 
 of benzol was imported from Germany but it was costly and did not 
 find extensive use. The petroleum derivatives, naphtha and benzine, 
 were cheaper and more abundant and they were used largely in rub- 
 ber ' manufacture, making "quick-drying paints, paint removers, 
 varnishes, shellacs and so on, to be a better solvent than naptha, but 
 it was too expensive. Since the war benzol has been manufactured 
 on a large scale in this country and some of the largest plants are in 
 Pennsylvania. This benzol is used not only for its solvent properties 
 but as a starting point for the manufacture of anilin. The latter is 
 then used to make anilin dyes and also in compounding rubber, mak- 
 ing type roller cleaners, shoe polishes, and one of the high explosives, 
 tetryl. 
 
 Closely related to benzol is toluol, extracted from illuminating gas 
 and latterly used in large quantities to make the charge for high 
 ' explosive shell, trinitrotoluol, commonly called TNT. Pennsylvania 
 has not only important plants for the nitration of toluol and the 
 purification of crude TNT, but also at least one large shell loading 
 plant, where the TNT is made into charges and loaded into shells, and 
 also one in which detonators are made from TNT and tetryl. Benzol 
 and toluol and their derivitives are all poisons to the blood and to the 
 nervous system, being absorbed largely through the skin. Benzol is 
 the ane most rapidly poisonous, a short exposure to heavy fumes 
 being frequently fatal. Anilin is volatile and has a rapid effect but 
 13 
 
192 
 
 is not so serious a poison as TNT which is more slowly absorbed but 
 for that very reason has a moi:e profound effect because it does not 
 give prompt warning of danger as does anilin. Tetryl is, so far as is 
 known, only slightly poisonous, producing an eruption on the skin 
 which is distressing but not dangerous. Toluol is like benzol in its 
 effects. The. extraction of benzol from coal tar in Pennsylvania has 
 been followed by several fatal cases of benzol poisoning. 
 
 The substitution of benzol for naphtha and benzine means that 
 work in rubber manufacture, in making and using shellacs and 
 varnishes, using varnish removers and paint removers, using rubber 
 cement for sealing cans and dry cleaning and dyeing, are probably 
 more dangerous occupations iiow than they used to be. Benzol is 
 also used in another new industry, the manufacture of carbolic acid. 
 Chronic benzol poisoning is not as yet very easy to recognize, but 
 investigations now being made on the blood of benzol workers will 
 probably make it easier to~ discover whether the ill health, the 
 anaemia, loss of strength, nervous symptoms, and sometimes gastric 
 symptoms, found among those who work with benzol are caused by 
 the benzol or by other factors. 
 
 DISEASE CAUSED BY PHYSICAL AGENTS. 
 This is a fairly full list of occupational poisons used in Pennsyl- 
 vania, but though they cause a good deal of industrial sickness, they 
 are not by any means as important as are certain other disease pro- 
 ducing factors in the industry in this state. One of the most import- 
 ant, if not the most important industry in Pennsylvania, is the manu- 
 facture of steel. No thorough study -has ever been made of the 
 occupational diseases of Pennsylvania steel workers, but we know 
 that there are many things about the making of steel, which are 
 harmful to health. Steel workers are exposed to poisoning not only 
 by carbon monoxide but sometimes also by lead, arsenic, sulphuretted 
 hydrogen and the cyanides. They must use great physical strength, 
 and if the strain is too great for the heart, there may be an acute 
 dilatation which may be slow in recovery or may be permanent. 
 Steel workers are also exposed to metallic dust and to sand, to great 
 ]ieat, to sudden changes of temperature, resulting in rheumatism, 
 lumbago, bronchitis, and. to light of such character and intensity 
 as to injure the eyes if they are not protected. To all these injurious, 
 features must be added the fatigue of the long work-day and the 
 seven day week. 
 
 TEXTILE INDUSTRY. 
 Another very important industry in Pennsylvania is the textile, 
 which is regarded as unhealtMul in all civilized countries. The badl 
 features in the textile trades are first the light fluffy dust of cotton, 
 or wool, more rarely flax ; the fatigue caused by noise, jarring,- and 
 monotonous work which yet demands constant attention; the heat 
 
193 
 
 and humidity. These, together with a rather low wage scale, are 
 all factors that go to bring about an abnormally high rate of tuber- 
 culosis, in the textile trades. The more immature the workers, the 
 more tuberculosis, and the more fatiguing the work, the more tuber- 
 culosis. Many girls between the ages of sixteen and twenty-four 
 are employed in the mills in and around Philadelphia and it is 
 just in thiw age group that the incidence of industrial tuberculosis 
 is heaviest. 
 
 COAL MINING. 
 Another important industry in Pennsylvania is coal mining. 
 Coal miners have a high accident rate and that fact affects -their 
 sickness rate. Accidents usually kill off or incapacitate men in the 
 earlier age groups, the very groups in which tuberculosis is usually 
 most prevalent. It is well known that coal miners do not have as 
 much pulmonai-y tuberculosis as does the population at large and 
 because of thig fact there is a general impression that the coal min- 
 ing industry is unusually healthful. Coal miners more than make 
 up for their low tuberculosis rate by their high rate of deaths from 
 other respiratory diseases. This is shown by a recent analysis made 
 of the mortality of the two coal mining cities of Scranton and 
 Wilkes-Barre compared with the mortality for the whole state of 
 Pennsylvania.' The reason for the excessive high death rate from 
 non-tuberculous diseases of the lungs is usually given as follows — 
 Coal dust is not very irritating and does not cause the sort of injury 
 to the lung tissue which is caused by steel or stone dust and which 
 prepares the way for a tuberculous inflammation. The effect of 
 coal dust IS to cause a very slow hardening of the lung which may 
 produce no symptoms or may cause asthma. If, however, the miner 
 contracts pneumonia, the hardened state of his lungs diminishes 
 very mxich his chance of recoverj\ 
 
 COMPARATIVE MORTALITY OF PENNSYLVANIA, 1911 TO 1915. 
 (Rate per 100,0000 population). 
 
 Cause of Death. 
 
 Scranton. 
 
 Wilkes- 
 Barre. 
 
 Bemainder 
 ol State. 
 
 
 79.9 
 16.6 
 261.2 
 153.5 
 
 74.9 
 
 19.4 
 
 212. B 
 
 179.7 
 
 110.5 
 
 
 16.4 
 
 
 184.2 
 
 
 98.9 
 
 
 
 ANTHRAX. 
 Pennsylvania being a seaboard state with an important port at 
 Philadelphia, has had a comparatively large numtoer of cases of that 
 rather unusual industrial disease, anthrax or malignant pustule. 
 Anthrax is caused by a very resistant bacillus which sets up a fatal 
 disease in cattle. It is especially in hides that are shipped to this 
 
194 
 
 country from abroad that this infection is found. Even careful 
 disinfection before shipping is not always enough to kill the germ 
 of anthrax which may retain its vitality and weeks later infect the 
 man who unloads the hides or sorts thenT'or carries them through 
 the processes of washing and tanning. 
 
 Between January 1st, 1913 and January 1st, 1916, there were 49 
 cases of anthrax in Pennsylvania, eight of them women. Seven of 
 the 27 cases reported during the first half of this period are known 
 to have been fatal, and out of 132 deaths from anthrax reportei 
 throughout the registration area of the United States in a period of 
 five years, 1910-1915, 13 occurred in Pennsylvania. i ' 
 
 The women who contracted anthrax were sorting hair and twist- 
 ing hair or were working in tanneries; the men had occupations 
 of great variety. They were hide and skin workers, wool and hair 
 workers, longshoremen unloading hides, laborers in tanneries, and 
 there was one representative of each of the following occupations, 
 inspecting raw stock, sorting raw hides, fixing a haircloth loom, 
 handling dirty rags for slioddy, handling hoofs in a glue factory, 
 examining haircloth, making brushes, working in a livery stable. 
 In addition there were two babies, one the child of a tanner, the 
 other the child of a coal miner, apparently infected from some 
 unknown soource. 
 
 There is no compensation for occupational disease in Pennsylvania. 
 In this respect some states are more fortunate but it would be a 
 great mistake to. think that the passage of a law, providing com- 
 pensation for occupational diseases would do away with the poverty 
 that is really attributable to sickness set up by or increased by the 
 workers' occupation. It is true that we are learning each year 
 more about the action of various poisons on the human -body and 
 also about such indirect factors in the production of disease as 
 fatigue, heat, and humidity. Nevertheless we can connect occupa- 
 tional disease only in a small number of cases with that degree of 
 positiveness that would be required under the law. It is only when 
 the disease is caused by a poison whose symptoms are unmistake- 
 able or by acute infection with a germ that can be identified, or 
 when it is caused by some physical agent such as excessive heat or 
 the pressure of air in a caisson that we can actually prove the occu- 
 pation to be responsible. 
 
 Nobody has any difficulty in deciding that lead colic or lead con- 
 vulsion in a white lead worker should be charged up to his occu- 
 pation, but it is a very diflferent thing to prove that a general hard- 
 ening of the arteries, with Bright's disease an4 perhaps softening 
 of the brain in a lead carter who has never had lead colic, is caused 
 by his occupation. Always there is far more doubt about the occu- 
 pational factor when the poisoning is chronic than when it is acute, 
 
195 
 
 and yet industrial poisoning is typically chronic, exceptionally acute. 
 There have been some very.startling cases of acute 'benzol poisoning 
 in Pennsylvania that attracted attention, were investigated by the 
 state authorities, and were made the ground for orders tending to 
 prevent such accidents in the future. But for every case of that 
 kind there are probably twenty or more of slow, chronic poisoning 
 with benzol in rubber works, in canneries, in straw hat manufac- 
 ture, when rosin is .used for sealing cans and in cleaning and dyeing. 
 In the great rolling mills around Pittsburgh, evei-y now and then 
 a foundryman is overcome with the fumes of carbon monoxide, ren- 
 dered unconscious perhaps, and when he recovers his senses, he is 
 confused and mentally unsound for some time, or contracts pneu- 
 monia within a short time. Such a case is undoubtedly occupational, 
 and nobody thinks of questioning it. But for every case of so-called 
 "gassing" in the mills, there are probably a hundred cases of 
 anaemia and malnutrition and neurasthenic troubles among pressers 
 in tailor shops, bakers, metal casters, linotypists and electrotypers, 
 all of whom work day after day in air slightly contaminated by tiie 
 fumes of carbon monoxide from naked gas burners. So also ^a case 
 of anthrax in a tannery worker, which develops into fatal blood 
 poisoning is recognized as occupational, but tuberculosis developing 
 slowly in a sandblaster of sanitary ware is not so recognized. 
 
 Many other instances could be cited to show that while acute 
 industrial poisoning can be readily recognized, chronic poisoning con- 
 stitutes a much harder problem, but even more difficult is the prob- 
 lem when we try to trace the connection between occupation and 
 disease in those trades where dust is the danger, dust that is not 
 poisonous or perhaps only slightly so. Felt hat makers have a high 
 tuberculosis rate and the injurious effect of the fine particles of fur 
 in the air they breathe is doubtless increased by the presence of the 
 mercurial salt with which the fur has been treated, but if a hat 
 maker shows no symptom of mercurial poisoning, only of consump- 
 tion, it is not easy to prove that he contracted the disease in the 
 course of his work. The same difficulty is seen in occupations where 
 metallic lead dust is present. We know that lead poisoning and 
 tuberculosis go hand in hand and that a lead trade in which men 
 remain for many years always has a high tuberculosis rate, but if 
 a consumptive printer does not give a history of lead colic, how are 
 we to prove that his occupation has brought on his disease. 
 
 The dusty trades, undoubtedly responsible for more disease than 
 any other class of occupations, because they employ so many more 
 people than do the notoriously dangerous trades, are not adequately 
 covered in any state by the laws designed to prevent disease or to 
 compensate workmen suffering from such disease, for this very rea- 
 son, the difficulty of proving the responsibility of the occupation 
 The dust that causes the harm is not the coarse, heavy dust that 
 
196 
 
 is easily seen and that the factory inspector can insist on having 
 done away with. Such dust cannot reach the lungs and injure them. 
 It is the fine, almost invisible particles that do the real harm, 
 because they can pass in with the breath and be carried down to 
 the lungs. The commonest form of injury by dust is a slowly devel- 
 oping fibrous change in the lungs which may become the seat of 
 a tuberculosis if anything happens to lower the worker's vitality, or 
 which may prevent his recovery if he contracts pneumonia. Obvi- 
 ously, no matter how positive we may feel that such results can 
 follow long exposure to fine atmospheric dust, we shall always find 
 it difficult to prove that any individual case of consumption or of 
 death from pneumonia was caused by a dusty occupation. This 
 means that no law, no matter how wide its application, will ever 
 cover all cases of occupational disease. 
 
 Part II.— Section IV.— Table I. 
 WORKMEN'S sick: AND DEATH BENEFIT FUND OF AMERICA, 
 
 1912-16.(1) 
 
 Occupation. 
 
 9. 
 10. 
 11. 
 12. 
 13. 
 U. 
 15. 
 16. 
 17. 
 IS. 
 19. 
 20. 
 21. 
 22. 
 23. 
 U. 
 25. 
 26. 
 27. 
 28. 
 
 34. 
 35. 
 
 37. 
 
 Barbers, 
 
 Bartenders, 
 
 BiieJdayers, 
 
 Carpenters, 
 
 Painters, 
 
 Plasterers, 
 
 Plumbers, 
 
 Sheet metal workers, 
 
 other building construction, 
 
 Oooks and waiters, — . 
 
 Engineers and firemen, stationary or power house, .. 
 
 Farmers, gardeners, florists, 
 
 Freight handlers, 
 
 Laborers, not specified, — 
 
 Auto, carriage and wagon manufacturing employes. 
 
 day products manufacturing employes, 
 
 Clothing manufacturing employes, 
 
 Dyers, 
 
 jaectrjcal workers, — -. 
 
 Pood— other than slaughtering and meat packing, .. 
 
 Slaughtering and meat packing, 
 
 Glassworkers, 
 
 Jewelers, ■ 
 
 Tanners, ' 
 
 Leather workers, 
 
 Liquor manufacturing employes, 
 
 Blacksmiths, ..„ 
 
 Machinists, 
 
 Molders, 
 
 other metal workers, 
 
 Printers, 
 
 Stone and granite workers, 
 
 l^xtile manufaeturing employes, 
 
 Tobacco and cigars, 
 
 Other manufacturing employes, 
 
 Miners, 
 
 Professional, — 
 
 Trade and clerical, 
 
 DriTers. 
 
 Railway employes, -,- 
 
 Woodworkers, 
 
 All other occupations, 
 
 Number 
 
 Number 
 
 Per Cent. 
 
 of 
 
 Receiving 
 
 of 
 
 Members. 
 
 Benefits. 
 
 Membership. 
 
 1,242 
 
 228 
 
 18.3 
 
 2,290 
 
 404 
 
 17.6 
 
 2,241 
 
 539 
 
 24.05 
 
 11,690 
 
 2,820 
 
 24.1 
 
 4,389 
 
 926 
 
 21.09 
 
 558 
 
 109 
 
 19.5 
 
 1,448 
 
 326 
 
 22.5 
 
 2,343 
 
 514 
 
 21.9 
 
 588 
 
 122 
 
 20.7 
 
 ' 2,339 
 
 484 
 
 20.6 
 
 3,378 
 
 766 
 
 22.6 
 
 1,203 
 
 243 
 
 20.1 
 
 724 
 
 199 
 
 27.4 
 
 17,700 
 
 4,886 
 
 27.4 
 
 735 
 
 180 
 
 24.4 
 
 662 
 
 144 
 
 22.08 
 
 4,847 
 
 883 
 
 18.2 
 
 748 
 
 164 
 
 21.9 
 
 988 
 
 215 
 
 21.7" 
 
 7,507 
 
 1,540 
 
 20.8 
 
 5,724 
 
 1,351 
 
 23.6 
 
 955 
 
 222 
 
 23.2 
 
 1,169 
 
 166 
 
 14.3 
 
 1,466 
 
 370 
 
 25.2 
 
 4,316 
 
 941 
 
 21.8 
 
 14,324 
 
 4,038 
 
 28.1 
 
 2,053 
 
 518 
 
 26.1 
 
 16,026 
 
 3,567 
 
 22.2 
 
 2,838 
 
 737 
 
 25.9 
 
 6,907 
 
 1,606 
 
 23.2 
 
 3,401 
 
 591 
 
 17.3 
 
 1,172 
 
 273 
 
 23.2 
 
 7,287 
 
 1,343 
 
 18.4 
 
 8,897 
 
 2,301 
 
 25.8 
 
 4,164 
 
 876 
 
 , 21.03 
 
 7,068 
 
 2,220 
 
 ' 31.4 
 
 1,192 
 
 146 
 
 12.2 
 
 5,591 
 
 956 
 
 17.09 
 
 6,890 
 
 1,977 
 
 28.6 
 
 699 
 
 177 
 
 25.3 
 
 6,093 
 
 1,338 
 
 21.9 
 
 9,258 
 
 2,109 
 
 22.7 
 
 (1) A compilatioUi was made of the data for each year, and this was combined for the five 
 year period. The combined figures for the five years represent the individual member one to- 
 flve times according to his period of membership. * 
 
PART II. 
 SECTION V. 
 
 Sickness Prevention. 
 
 (i&t) 
 
(198) 
 
199 
 
 ♦ SICKNESS PREVENTION. 
 
 It would be hard to over-estimate the importance of sickness pre- 
 vention, the fifth subject assigned to the Commission for investiga- 
 tion. The Committee of One Hundred on National Health, in its 
 "Report on National Vitality," stated that "at least fourteen years 
 could be added to human life by the partial elimination of prevent- 
 able diseases » * * The actual economic saving annually 
 possible in this country by preventing needless deaths, needless ill- 
 ness (serious and minor), and needless fatigue, is certainly far 
 greater than one and a half billions and may be three or more times 
 as> great.'" 
 
 "Prevention" has come to be the key- note of health policies. It 
 is being proved that science and care can produce a stronger race, 
 and that a policy which not only cares for ills when they arrive, 
 but uses every effort to prevent them, is a policy of real economy 
 and efficiency. 
 
 Ideas of public health work have materially changed within the 
 last few years. In its essence the change has been to place the 
 emptasis on "people" as well as on "things." The old method of 
 concentrating entirely on swamps, damp cellars, garbage-collection 
 and the disposal of sewage, was not effective in the largest sense, 
 for disease continued to exist where things were all right, among 
 the rich and the poor, in good houses and in bad. 
 
 In preventive work among people two methods have been used. 
 Impersonal education, in the way of literature, meetings, exhibits, 
 and the like; and personal education, carried to the individual largely 
 through the public health nurse. "By public health nurse is meant 
 not only a nurse employed by municipalities or public officials, such 
 as schools, health departments, etc., but any graduate nurse who 
 is doing some form of social work in which her training as a nurse 
 comes into play and is recognized as a valuable part of her equip- 
 met. Her scope is not necessarily confined to districts, nor is her 
 work limited to the early conception of the nurse's province— simply 
 the bed-side care of the sick." This nurse attempts to teach the 
 simple laws of health and hygiene in relation to the individual and 
 the home ; in other words, she tries to teach peoplp how to get well, 
 how to keep well, and how to keep sickness from others. Dr. C. E. A. 
 Winslow of Yale Unversity, one of the leading sanitarians and public 
 health authorities, says, "Among , modern institutions for the pro- 
 tection of public health, the visiting nurse is the most important 
 figure." 
 
 The Metropolitan Life Insurance Company has fully realized the 
 value of the principle of prevention and of the Visiting Nurse. In 
 1909 this Company introduced Visiting Nurse Service for its indus- 
 
 (') Pages 103 and 120. 
 
200 
 
 trial policy holders in New York City as an experimental means 
 of diminishing claim-rates through reducing mortality among these 
 policy-holders. The results were so satisfactory that the service 
 was raiydly extended to other cities, and by 1916 was available to 
 90 per cent, of the holders of industrial policies in over 2,000 cities 
 in the United States and Canada. In 1916, 221,566 patients received 
 nursing care, at a cost to the Company of over $600,000. However, 
 the constant improvement in mortality experience of the Company, 
 during this period, has amply repaid them for such expenditures. 
 From 1911-1915 the decline in the mortality rate among industrial 
 policy holders was 9.7 per cent., while for the entire National Regis- 
 tration Area it was but 4.9 per cent. The following table shows this 
 decline through 1916. 
 
 KATES PER 100,000 FOR CERTAIN CAUSES OF DEATH, 1916 AND 1911 
 
 COMPARED. 
 Metropolitan Life Insurance Company (Industrial Department) and Registration 
 Area of the United States. (White and Colored Lives Combined) . 
 
 
 Metropolitan Life In- 
 surance company (In- 
 dustrial DepartmenW.* 
 
 Begistration Area 
 
 in United Statqs 
 
 of America. 
 
 Causes of Death. 
 
 Bates per- 
 100,000. 
 
 Per 
 Cent. 
 of De- 
 crease 
 
 in 5 
 Tears. 
 
 Bates per 
 100,000. 
 
 Per 
 Cent, 
 of De- 
 crease 
 
 in 5 
 Tears. 
 
 
 1916. 
 
 1911. 
 
 1916. 
 
 1911. 
 
 All causes of death. 
 
 1,168.1 
 
 1,253.0 
 
 6.8 
 
 1,398.9 
 
 1,415.9 
 
 1 2 
 
 
 
 Typhoid fever, -^ 
 
 12.9 
 
 40.4 
 171.5 
 17.4 
 
 98.8 
 
 22.8 
 
 58.9 
 
 203.0 
 
 19.8 
 
 97.9 
 
 43.4 
 
 31.5 
 15.5 
 12.1 
 
 t.9 
 
 13.3 
 
 39.1 
 123.8 
 16.3 
 
 105.1 
 
 21.0 
 
 49.0 
 
 138.0 
 
 16.0 
 
 107.3 
 
 36.7 
 
 Acute iwfectious diseases of childhood (measles, 
 scarlet fever, whooping cough, diphtheria), '___ 
 Tuberculosis of the lungs 
 
 20,2 
 10.3 
 
 
 tl.9 
 
 External causes (accidents, suicides and homi- 
 cides, ~ ~ - - 
 
 2.1 
 
 
 
 ♦MetropcIitSn exposure and deaths contain no persons under one year of age; Begistration 
 Area rates are on basis ol estimated population and deaths at all ages. 
 tPer cent, increase in S years. 
 
 With the exception of "external causes," the rate among industrial 
 policy-hold«rs has decreased in every instance, in much greater pro- 
 portion than tlie corresponding rate for the Registration Area. The 
 greatest reductions in every instance appear in those diseases to 
 which the Company's Nursing Service is giving particular attention. 
 The maternity service comprises one-fifth of the entire nursing serv- 
 ice among industrial policy holders of the Company ; the decrease in 
 the death rate from diseases relating to child birth has been over 12 
 per cent., while the population at large has suffered an increase of 
 nearly two per cent. From 1911 to 1915, the death rate from diseases 
 of the puerperal state fell from -72.9 per 100,000 to G5.3; a decline of 
 10.4 per cent. During this same time the decline in the Registration 
 Area was but 4.5 per cent. 
 
201 
 
 In explaining the remarkable improvement in the death rate of 
 its policy-holders, the Company says, "It is impossible to disassoci- 
 ate the effect of the nursing service from that of the other activities 
 of the Company and from the results of the public health work of 
 the communities. The extensive distribution of "the Company's edu- 
 cational literature, the cooperation with health officers and the very 
 excellent activities of so many of the local and state departments 
 of health, have all played an important part in determining the favor- 
 able returns. But the country-wide extension of the nursing service 
 to include over 200,000 patients annually, the intensive work done 
 often in the nature of emergent relief, the education in personal 
 hygiene which follows the more than a million visits made by the 
 nurses to industrial homes, together must be credited .with a large 
 share in the mortality reduction. In no other way can we explain 
 the more favorable condition which prevails among the insured than 
 among the general population."^ 
 
 Another evidence of what can be done by intensive preventive 
 effort through personal education and early medical treatment in a 
 restriclecl community is furnished by the attempts at group medicine 
 now being made in the clinic systems of the University of Wisconsin 
 and of the University of California. In Wisconsin it is claimed that 
 the work of the Clinic has improved in a marked degree the health 
 _,of the students by enabling them to have attention as soon as it is 
 needed, and thus to escape long illnesses which they would have 
 suffered had' they not had early care. The percentage of students 
 seeking medical advice has increased markedly each year owing to 
 the fact that they have learned the value of this early treatment, 
 which has, in turn, brought a decrease in the amount of serious 
 illness. In 1910-1911 at no time more than 20 per cent, of the stu- 
 dents sought medical advice, while in the three years following this 
 proportion increased to 25, 29, and 37 per cent., respectively. In 
 the last year, 1913-14, the increase was uniformly great through- 
 out the months of the college year. The percentage of the student 
 body seeking medical advice on February 1, 1914 was almost double 
 the percentage at the corresponding time in 1911. The number 
 reporting on October 1, 1913 was six times the corresponding num- 
 ber for 1910 ; the increase, in short, was felt throughout the entire 
 college year, because of the educational effort to secure early report- 
 ing and prevent serious illnesses. 
 
 Owing to this early treatment the number of complications in 
 cases of grip, for instance, has fallen steadily. In December 1910, 
 one-fifth of the student body reported grip, and 58 per cent, of these 
 "grip" cases developed complications such as inflammation of the 
 ear, eye, etc. In December 1913, when almost two-fifths of the stu- 
 
 ~7M£ee K. Prankel and Louis I. Dublin, -Visiting Nursing .Tnd Life Insurance." June, 1918, 
 page 55. 
 
202 
 
 dent body reported the disease but four per cent, developed compli- 
 cations; the percentage of complications developing decreased as 
 the percentage of students seeking medical advice increased. 
 
 The clinic claims that likewise the average time lost by students 
 because of illness has been greatly reduced, from eight and one-half 
 days in 1910-1911 to two and one-half days in 1913-14. Certainly 
 nothing could speak more strongly for the results of preventive work 
 and early, treatment. 
 
 The statistics of the University of California compulsory clinic 
 plan are even more striking. This clinic is financed by a compulsory 
 fee of ^3.00 a semester, which each student pays. As the student 
 body increases, the medical staff increases. The primary purpose of 
 the work is, according to Dr. Legge, to establish a place where "stu- 
 dents can be scientifically treated before a serious condition devel- 
 ops, and through educational means taught how to live, thereby elim- 
 inating disease by every available measure.'" 
 
 To accomplish this end every health measure deemed necessary 
 is enforced among the students. Each student is given a medical ' 
 examination on entrance, and in this way it is "possible to inform 
 him correctly as to his abilities for physical exercises, class-room 
 work, college sports, etc. Numerous defects, local infections, and 
 occasionally graver conditions which might also jeopardize the health 
 of others and be a menace to the community, are detected and 
 treated. Often students are relieved of imaginary diseases. In 1915 
 we found that 64 per cent, of the freshmen had errors of sight refrac- 
 tion, and our occulist wrote 700 prescriptions for proper glasses. The 
 dental examination revealed that only 82 men and 56 women out 
 of 1513 students had normal teeth. Numerous other illustrations 
 could be cited, such as postural defects, diseased tonsils, chest-dis- 
 eases, etc.'" 
 
 During the year 1915-16 the average number of daily dispensary 
 cases was 126.3, with an average number of annual treatments per 
 individual patient of 7.8. Throughout the college year, 4,516 stu- 
 dents received medical treatment or advice. This was 71 per cent, 
 of the total enrollment. "To the ipinformed," says Dr. Legge, "it 
 might appear that this large percentage of cases would indicate 
 unusual morbidity, but as a matter of fact the purpose is to encour- 
 age early advice for incipient conditions, thereby avoiding graver 
 complications and development, — the practical application of the 
 'stitch in time.' "^ 
 
 It should not be necessary to emphasize the necessity of a further 
 application of the "stitch in time" theory. In the tabulated causes 
 of rejection in the report of the Provost Marshal General on the 
 operation of the first selective draft, fully 50 per cent of the rejections 
 
 (')Robert T. Legge, California State Journal of Medicine, April, 1917. 
 
203 
 
 were shown to be due to causes which, if treated in time, would have 
 been preventable or correctable. Twenty-two per cent, were 
 attributed to eye conditions, six per cent, to ear, nine per cent, to 
 teeth, and four per cent, to physical underdevelopment. 
 
 When w« turn to the actual work being done in Pennsylvania to 
 reduce sickness and promote health, we find that it is carried on~ 
 principally by state and local boards of health and by various private 
 agencies. 
 
 Especially in the large cities, much of the work of sickness preven- 
 tion is carried on by private agencies. In Philadelphia alone approxi- 
 mately $200,000 was spent in this \way in 1917 by fifty or more organi- 
 zations, including hospital social service departments, child-welfare, 
 housing and visiting nurse societies. There are at work throughout 
 the state some 630 public health nurses, only 274 of whom are paid 
 from public funds. By spreading a knowledge of personal hygiene 
 and child welfare; of community sanitation and of methods of disease 
 prevention, these public health nurses are doing a work of inestimable 
 value, and through their contact with the individuals they are able to 
 interpret their health message in the language of that individual's 
 needs. Approximately a third of all these nurses are in Philadelphia, 
 and seventy-five more are centered in Pittsburgh; Wilkes-Barre, 
 Scranton, Erie, Harrisburg, York and Reading have from ten to 
 fifteen nurses each, and the remainder are scattered through the state. 
 Of the 630, approximately 260 are doing general visiting nursing ; 130 
 are tuberculosis nurses, 100 are child welfare nurses, eighty are school 
 nurses, and sixty are rendering nursing service in industrial 
 plants.^ 
 
 Much educational work is undertaken by the private organizations 
 promoting health standards, as exampled by such publicity work as 
 that done by Housing Associations and by the Pennsylvania Society 
 for the Prevention of Tuberculosis. Here educational health work 
 has been carried into the schools, the moving pictures and the press, 
 and bulletins are regularly issued in which health standards are set 
 forth. Much preventive work is carried on indirectly by different 
 types of social agencies emphasizing diet, cleapliness, and carrying, 
 as does the public health nurse, a message of hygiene to the individual 
 family. The importance of work of this sort done by the hospital 
 dispensaries and the hospital social service workers,, as well as by 
 private physicians, cannot be overestimated. 
 
 Certain progressive employiers in all parts of the state have insti- 
 tuted measures for disease prevention, and may have employed fac- 
 tory doctors or industrial nurses, or both. Such work is of great 
 value, but is, in the nature of things, confined to the larger, more pro- 
 -gressive companies, where disease-producing conditions are likely to 
 
 (') Owing to war conditions, exact figures are not available. 
 
204 
 
 be reduced to the minimum. Like any voluntary health insurance, it 
 covers least those who need it most. Far too often it is limited to 
 industrial accidents, or to first aid measures and the treatment of 
 obvious disabilities, in a dispensary. The work is therefore super- 
 ficial and does not touch either the larger and more serious group of 
 diseases of a non-accidental nature, or the more far-reaching field of 
 prevention, which goes back to the causes of sickness within both the 
 factory and the home. 
 
 Besides the multitude of private agencies, the state has recognized 
 its responsibility for the preservation of health by the establishment 
 of the State Department of Health, all the work of which is in reality 
 largely preventive. In addition to its general work, the State 
 Department of Health has direct control of all public health, work 
 in the 1,783 townships having a population of less than 250 to the 
 square mile. Altogether these rural communities contain 2,225,000 
 persons, or about one quarter of the population of the state. 
 Through educational publicity work of all sorts, the Department 
 attempts to teach people how to keep from getting sick. The various 
 divisions into which the department is organized indicate the range 
 of its work. 
 
 The Bureau of Vital Statistics giveg a knowledge of existing dis- 
 eases which should and can be combated : it has a personnel of twenty- 
 five to thirty, and a series of 1,070 local registrars, each with a 
 deputy. The Division of Medical Inspection which carried on public 
 health activities in the small towns has a personnel of approximately 
 800,. in addition to 921 school medical inspectors, whose importance is 
 later discussed. The Division of Sanitary Engineering advises on 
 water and sewage systems and prevents pollution of water supplies, 
 employing a staff of 106. The Division of Laboratories and the Dis- 
 tribution of Biological Products, makes analyses for physicians and 
 supplies them with various serums. A recently created Bureau of 
 Housing was inactive in 1913-1915 because no funds were appro- 
 priated for it, but since that time has been actively organized. The 
 Divisions of Tuberculosis Sanitoria and Dispensaries do exceedingly 
 important preventive work through the three State Tuberculosis 
 Sanitoria at Cresson, Mont Alto and Hamburg, and through 119 
 tuberculosis dispensaries, employing 200 physicians and 119 nurses. 
 The work of these nurses includes not only the prevention and care of 
 tuberculosis, but also Child Welfare and Health Work in general in 
 the homes of tuberculosis patients. Milk, eggs and other forms of 
 charitable relief are furnished to needy patients, and follow-up sys- 
 tems are maintained. The tuberculosis work is perhaps the most 
 important work of the State Department. 
 
 A similar chain of dispensaries for the treatment of venereal dis- 
 ease is now being established by the Division for the Treatment of 
 Veneral Diseases. 
 
205 
 
 There is also a Division for the Control of the Sale of Narcotics, 
 and a Division of Public Service, which attempts to maintain sani- 
 tary standards in hotels, restaurants, and other places where food is 
 sold. 
 
 The Division of Child Hygiene is organized to work for the lower- 
 ing of infant mortality in the state, and has a staff of five nurses for 
 the state, exclusive of Philadelphia, to assist communities in estab- 
 lishing child welfare activities. The State Department of Health 
 alone estimates that it saved 60,000 lives between 1906 and 1914. 
 
 Noteworthy as are these results, the Health Department itself 
 would be the first to acknowledge that it does not touch the greater 
 part of existing sickness or adequately meet -the problem of its pre- 
 vention. Dr. Wilmer R. Batt, chief of the Bureau of Vital Statistics, 
 as has been previously stated, gives as "the adopted field of public 
 health activities," "the acute communicable diseases of epidemic 
 type" (including tuberculosis), and the diseases of infants. In 1915, 
 these, diseases accounted for somewhat less than a third of the deaths 
 in Pennsylvania in that year. Even within the field of public health 
 work, many local health departments are ineffective or fail to act, 
 especially in the smaller towns. The State Health Department, in 
 discussing the health work of the boroughs, in which live 2,225,000 of 
 the population of the state, enumerated as handicaps the difificulty of 
 getting competent citizens of good standing to serve, the jealousy of 
 such bodies as school boards an^ borough councils, failure to enforce 
 quarantine according to the rules of the state, especially where there 
 are only a few cases of disease, and laxity in attending to such nuis- 
 ances as. poor housing and the improper disposal of garbage and 
 sewage. Tbe difficulty of obtaining sufficient appropriations, also 
 mentioned, is not confined to the boroughs. 
 
 All the limitations and many others were emphasized in recent 
 surveys made under the supervision of the Division of Child Hygiene 
 of the State Department of Health. Of fourteen communities studied 
 only three had active local boards of health or health officers. These 
 communities ranged from 1,200 to 35,000 in population, and several 
 of them were important industrial centers. The large percentage of 
 foreigners in almost all of them madfe doubly necessary active health 
 work and the enforcement of sanitary laws. Yet in only two of the 
 communities were contagious diseases carefully reported. In eight 
 out of the fourteen, the housing and general sanitary conditions were 
 reported as very serious. In one city of over 30,000 the garbage 
 collection depended entirely upon volunteers, and children often 
 gathered it in open express wagons. The housing conditions showed 
 extreme over-crowding in the industrial centers, and in the rural 
 communities many of the prbblems were even more serious — water 
 standing in cellars, old houses in bad need of repair, and wholly 
 
206 
 
 improper facilities for the disposal of waste. In one mining com- 
 munity where more than two-thirds of the population of 16,000 were 
 foreigners, the infant death rate in 1917 was 177 per 1,000. From 
 one-third to one-half of the school children were undernourished, the 
 number of premature and still births was above the average, yet 
 there was no infant welfare or prenatal work, contagious diseases 
 were not reported, garbage was deposited on a dump, sewage was 
 carried off in an open sewer, and the Board of Health was purely 
 a "nominal body." 
 
 In another instance where a still larger proportion of the com- 
 munity were foreigners, it was reported that from 1,100 to 1,300 
 children were born every year, and that three out of every five of these 
 children died under five years of age." The housing conditions in 
 this commiinity were rated as the worst in Pennsylvania. No build- 
 ing, plumbing, or milk inspection was made. The appropriation for 
 health-^work was |1,200, while the population was approximately 
 35,000. The percentage of illiteracy among the men of voti:^g age 
 in this community was 28.6, the highest rate for any city of similar 
 size in the state. 
 
 In many instances what sanitary laws were found, were not en- 
 forced. A laxity in the enforcement of school attendance, bad sani- 
 tary and housing conditions, lack of nursing and hospital facilities, 
 and high death rates, went hand in hand. Four communities had 
 no appropriations whatsoever for health work. Several had health 
 offlcers who were not in any way qualified. The salaries of these 
 officers, sometimes as low as fSOO.OO a year, did not permit efficiency 
 or enforcement. The State Department of Health attributes the 
 high mortality rate in these communities to the (1) poor housing, 
 (2) insanitary conditions of streets and alleys, (3) failure to report 
 contagious diseases, (4) lacli of infant welfare and prenatal work 
 (5) improper feeding of infants, because of the poor milk supply 
 and patent mixtures, (6) failure to call a physician (especially among 
 foreign families), except in extreme cases, and •(7) very improper 
 care at confinement because of unregistered midwives and inexperi- 
 enced neighbors or friends. 
 
 For many of these conditions the community is directly respon- 
 sible. Yet outside the largest cities it is the exceptional place which 
 has even a full time health officer, much less an adequate health 
 appropriation. The American Public Health Association claims that 
 a dollar per person a year would be the desirable amount for public 
 health work. The state's largest city, Philadelphia, had an appro- 
 priation in 1917 of 10.46 per capita, and in 1918 of |0.42. In at- 
 tempting to save money lives are resklessly lost, for in the absence 
 of adequate funds, public health work must fail to exercise its due 
 preventive effect even within its adopted field. 
 
207 
 
 Perhaps the most signrflcant available material on sickness pre- 
 vention in this state is the material on the medical inspection of 
 school children. In considering prevention we instinctively turn to 
 infant and child vv^elfare work. The men rejected in the draft as 
 physically unfit were the school children of yesterday, and if their 
 defects had been treated earlier they might not have been disquali- 
 fied. Dr. Frederick Peterson of the National Education Association 
 said recently, "Authorities show us that there are physical defects in 
 75 per cent, of the school children of to-day, most of them preventable 
 and remediable, heart-and-lung-diseases, disorders of hearing and 
 vision, malnutrition, diseased adenoids and tonsils, flatfoot, weak 
 spines, imperfect teeth — » * « » compulsory education we have — 
 compulsory feeding and training of the mind. Compulsory health 
 we must have — compulsory feeding and training of the body."^ 
 
 In Pennsylvania medical inspection of school children is compul- 
 sory only for the first and second class districts. For the third and 
 fourth class districts, that is for districts, having a population of 
 - 5 000 to 30,000 and of 5,000 or less,, inspection is optional, but a 
 definite vote declining it is necessary, and few school boards take 
 this action. The result is that in 1918 of 2,589 school districts in 
 the state, there was medical inspection in 2,437, or almost 94 per 
 cent. The districts were divided as follows: 
 
 4th class, :- 2,382 Medical inspection in 2,321 
 
 3rd class, 191 Medical inspection in 190 
 
 2nd class, 14 Medical inspection in 14 
 
 1st class, 2 Medical inspection in 2 
 
 Total, 1.589 Medical inspection in 2,4S7 
 
 When medical supervision in schoo.ls was first introduced into 
 the United States some twenty years ^go, the primary purpose was 
 a desire to reduce the acute communicable diseases. Since then the 
 conception of what preventive work may accomplish has greatly 
 extended the field of this health activity. "Although lessening of 
 communicable disease is necessary to be kept in mind whUe per- 
 forming the work, by far the most important phases of medical super- 
 vision are those dealing with the broad problems of school hygiene 
 by practical teaching and by medical inspection of the individual 
 pupil and the giving of proper advice or treatment to those found 
 defective; this may be. carried even to the segregation of certain 
 groups of diseased children while continuing their school work; to 
 providing separate schools for the defective and incorrigible; to 
 providing free medicine or dental care to the poor; to surrounding 
 the child with proper sanitary precautions in buildings and grounds, 
 with a safe water supply; and in some instances even to supply 
 proper nourishment."^ 
 
 (>)Litcrary Disest, October 12, 1918, page 20. 
 
 C'iB^ort on Sociil Medical Supervision, Washington, D. C, 1914. 
 
 14 
 
208 
 
 From the time of the passage of the School Code in 1911, the growth 
 of School Medical Insijection in the fourth class districts of the state 
 is significant : 
 
 
 ' School Year. " 
 
 Districts' 
 Impected. 
 
 School BuUdinss, 
 Inspected. 
 
 Pupils 
 la^ected. 
 
 1911-12 ' 
 
 - . .-.■.■■; . ^. *. 
 
 757 
 1,469 
 1,881 
 2,159 
 
 3,572 
 7,375 
 S,969 
 11,036 
 
 145,499 
 
 1912-lS 
 
 
 305,372 
 
 191S-I4, — 
 
 
 344,099 
 
 1914-15 
 
 
 469,199 
 
 
 
 
 
 1,311,603 
 
 During this four year period in the fourth class districts about a 
 million and a quarter children have been examined; of the 469,199 
 examined in 1914-15, 335,427 or 71.5 per cent, were found to be de- 
 fective. Of these 44 per cent, had multiple defects. In the third 
 class distriicts where 48,787 pupilis in 21 counties were inspected, 
 33,552, or 68.8 per cent, were found to be defective. The National 
 Education Association after a survey in 1914 of country school con- 
 diiiians, came to the conclusion that wherever urban and rural statis- 
 tics were contrasted, the country child was found to be from five to 
 twenty per cent, more defective than the city child. In Pennsylvania 
 they estimated that 75 per cent, of the children were defective in the 
 rural population of a given county. Apiong the school children in 
 Altoona and Pittsburgh, the per cent, of defectives for the same year 
 was 69 and 72 per cent., respectively. 
 
 The powers exercised by the Health and School authorities are 
 purely recommendatory, with the exception of the segregation of 
 communicia.ble diseases. Notes are sent through the teacher to the 
 parents of defective children, giving advice as to treatment. In 
 fourth class districts in 1914-15, 90.8 per cent, of the children having 
 defects received these letters of advice. More than 51 pei* cent, of 
 those examined had been followed through the year, but only 22 per 
 cent, of these were getting some sort of treatment. An examination 
 of the nature of the defects in the pupils examined brought out the 
 fact that the large majority are easily correctable if treated in time. 
 Eyes, tonsils and teeth can all be remedied if the treatment is given 
 early, and they account for the largest numbers of defects. 
 
209 
 
 NATURE OF DEFECTS.i 
 
 Per Cent, ot 
 Total Pupils 
 
 „ . . ., . Examined. 
 
 Number of pupils wrth defective vision, 83,748 IT 8 % 
 
 1 eye, ._ 27,934 
 
 2 eyes. J 55,gl4 
 
 Number with other eye afflictions, 5,512 1.64% 
 
 (Conjunetiviiiis, iritis, trachoma, astigmatism, etc.) 
 
 Number with detectivs hearing:, 15,600 3.3 '% 
 
 Number with defective breathing, 22,837 i.9 % 
 
 (Of these, 6,713 or more than 25% were "suspected" of having 
 adenoids.) 
 
 Number with defective teeth, .. 252,174 63 7 % 
 
 (Of these, 45.3% had decayed teeth.) 
 
 Number with enlarged tonsils, 123,222 26.3 % 
 
 Number with enlarged cervical glands, 22,Sr4 4.9 % 
 
 Number with tuberculosis, 789 .17% 
 
 Number with nervous diseases, 755 .16% 
 
 Number with sMn diseases, 6,296 1.3 % 
 
 Number with malnutrition 8,578 1.8% 
 
 Number with deformities, 1,645 '.. 
 
 Number with quarantinable diseases, J 56 .04% 
 
 Of those having more than one defect, 54,225, or more than 36 per 
 cent, had defective tonsils and teeth. 
 
 The result of treatment on these correctable defects is easily seen. 
 
 Of the 10,041 cases of defective vision treated, 6,899, or 68.7 per 
 cent, were improved. ^ ' 
 
 Of the 1,321 cases of defective hearing treated, 762, or 57.6 per 
 cent, were improved. • 
 
 Of the 1,190 cases of defectiA'e breathing treated, 724 or 60.8 per 
 cent, were improved. 
 
 Of the 45,119 cases of defective teeth treated, 45,119 or 100 per 
 cent, were improved. 
 
 Of the 6,844 cases of defective tonsils treated, 4,373 or 63.8 per 
 cent, were improved. 
 
 Of the 150 cases of defective skin diseases treated, 116, or 77.2 per 
 cent, were improved. 
 
 Of the 178 cases of malnutrition treated, 107, or 60.1 per cent were 
 improved. 
 
 In spite of the fact that so small a proportion of the total number 
 of defective children — only 16.3 per cent really secure treatment, the 
 reduction in the number of defective pupils is decreasing materially 
 every year. In 1911-12, 76.7 per cent of those examined were found 
 to be defective. In 1914-15 this had fallen to 71.5 per cent. The 
 number of pupils with defective tonsils has been reduced from 35.1 
 per cent to 26.2 per cent; with defective vision, from 29. per cent 
 to 17.8 per cent. 
 
 1911-12. 
 
 1912-13. 
 
 1913-14. 
 
 145,199 
 
 305,372 
 
 377,079 
 
 78.7 
 
 74.9 
 
 72.7 
 
 29.0 
 
 27.0 
 
 24.2 
 
 3.4 
 
 2.9 
 
 3.3 
 
 10. S 
 
 3.4 
 
 5.7 
 
 8.7 
 
 6.9 
 
 6.9 
 
 35.1 
 
 218.5 
 
 28.0 
 
 1914-15. 
 
 Total number inspected, 
 
 Per cent, of defective pupils, 
 
 Per cent, ol pupils with detective vision, 
 
 Per cent, of pupils with defective hearing, 
 
 Per cent, of pupils with defective nasal breathing. 
 Per cent, of pupils with enlarged cervical glands. 
 Per cent, of pupils with defective tonsils, 
 
 469,199 
 71.5 
 17.8 
 3.3 
 4.9 
 4.9 
 
 (1) Department of Health, 9th Annual Report, 1914, Part I. 
 
210 
 
 A large part of this reduction, especially of defects of vision, is 
 due to the educational work instigated by the State Department pf 
 Health and the various societies throughout these districts. Tooth- 
 brush drills, health charts, and the proper teaching of hygiene, can 
 but produce significant results. 
 
 The activities of the School Medical Inspectors in these 4th class 
 districts have not been confined solely to the medical examination of 
 the children. Sanitarj' inspection of the school buildings has been 
 instituted, and by notifying school boards of bad conditions and 
 suggesting possible remedies, insanitary conditions in these build- 
 ings have materially improved. In 1914-15, 2,353 out of the 2,377 
 4th class districts were inspected. The 12,525 buildings inspected 
 contained 19,892 rooms. Ninety-eight 'and five tenths per cent of 
 these buildings were insanitary in one or more points. 
 
 No adjustable seats or foot stools, 79.6% of the buildings. 
 
 Unjacketed stoves, 38.6% of the buildings. 
 
 ^ No thermometers, 37.3% of the buildings. 
 
 No provision to keep air moist, 63.8% ol-the buildings. 
 
 No fresh air inlets at stove or furnace, 67.8% of the buildings. 
 
 Windows only ventilation, 74.4% of the buildings. 
 
 Ventilation shields not In use, 56.1% of the buildings. 
 
 Insanitary water container — - 2S.1% of the buildings- 
 Common drinking cup, 37.2% of the buildings. 
 
 Common towel, /- 38.4% of the buildings. 
 
 Privies unclean, 22.5% of the buildings. 
 
 Pri'ies improperly built, 61. 2%-of the buildings. 
 
 Vaults insanitary, 71. ^o of the buildings. 
 
 No disinfectant used, 49.1% of the buildings. 
 
 The light area in 42.1 per cent of the rooms was judged insuflflcient. 
 The relation between this insanitary environment and the fact that 
 almost three-fourths of our country school children have physical 
 iiefects, is obvious. 
 
 Standards of inspection were raised with distinct improvements 
 noted during the year. Insanitary sweeping was reduced from 60 
 to 51 per cent. Insanitary dusting was reduced from 43 to 32 per 
 cent. Insanitary water containers were reduced from 37 to 25 per 
 cent. Insanitary cleaning of the water containers was reduced from 
 50 to 44 per cent. 
 
 More recent figures on school medical inspection are available for 
 Philadelphia. In 1916, 151,869 pupils were examined or about 75 
 per cent of the total number of school children. The city Depart- 
 ment of Health has never had the necessary facilities for fully carry- 
 ing out the law, and examining all school children. One hundred and 
 sixty-seven thousand, two hundred and sixty-nine defects were rec- 
 ommended for treatment. 
 
 The majority of the defects found in these children, like those 
 found in the school children of the 4th class districts of the state, 
 are correctable. 
 
21,960 
 
 13.1 % 
 
 28,401 
 
 16.9 % 
 
 l',681 
 
 1.04% 
 
 76,923 
 
 45.9% 
 
 S,132 
 
 l.S % 
 
 3,222 
 
 1.9% 
 
 883 
 
 
 
 568 
 
 
 260 
 
 
 21 
 
 
 25,313 
 
 15.1 % 
 
 2,865 
 
 T.7^,, 
 
 211 
 
 DEFECTS RECOMMENDED FOR TREATMENT. 
 Philadelphia School Children, 1915-16. 
 
 Per Cent. 
 
 of Total. 
 
 Eye, 
 
 Sose, throat, mouth, 
 
 Ear, 
 
 Teeth. ^ 
 
 Orthopedic, 
 
 Nutrition, , 
 
 Beart. 
 
 Nervous diseases, 
 
 Defective mentality, 
 
 Giastro-intestinal, 
 
 Skin, 
 
 Acute iUness and accidents, 
 
 "Poor niatrition and eye strain are the two basic and original de- 
 fects, and the majority of the physical defects of later childhood are 
 secondary defects resulting from neglect of these.^" For example, 
 chronic heart disease is often the result of acute infections like 
 tonsillitis or influenza and defective hearing is often the result of 
 adenoids, which in turn, can be traced in many cases to poor 
 nutrition. 
 
 "Some of the figures given are too low, because in the poorer sec- 
 tions of the city the inspectors become dulled to the existence of 
 poor nutrition in its moderate degree, and because care is possible 
 only by impossible changes in the homes. The number of stoop- 
 shouldered children recorded is likewise too small, because the lack 
 of facilities for corrective work has tended to make the inspectors 
 overlook mild cases. In 1917, with the institution of corrective 
 gymnastics, there will be over 10,000 stoop-shouldered children 
 nominated for corrective exercised by medical inspectors. The items 
 chorea, constipation, appendicitis, etc., represent chance discoveries 
 and emergency cases, rather than comprehensive and thorough exam- 
 inations of parts of the body.'" 
 
 Many factors influence the correction of these defects. The most 
 important are (1) the nature of the disease or defect, (2) the use of 
 the school nursg; and (3) the attitude of the parents. In 1916 in 
 Philadelphia 149 schools employed nurses, and fifty-two did not. The 
 employment of a school nurse almost doubles the efficiency of the 
 inspector, and greatly increases the per cent, of defects corrected. 
 The percentage of physical defects corrected in 1916 varied from 
 33.1 per cent, to 43.6 per cent, in schools where no nurse was em- 
 ployed. Where a nurse was employed, the percentages were from 
 40.5 to 65— according to the social grade of the school. 
 
 During the last five year period in Philadelphia the percentage of 
 cases receiving treatment has constantly increased. 
 
 In 1912 only 45 per cent, of the cases recommended for treatment 
 received it, wtile in 1916 this percentage had increased to 54.9. In 
 
 (») Annual Report, Bureau of Health, Philadelphia, 1916, pages 31 and 36. 
 Olnnual Report, Bureau of Health, Philadelphia, 1916, page 36. 
 
212 
 
 the treatment of "important defects" the increase has been from 31.4 
 to 43.8 per cent. ; in the treatment of "unimportant defects" from 
 85.5 to 95.3 per cent. 
 
 Of the 54.9 per cent, receiving treatment, 33.9 per cent, were treated 
 through a private physician, 22.5 per cent through a dispensary, 12.1 
 per cent, through a nurse, 31 per cent, through the parents, and 0.5 
 per cent, through the medical inspector. It is significant that in 
 the analysis of the type of treatment received, the number of defects 
 treated through a dispensary increases steadily and the number 
 treated through a private physician decreases, as the social grade of 
 the school is lowered. Thus in 1916 in schools of Social Grade A, 60.3 
 per cent, of the defects were treated by a physician, and 17.2 by a 
 free dispensary. In schools of Social Grade C, only 22 per cent, 
 were treated by private physicians while 25.6 per cent, obtained care 
 through free dispensaries. 
 
 In the case of the 45 per cent, of the defective children who re- 
 ceived no treatmMrt, in 78 per cent, of the cases, the non-treatment 
 was due to the perusal of the parents. Poverty and ignorance play a 
 large par^^bere, as well as the lack of dispensary facilities. The re- 
 sults of the treatment, where it was secured, ^show without question 
 the need for further and more complete medical inspection. Of 
 some 76,045 cases of defects in schools employing nurses where the 
 results of treatment were examined, it was found that in only 2.6 
 per cent, there was no marked improvement. In 71.7 per cent, the 
 defect had been cured and in 25.8 per cent, it had been materially 
 improved. Considering the "important defects" separately, we find 
 that more than 61 per cent, were cured and more than 34 per cent, 
 were improved. 
 
 '' These figures speak for themselves. When we go behind the school 
 children to the babies we find the need of measures for sickness pre 
 vention still more urgent. The startling infant mortality rates in 
 this state have been discussed at length in Part II, Section I. The 
 need for maternity care was brought out in every survey made. "As 
 the twig is bent, so is the tree inclined." 
 
 The question is, how to stimulate a more general and more ex- 
 tensive movement for disease prevention. 
 
 The state has a definite responsibility in seeing to it that some 
 action is taken' both to more adequately treat actual sickness and 
 to prevent it by an attack upon its causes. The state alone has the 
 power to act in a way which will be far reaching and democratic; 
 which will not limit the solution to the chosen few of an individual 
 group. 
 
 Among proposals for aiding in this solution stands State Health 
 Insurance, claiming to provide care for employees when ill, and to 
 stimulate sickness prevention and keep them well. 
 
213 
 
 Any insurance plan, as a matter of business efficiency, must pro- 
 vide and further preventive measures; Health Insurance and pro- 
 grams for sickness prevention- are not opposed in any way to each 
 other. Neither takes the place of the other, and both are necessary. 
 
 Advocates of social insurance claim that nothing so quicWy stimu- 
 lates preventive effort as the enactment of insurance laws. Two 
 reasons appear for 4his stimulus to prevention created by insurance. 
 One is the desire of the insurance organization to reduce its losses. 
 The other is the desire of the persons paying for insurance to reduce 
 the cost. 
 
 Dr. I. M. Eubinow, one of the leading American students of social 
 insurance, has recently given a clear description of these preventive 
 forces, enumerating the different kinds of "preventive work carried 
 on because of insurance." 
 
 "Not only have the insurance organizations of various types 
 worked for prevention and reduction of losses, b\it they have also en- 
 deavored to obtain the co-operation of the insured in exercising better 
 care, while relieving him of the fear of loss ; they have introduced 
 another motive through the mechanism of premium adjustment."^ 
 Fire insurance has resulted in stricter building laws, in better fire 
 extinguishing facilities, in the development of automatic sprinklers ; 
 Commercial Life Insurance Companies have found it to their ad- 
 vantage to establish and encomrage public health nursing and life- 
 extension movements ; compensation insurance has given a tremen- 
 dous stimulus to industrial safety; health insurance in Europe has 
 stimulated better care of the sick and convalescent, and unemploy- 
 ment insurance has stimulated better provision for public employ- 
 ment ofifices. 
 
 If State. Health Insurance gives promise of stimulating adequate 
 measures for sickness prevention, and so making possible the elimi- 
 nation of from 40 to 60 per cent, of existing illness, while at the 
 time it makfes provision for the treatment of that large part of the 
 population which will continue to suffer from the burden of sick- 
 aess, it is worthy of thorough study and careful consideration. 
 
 From all the statistics gathered and special studies made it is 
 startlingly evident that some far-reaching measures are needed in 
 Pennsylvania, both for the efficient -care of employees and their 
 families when actually ill and also for the prevention of disease, if 
 this state is to fulfill its great responsibility to the citizenship of 
 the future. 
 
 Any constructive action which the Commission can take to meet 
 these needs will be a direct contribution to the strength of the Com- 
 monwealth. 
 
 (1) t. M. RubinoTT, "Prevention vs. Insurance," The New Republic, July 27, 1918, page ; 
 
(214) 
 
PART III. 
 Health Insurance. 
 
 ( 215 ) 
 
(216) 
 
217 
 
 PART III. 
 
 SECTION I 
 
 Social Insurance. 
 
 Insurance is a provision made by a group of persons for distribut- 
 ing among themselves the losses which may come to any one of them 
 from hazards to which they are all subject. "Insurance in all its 
 forms," says Thomas B. Love, Assistant Secretary of the Treasury, 
 "is the best expression in organized business terms of the great social 
 principle of mutuality and co-operation." As a distributor of risk, 
 £tll insurance is social in principle, even when conducted on a com- 
 mercial basis. It removes from the individual the anxiety and re- 
 sponsibility of the burden of risk by allowing him to pay a very small 
 share of every man's loss in order to have his own loss distributed 
 in the same way. Owners of property, both large and small, as a 
 rule, prefer the certain loss, of relatively insignflcant annual 
 premiums, calculated to cover risk, cost of administration and busi-. 
 ness profit to the insurance carrier, to the chance of losing the entire 
 value of their property. Fire and marine insurance, because of the 
 obvious nature of the risks involved, were among the first types of 
 such protection to develop. But gradually the seriousness of other 
 hazards was recognized, and systems for insuring lives, property and 
 business enterprises against every conceivable riskhave been worked 
 out. 
 
 Among the more recent hazards to be definitely recognized and dis- 
 tributed are those arising from ill health. The realization of the fact 
 that few workers by hand or by brain can afford the more or less com- 
 plete loss of earning power frequently suffered from entirely unfor- 
 seen attacks of illness has led to the practice a,mong the more in- 
 telligent and prosperous workers of carrying health insurance in 
 addition to life, accident or fire insurance. 
 
 The term "social insurance" as contrasted with commercial insur- 
 
 - U 
 
 ahce has come to have a special and distinct meaning, both in this 
 country and abroad. It is recognized that while there are few indi- 
 viduals with sufQcient resources to meet alone the numerous risks to 
 which they are subject, the wage earning classes of the population 
 are peculiarly subject to certain economic hazards. Sickness, per- 
 manent or temporary invalidity, accident, old age and unemploy- 
 ment all interfere with regular work and hence with the steady 
 income necessary to maintain proper standards of living. Circum- 
 stances of work and of living for which industry and the state are 
 
21& 
 
 in a certain sense responsible make these hazards greater for em- 
 ployed persons as a class than for others. Increased hazards 
 mean higher premium rates for protection in companies operating on 
 a commercial basis, and this fact, coupled with the frequent inade- 
 quacy of resources of the exposed persons, make commercial health, 
 accident, old age, or unemployment insurance for them an impos- 
 sibility. 
 
 Not only the workers themselves, but both industry and the state 
 suffer severely as a result of the industrial ha2;ards to which em- 
 ployed persons are subject. 
 
 Eecognizing these facts, organized society in the form of state gov- 
 ernments both in Europe and in America has in recent years begun 
 to distribute the risk among the three factors responsible for and 
 exposed to it, employees, employers and the state. This has been 
 done by the regulation of insurance carriers and the elimination of 
 profit, thus reducing the premium rate, by the assumption of a part 
 of the cost of administration, by imposing upon the employing class 
 a share in the cost, and by compelling the wage earner to contribute 
 his share. 
 
 The only general experience with social insurance in the United 
 States is in the field of Workmen's Compensation, but in Europe 
 almost universal provision has been made to meet the problems of 
 sickness, old age, invalidity and unemployment, as well as industrial 
 accidents among wage workers, by systems of social insurance. In 
 some cases these systems are voluntary, regulated and subsidized by 
 the state, but they are rapidly being replaced by compulsory social 
 insurance acts. 
 
219 
 
 PART III. 
 SECTION II. 
 Health Insurance in Europe.-^ 
 Health Insurance in some form or other has been in existence in 
 Europe almost since the beginning of wage employment itself. Long 
 before the political development of state insurance systems, mutual 
 insurance against sickness was being administered by the many sick 
 benefit societies originated by the wage-workers themselves as an 
 attempt to distribute risks. 
 These original societies were of several kinds: 
 
 1 — Private mutual societies composed of persons of various 
 occupations. These were usually local in character and at- 
 temptea to maintain more or less complete systems of insur- 
 ance. In France and Belgium great emphasis was laid on 
 annuities, but sick benefits gradually assumed importance in 
 all countries. The chief features of these benefits were medi- 
 cal care and hospital care, medicines, and cash benefits for 
 members, medkal care and sometimes cash benefits for the 
 families of members, and lump sums paid at times of con- 
 , finement. 
 
 Few of these societies accumulated a sufficient reserve to 
 insure actuarial solvency, and almost none of them adjusted 
 their dues to meet the increasing hazards due to the advanc- 
 ing age of their members. Consequently, financial ruin was 
 a constant danger. 
 2 — ^Federated or affiliated societies grew out of the combining 
 of many of the local bodies. Meetings were held regularly, 
 and rituals were gradually developed. This form of lodge 
 organization exists to-day in thousands of fraternal societies 
 all over the world. Some of these affiliated societies grew 
 to enormous size, especially in England, and administered 
 both life insurance and health insurance. Scarcely any of 
 them however, were solvent, as -a whole. In England in 1909, 
 before the passage of the National Health Insurance Act, 
 the Manchester Unity of Odd Fellows and the Ancient Order 
 of Foresters had each about 1,000,000 members, and a large 
 number of lodges, but in botb of them the insolvency of some 
 of the branches more than offset the flourishing condition of 
 others. 
 3 — ^Establishment societies among the employees of individual 
 establishments or businesses and frequently supported in 
 part by the employers were also formed for the administra- 
 tion of sick benefits. Membership in some of these funds 
 was required by the employer, while in other cases it was 
 
 (')See TaWes I and II at end o( Part in. 
 
220 
 
 voluntary. The influence of the employer seems to have 
 been the chief difficulty in these funds. Employers of course 
 used their influence with varying motives. In some cases 
 the organization of employees in the funds was used to pre- 
 vent the formation of labor unions among them, and often 
 the mobility of labor was interfered withj for employees 
 were usually unwilling to leave funds to which they had 
 contributed and from which they had not received benefits, 
 unlass their contributions could be refunded to them. 
 4 — Trade Unions began at an early period to include the pay- 
 ment of sick benefits among their other activities. They 
 almost invariably failed to provide for solvency, however, 
 making no adjustment of rates to correspond to the increas- 
 ing risks of advancing age, and not attempting to maintain 
 reserves sufficient to assure the payment of claims perman- 
 ently. The constant admission of young men to membership 
 helped to stabilize the risk, but the rate of increase in mem- 
 bership was largely dependent on the ability of the Unions 
 to improve industrial conditions, an^ showed wide fluctua- 
 tions. 
 VOLUNTARY HEALTH INSURANCE SUBSIDIZED BY THE STATE. 
 
 Kealization of the benefits to be secured from these insurance 
 schemes, and of the financial difficulties confronting them has led 
 various European governments to encourage their growth by grant- 
 ing subsidies to certain societies which conform to specified stand- 
 ards. "It has been a noticeable feature in the subsidized state in- 
 surance schemes that the rapidity and energy of their growth seems 
 to have been in ratio to the subsidies obtained from the state. With- 
 out state aid, only the more thrifty and well paid of the workers 
 seem voluntarily to insure, and many of these often are unable to 
 keep up their insurance and drop it. As long as the state held 
 aloof and siinply exercised control without giving assistance, the 
 growth of this voluntary insurance has always been slow. The^more 
 the state has given assistance, the greater has been the number of 
 workmen who have been able to secure the protection they seek."^ 
 
 DENMARK. 
 
 The system of voluntary subsidized health insurance in operation 
 in Denmark has remained practically unchanged for more than 
 twenty-five years, and is an interesting example of this method. 
 
 After thirty years of investigation and discussion, the present law 
 was adopted on April 12, 1892. 
 
 Four investigations of sick .benefit societies by governmental Com- 
 missions bad revealed the fact that the 1,000 societies in existence 
 just before the, passage of the law had a combined membership not 
 
 (') American Medical Association — Social Disnrance Series, Pamphlet 11, page 10. 
 
221 
 
 exceeding eight per cent, of the population, that less than one-third 
 of the societies furnished both money benefits and medical aid, and 
 that the' amount of benefit was usually very small, in some districts 
 as low as one-quarter krone (less than seven cents) a day. 
 
 As first drafted, the law of 1892 provided for compulsory health 
 insurance, but, after prolonged discussion, the principle of subsidies, 
 combined with regulation, was substituted for the compulsory prin- 
 ciple. The regulations to which the societies must conform in order 
 to secure the subsidy are very simple. Each society must contain at 
 least fifty members, the maximum age limit being forty years, and 
 may be organized either by locality or by industry. The membership- 
 must consist of wprknien receiving small incomes or of o^ber persons 
 of similar economic condition. No person may belong to more than 
 one society. No medical examination is required for admission, but 
 no benefits are provided for chronic diseases existing at the time of 
 entrance. 
 
 Certain I minimum benefits must be given by the societies, and cer- 
 tain extensions are permitted within prescribed limits. The required 
 benefits are: 
 
 1 — free medical and''hospital care for members and for their 
 
 ; children under fifteen who live at home. 
 
 2 — A cash sick benefit determined on the basis of the sick 
 
 person's average wage for the entire membership. This 
 
 benefit must not exceed two-thirds of the normal wage of 
 
 the sick person or fall below 40 ore (9.50 cents) per day. 
 
 The usual range is from 11 cents per day for employees in 
 
 the country to 54 cents for those in the city. 
 
 No benefit is paid for illness lasting less than three days, and no 
 
 benefits are required for normal confinement or pregnancy, although 
 
 these may be included voluntarily by the society. Funeral benefits 
 
 are not allowed and the furnishing of drugs and supplies is optional. 
 
 Societies may increase the waiting period from three to seven days, 
 
 and benefits to women and minors may be decreased, Avhile diseases 
 
 resulting from immorality or intemperance may be excluded. The 
 
 minimum period during which benefits must be furnished is thirteen 
 
 weeks. 
 
 The operation of the law has tended to increase materially the 
 membership in sick benefit societies. In 1893 there were 457 reg- 
 istered societies with a membership of 116,763, while in 1914 the 1,547 
 registered societies had 843,244 members, or about 30 per cent. of_ 
 the adult population. Women have for the past several years con- 
 stituted the majority of those insured. 
 
 Less than 30 per cent of the socities pay more than 16 cents per 
 day to male members, and less th^n 15 per cent, pay as much as 16 
 cents per day to women. About 23 per cent, pay benefits for more 
 
222 
 
 than thirteen weeks, 17 per cent, having a twenty-six week period, 
 and three funds having a longer period. Only about 40 per cent, 
 supply any drugs at all, aind only 18 per c«it. pay for the entire 
 cost of ordinary medicine. 
 
 The state subsidy is apportioned among the societies in two ways ; 
 one-half is determined by the membership at a rate not to exceed two 
 kroner per member, and one-half by the amount of dues collected from 
 members. This portion cannot exceed one-fifth of the members' con- 
 tributions. 
 
 Several communal governments also give subsidies to the societies 
 in their districts. In 1914 these subsidies amounted to 28 per cent, 
 of the total income of. the societies. 
 
 INCOME OF SICK BENEFIT SOCIETIES.i 
 
 Tear. 
 
 1895, 
 1900, 
 1905. 
 1910, 
 1914, 
 
 Membersbip 
 Dues. 
 
 $969,063 
 
 1,959,957 
 
 876,899 
 
 1,226,910 
 
 1,745,020 
 
 State 
 Grant. 
 
 $410,641 
 833,745 
 382.064 
 534,407 
 741,017 
 
 Communal 
 Grant. 
 
 $34, -707 
 64,290 
 23,121 
 36,856 
 54,592 
 
 All others. 
 
 $114,078 
 240,747 
 64,498 
 96,066 
 139,631 
 
 Total. 
 
 $1,528,509 
 3,098,739 
 1,346,582 
 1,894,239 
 2,680,620 
 
 In addition to these money grants, the societies also receive other 
 subsidies. The communes are required by the law to treat members 
 of registered societies in hospitals at half the regular rates and to 
 provide free transportation for physicians and midwives to the homes 
 of members in rural districts. 
 
 The cost of operation of the whole system increased from |258,07S), 
 in 1893, to |2,604,400, in 1914, or more than nine fold, but so great 
 was the increase in the membership of the funds that the average cost 
 per member advanced only thirty-eight per cent.' the largest increase 
 being in the cost of hospital and medical service. 
 
 0) Report ol the Sociial Insurance Commission of California, page 200. 
 
223 
 PER CAPITA COSTi. 
 
 Tear. 
 
 Money 
 Benefits. 
 
 Hospital. 
 
 Medicine. 
 
 Physician. 
 
 Adminis- 
 tration'. 
 
 Total. 
 
 Per Cent. 
 Adminis- 
 tration 
 Cost. 
 
 1893 - 
 
 $1 01 
 
 1 01 
 
 1 04 
 
 1 02 
 
 93 
 
 93 
 
 ' $0 12 
 14 
 18 
 27 
 81 
 39 
 
 $0 28 
 28 
 31 
 84 
 32 
 33 
 
 $0 82 
 
 77 
 
 88 
 
 99 
 
 1 11 
 
 1 18 
 
 $0 19 
 17 
 19 
 20 
 24 
 26 
 
 $2 22 
 237 
 260 
 282 
 291 
 3 OS 
 
 8 6 
 
 1895. 
 
 7 3 
 
 1900 
 
 7.8 
 
 7.1 
 
 1905, 
 
 1910, 
 
 
 1914, 
 
 8.1 
 
 
 
 The experience of Denmark with state subsidized health insurance 
 seems to indicate that to produce satisfactory results the subsidy 
 must be very substantial in amount. 
 
 SWITZERLAND. 
 
 Efforts to establish a comprehensive insurance system in Switzer- 
 land have covered a period of forty years. After several careful sur- 
 veys had been made, a constitutional amendment was passed by the 
 Council and approved by a> referendum vote on October 26, 1890, 
 authorizing the passage of compulsory insurance acts. A law provid- 
 ing for compulsory insurance against both sickness and accident was 
 passed by the Council on October 2, 1899, but rejected by a popular 
 referendum on May 20, 1900. In 1906, after further investigation, 
 an act providing for comfpulsory accident insurance and a heavily 
 subsidized system of sickness insurance was introduced into the 
 Council. It was finally passed on June 13, 1911, and approved by 
 referendum vote on February 4, 1912. 
 
 This law recognized the principle of compulsory health insurance 
 by authorizing the dift'erent cantons and communes to declare the 
 insurance compulsory either generally or for certain classes of per- 
 sons, to establish public funds in case they are needed, and to compel 
 employers to attend to the collection of the contributions of their 
 employees compulsorily insured in the public funds, without, how- 
 ever, binding the employers themselves to the payment of the con- 
 tributions. In case the cantons or communes assume the responsi- 
 bility of the payment of all or a part of the contributions of indigent 
 insured persons, the Confederation agrees to grant special subsidies 
 to them equal to one-third of their disbursements. 
 
 As in Denmark, subsidies are granted to mutiial aid associations 
 under certain conditions. They must not operate for profit, must 
 have their headquarters in Switzerland, and must admit to member- 
 ship any Swiss citizen who conforms to their provisions for admis- 
 sion. Swiss Citizens must not be treated less favorably than persons 
 of other nationalities. Women shall be admitted on the same terms 
 as men, except to funds of a trade union or establishment fund 
 
 (^)Beport of the SoMal Insurance Commission of California, page 199, Table IT. 
 
 15 
 
224 
 
 wiiere only men are employed. Insurance benefits shall not vary 
 according to sex unless the contributions sho\v a corresponding varia- 
 tion. No person shall be excluded from membership for religious 
 or political causes. Swi.ss funds, unlike those in Denmark, are re- 
 quired only to insure to their members either medical care and medi- 
 cines or a daily cash benefit of not less than one franc (19.3 cents), be- 
 ginning at least with the fourth day of sickness. Benefits must be 
 paid for at least 180 days during a period of 360 consecutive days. 
 Childbirth must be regarded as an illness and, provided, the insured 
 person has been a member of the fund for nine months, both cash and 
 medical benefits shall be provided for at least six weeks, and if the 
 mother nurses the child an additional benefit of 20 francs ($3.86) 
 must be paid. 
 
 The choice of physician or druggist is left to the patient unless 
 the fund contracts for these services. Payment for medical and 
 pharmaceutical aid is made according to a schedule fixed by the 
 cantonal governments in conference with representatives of the 
 funds and with the professional associations of physicians and phar- 
 macists. 
 
 Recognized societies receive the following annual "subsidies: 
 
 1 — For children up to fourteen years, 3.50 francs (67;5 cents). 
 2 — When the fund insures either medical care or cash benefit, 
 — 3.50 francs (67.5 cents) for each adult male, and four frans 
 
 (77.2 cents) for each adult female. 
 3 — If the fund insures both miedical care a:ul cash benefits, 
 
 five francs (96.5 cents), for both sexes. 
 4 — If the fund increases the benefit period from 180 to 360 
 
 days, an additional 50 centimes (9.7 cents). 
 5-^For each confinement, an additional 20 francs (f3.86). 
 — For each nursing benefit, an additional 20 francs (|3.86). 
 7— In mountainous districts where communication is difficult 
 and the population sparse, an additional subsidy of seven 
 francs (|1.35). 
 The system went into effect on January 1, 1914, and since that 
 time 10 cantons, including Zurich, have declared the insurance com- 
 pulsory. 
 
 FRANCE. 
 The French act of June 29, 1894 established compulsory sickness 
 insurance for seamen and railway employees, and for miners earn- 
 ing up to 2,500 francs (|482.50) per year. Under this system, em- 
 ployees contribute not more than two per cent, of their wages or 
 $9.65 per year, employers pay a sum equal to one-half of the contribu- 
 tions from employees, and subsidies are received from the state and 
 from charitably inclined persons. Medical attendance, medicines and 
 cash benefits are paid to sick members, and death benefits and an- 
 nuities may also be paid to dependents. 
 
225 
 
 -Since 1910 very small state subsidies have been paid to recognized 
 voluntary sick benefit societies to which other employees might be- 
 long. Only one-half the activity of these societies is in the field of 
 sickness insurance, however, as funeral benefits, and aid to widows, 
 orphans, invalids, and old persons are also included. It is impos- 
 sible to tell exactly how many members of the funds are insured 
 against sickness, but the proportion seems to be very low and the 
 protection afforded far from adequate. 
 
 COMPULSORY HEALTH INSURANCE. 
 
 The experience of these various countries has emphasized several 
 serious faults in voluntary health insurance systems. The most ap- 
 parent of these is the impossibility of reaching the most needy class 
 without compulsion. In all voluntary systems the proportion of 
 insured is in inverse ratio to the economic status. The willingness 
 and the ability to insure presuppose a degree of education and the 
 existence of a surplus which are impossible ^mong a large proportion 
 of employees under present industrial conditions. Moreover, "little 
 or no account is taken in voluntary systems of the responsibility of 
 industry and of society in general for a large part of existing sick- 
 ness among employees. The economic burden cannot be equitably 
 divided so as to give the employer and the state their full share, 
 but is left to be borne by those whose resources are least adequate to 
 meet it. Standardization • of service and economy of administration 
 are almost impossible in a system of voluntary insurance. Standards 
 are invariably lower in some societies than in others, as is shown 
 by the great difference in the character and amounts of medical and 
 cash benefits provided and by the varying degrees of solvency among 
 the funds. 
 
 The rapid growth of compulsory Ja-ealth insurance within the past 
 decade has been striking. Since 1900, nine countries, Luxemburg, 
 Norway, Serbia, Great Britain, Russia, Roumania, the Netherlands, 
 Sweden and Belgium have established compulsory systems. 
 
 GERMANY. 
 Germany was the first nation to adopt the principle of compulsory 
 health insurance. The sickness insurance law of 1883, passed after 
 years of experiment with varying degrees of compulsory insurance 
 in different parts of the Empire, made no attempt to centralize con- 
 trol. Existing agencies, were utilized to the fullest possible extent, 
 t\e aim sought being mutual insurance with self administration. 
 -Insurance was made compulsory for all workingmen and technical 
 employees in mines, quarries, factories, and other industrial concerns, 
 and eight kinds of societies were recognized, the only common re- 
 
226 
 
 quirement being that they should make annual reports and conform 
 to provisions regarding minimum benefits and methods of investing 
 funds. 
 
 1 — Commercial societies (Gemeindekrankenkassen) were estab- 
 lished under the law to provide insurance for all persons of whatever 
 occupation, who were obliged to insure but did not belong to any 
 other sick benefit society. 
 
 2 — Local societies (Ortskrankenkassen) were established by town- 
 ships for the various trades, two or more townships often uniting to 
 form one society. At present, these are the most popular of all the 
 societies. 
 
 3 — Factory societies (Betriebskrankenkassen), created by propri- 
 etors of factories in which more than 50 workers were employed, 
 particularly in trades where the risk of sickness or accident was 
 high. Management was under the joint control of employees and 
 employers. 
 
 4 — Builders' societies (Baukrankenkassen), which were practically 
 establishment funds founded by contractors in building operations 
 and in public works, because of the great risks of these trades. 
 ) 5 — Guilds, sick-clubs, or trade societies (Innungskrankenkassen), 
 authorized by the national trades regulation law. These did not 
 possess legal personality, but were considered a mere function of the 
 guilds or trade unions. 
 
 6 — Miners' societies (Knappschaftskassen), formed in accordance 
 with the mining laws of the several kingdoms. 
 
 7 — Voluntary mutual aid societies (Hilfskassen). These were the 
 friendly societies supported and controlled solely by the members 
 without any participation from employers. Membership was usually 
 without regard to trade. They were not under the control of authori- 
 ties except that they must grant the minimum benefits required by 
 law. 
 
 8 — Independent state societies (Landesrechtlichehilfskassen). These 
 were voluntary associations, organized under the auspices of certain 
 kingdoms of the empire.^ 
 
 In 1884 an act was passed providing for compulsory accident in- 
 surance and in 1889 old age and invalidity were also included in 
 the insurance system. These acts, and the sickness insurance law 
 with numerous amendments and additions, were embodied in the 
 present social insurance code of Germany, in 1911. This act added 
 the two large groups of domestic and farm hands to those already 
 insured as well as various minor groups of professional and semi- 
 professional employees. The first 13 weeks of accident benefits are 
 also taken care of by the sickness insurance system. 
 
 OAmerlcan Medical Associalion — Social Insurance Series, Pamphlet No. 11, pages 14-16. 
 
227 
 
 The fundamental features of the sickness insurance law may be 
 outlined as follows: 
 
 I — Insured Persons. 
 
 a — All workmen, helpers, jpurneymen, apprentices, persons en- 
 gaged in home-working industries, and servants are com- 
 pelled without regard to income to be insured, as well as 
 all other persons employed and earning 2,500 marks (|595) 
 a year or less. This second group includes about 250,000 
 persons in commercial and professional pursuits, such as 
 druggists, teachers, and members of theatrical companies 
 and orchestras, 
 b — ^Voluntary members: all employees whose income does not 
 not exceed 2 500 marks (|595) and who are not under 
 compulsion to insure; members of an employer's family 
 working for him without remuneration; tradesmen who do 
 hot have regular employees, or at the most, two. In these 
 cases the fund may impose an age limit and may require 
 applicants to submit to medical examination. 
 
 It was estimated that the total number of persons who 
 would be insured under the law from July, 1912, would be 
 12,918,000, made up as follows: 
 
 Compulsory contributors, 13,089,000 or 94 per cent. ; 
 voluntary contributors, 829,000 or six per cent. This num- 
 ber would be equal to about 31 per cent, of the total pop- 
 ulation, and 77 per cent, of the occupied population, of the 
 Empire.^ It has been of course, because of the war, im- 
 possible to get any data on the actual number of those 
 insured since the law went into effect. 
 11 — Organization and Administraticjin of Insurance. 
 
 The machinery for carrying out the provisions of the 
 health insurance law is entirely of a mutual character. 
 The funds recognized under the law of 1883 are still used as 
 insurance carriers, with some changes made by the 1911 
 insurance code. The local and factory societies have been 
 recognized as the standard as they are the most efficient 
 types ; the mutual aid societies have been discouraged by 
 a minimum membership requirement of '1,000; the com- 
 mercial societies have been eliminated and in their stead a 
 new type of so-called rural fund has been established to 
 include domestics, farm hands, and low-wage workers. It 
 is estimated that approximately 37 per cent, of those in- 
 sured are in local funds, 37 per cent, in rural funds and 15 
 per cent, in establishment funds, leaving only about 10 per 
 cent, for all the other types of funds.^ 
 
 (!) Social Insurance in Germany, W. Harbutt Davison, page 31. 
 
 (2)Iierican Medical Association, Social Insurance Pamphlet No. 11, page 15. 
 
228 
 
 The funds are practically self-governing, each fund hav- 
 ing a general and an executive committee. T,wo-thirds of 
 the members of the general committee are elected by the 
 insured employees and one-third by4;he employers, and the 
 members of the executive committee are chosen in the same 
 proportion by the two groups of the general committee. 
 
 Supervision is exercised through a state administrative 
 machinery consisting of the Imperial Insurance OfSce, the 
 Superior Insurance 0£Qces, for districts roughly correspond- 
 ing to our judicial'districts, and the Local Insurance Offices 
 for districts corresponding to our counties or large cities. 
 In each of these offices the Government, the employers and 
 the emploj'ees are represented. 
 
 Ill — Contributions. 
 
 These are managed on an assessment basis. 
 
 a — If the employee is insured through a mutual aid society, 
 which is entirely under the control of its members, no 
 contribution is made by the emjployer. This is also true 
 in the case of those who are voluntarily insured. 
 
 b — Employees insured in any other form of society pay two- 
 thirds the cost, and the employers pay one-third. The 
 actual amounts are not fixed by law, but vary with different 
 funds and different years. However, the normal maximum 
 rate is four and one-half per cent, of the basic wage. An 
 increase beyond this rate requires the consent of both em- 
 ployers and employees as represeiited in the management 
 of the fund, unless the increase is necessary to provide the 
 regular minimum benefits. In the latter case, such consent 
 is necessary to raise the rate above six per cent. In 1912 
 the usual rate of contribution was from two to three per 
 cent of the wage rate. 
 
 c — Employers are held responsible for the collections of pay- 
 ments from their employees, and are permitted to deduct 
 such amounts from wages. They are also required to see 
 that their employees are insured, under penalty of fine and 
 liability for the cpst of treatment. 
 
 d — The imperial, state and communal authorities assume a 
 certain part of the cost of the system, by paying for the 
 supervision and giving treatment to insured persons in 
 public hospitals at special rates. 
 
 The following table shows the financial details of the 
 operation of the German Sickness Insurance System, from 
 1911 to 1913. 
 
229 
 
 RESULTS OF THE OPERATION OF GERMAN INDUSTRIAL SICK 
 FUNDS, 1911 TO 1913, (INCLUDING THE FIRST 13 WEEKS OF AC- 
 CIDENT BENEPITS.i 
 
 Total, all PUnds. 
 1911. 1912, 1913. 
 
 Per Member. 
 1911. 1912. 1913. 
 
 Number of funds, 
 
 Average membership, 
 
 Average membership ^per fund,-. 
 Oasee of sickness of members in- 
 
 • volviug disability, 
 
 Days of sickness involving pay- 
 ment of^pecunia^y benefits or 
 
 hospital treatment, 
 
 Ordinary receipts (interest, en- 
 trance fees,, contributions, sub- 
 sidies, and miscellaneous re- 
 ceipts, exclusive of receipts for 
 
 invalidity insurance), 
 
 Ooutributions and entrance fees, 
 Ordinary disbursements (costs 
 of sickness, refund of contri- 
 bution and entrance fees, cost 
 of administration , exclusivt 
 of those for invalidity insui 
 ance, miscellaneous disburse- 
 ments), 
 
 Costs of sickness, 
 
 Medical treatment, 
 
 Medicines and other cura- 
 tives, 
 
 i Pecuniary sick benefits, 
 
 Maternity benefits, 
 
 . Keat'h (funeral.) benefits, — 
 
 Hospital treatment, 
 
 Oare of convalescents, 
 
 Costs of administration (exclu- 
 sive of those for invalidity 
 
 insurance), 
 
 Excess of assets over liabilities. 
 
 23,109 
 
 13,619,048 
 
 589.34 
 
 5,772,388 
 115,128,905 
 
 $98,125,16E 
 92,449,305 
 
 93,420,889 
 85,077,474 
 19,933,505 
 
 12,654,754 
 
 36,562,748 
 
 1,618,199 
 
 2,029,064 
 
 12,223,171 
 
 66,036 
 
 5,281,065 
 74,096,997 
 
 21,659 
 
 13,217,705 
 
 610.26 
 
 5,633,956 
 112,249,064 
 
 ^e, 390, 722 
 93,679,394 
 
 94,018,781 
 85.617,576 
 20,380,724 
 
 13,020,038 
 35,794,829 
 1,715,038 
 1,888,035 
 12,745,783 
 73,179 
 
 5,140,414 
 73,133,115 
 
 21,342 
 
 13,566,473 
 
 635.67 
 
 5,710,25^ 
 117,436,644 
 
 $104,909,309 
 98,588,587 
 
 103,000,076 
 92,983,399 
 22,368,051 
 
 14,355,602 
 38,446,843 
 1,803,748 
 1,911,602 
 14,026,202 
 81,352 
 
 5,157,354 
 73,986,569 
 
 0.42 
 8.45 
 
 $7 20 
 6 79 
 
 6 86 
 6 25 
 1 46 
 
 2 68 
 12 
 15 
 90 
 005 
 
 5 47 
 
 0.43 
 8.49 
 
 $7 52 
 7 09 
 
 7 11 
 6 48 
 1 54 
 
 2 71 
 13 
 14 
 
 0O5 
 
 5 53 
 
 0.42 
 
 8.66 
 
 $7 73 
 7 27 
 
 7 59 
 6 85 
 1 66 
 
 1.06 
 
 283 
 
 13 
 
 14 
 
 1.03 
 
 007 
 
 -45 
 5 43 
 
 IV— Benefits. 
 
 a— The law specifically states that the benefits are not public 
 charities.. The right to benefits begins with membership. 
 
 b— Medical benefits include medical, hospital and nursing care, 
 medicines, and all necessary appliances, trusses, glasses, 
 etc., from the beginning of illness regardless of whether 
 it c'aiises inability to continue working, up to 26 weeks in 
 one year. 
 
 c— Cash benefits equal to 50 per cent, of the standard wage, 
 begin with the fourth day of illness, and are paid for each 
 working day lost up to 26 weeks in one year. The insured 
 are classified into different wage groups, but the basic wage 
 in any group cannot exceed five marks (|1.19) per day. 
 The maximum normal sick benefit therefore is 60 cents per 
 day. When the patient is sent to a hospital, the cash bene- 
 fit is stopped unless needed for the support of the de- 
 pendents. 
 
 ITiMontHly Report, United States Bureau of Litbor Statistics, April, 1916, page 98. 
 
230 
 
 d — Maternity benefits equal to the cash ' benefits described 
 above are provided for insured women for a period of 
 eight weeks, of which six must be after delivery. Instead 
 of this benefit, home treatment or hospital care with half 
 cash benefit n^ay be given. The same cash benefits are 
 provided for six weeks for disability due to pregnancy, 
 e — Funeral benefit in case of death of the insured equals 
 twenty times the basic daily wage. 
 
 "But while these four forms of benefits constitute the 
 legal minimum required by the sickness insurance funds, 
 they give a very inadequate conception of the entire serv- 
 ice rendered. In various ways the insurance may and does 
 extend the minimum amounts, and within the prescribed 
 limits of the acts establishes even other benefits dealing 
 with sickness. 
 
 "These so-called optional benefits may be classified as 
 follows: 
 
 1 — Increase of compulsory benefits. 
 
 (a) — Increase of sick benefit up to 75 per cent, of 
 
 wages, 
 (b) — Grant for Sundays and holidays. 
 (c) — Extension of sick benefits up to fifty-two 
 
 weeks, 
 (d) — Reduction or abolition of the waiting period 
 in all cases, or only in cases of industrial ac- 
 cidents, or in cases lasting over one week. 
 (e) — Increase of benefit payable to family when in- 
 sured receives hospital treatment, from one- 
 half to the full amount of the sick benefit. 
 (f) — Increase of funeral benefit, up to forty times 
 
 the daily wage. 
 (g) — Increase of minimum for funeral benefits to 
 50 marks (|11.90). 
 2 — jSTew Benefits. 
 
 (a) — Hospital treatment, 
 (b) — Nurses? attendance. 
 
 (c) — Appliances to prevent disfigurement or de- 
 formity, 
 (d) — Grant of special diets, 
 (e) — Grant of other therapeutic means. 
 (f) — Sick benefits (up to one-half the regular sick 
 benefit) to insured persons under treatment in 
 hospitals. 
 (g) — Pregnancy benefits up to six weeks, 
 (h) — Medical treatment for ailments due to preg- 
 nancy. 
 
231 
 
 (i) — Nursing benefits (or motherhood benefits) up 
 to twelve weeks after confinement. 
 
 (j) — Convalescent care up to one year after illness, 
 3 — Extension of Benefits to Dependents. 
 
 (a) — Medical treatment to dependent family. ^ 
 
 (b) — Maternity benefit to wife of insured. 
 
 (c) — Funeral benefits for death of husband or wife 
 or child. 
 "Mauy of the funds, and especially the larger ones in the 
 large cities, have embodied some of those permitted exten- 
 sions, of which the most important are the increase of the 
 money benefit above the legal minimum of 50 per cent, of 
 wages, the extension of both the medical and money benefits 
 beyond the minimum of 26 weeks, the establishment of a 
 compulsory hospital benefit, which is not specifically re- 
 quired by the law, increase of the duration of the maternity 
 benefits, convalescent care and extension of the medical, 
 maternity and funeral benefits^ to the immediate family of 
 the insured. This very wide utilization of the possibilities 
 of democratic management of the fund is a very significant 
 feature of the development of health insurance in Germany. 
 Concerning one or two of these features accurate informa- 
 tion is available. 
 
 "The great majority of the funds have not exceeded the 
 minimum requirements regarding the number of weeks for 
 which cash benefits are paid, but the increase of the weekly 
 benefit over the minimum amount is much more frequent. 
 Detailed information concerning some of the extensions by 
 large funds is given in I. Gr. Gibbon's "Study of Medical 
 Benefits in Germany and Denmark," page 278, for twenty- 
 eight large local funds, with a combined membership of 
 1,100,000. Eighteen of these funds paid sick benefits of 50 
 per cent., one, 55 per cent., one, 58.5 per cent., six, 60 per 
 cent., and one, 62.5 per cent, of wages. In two funds the 
 waiting period was reduced to two days and in five funds 
 to-one day. One fund extended the period of money benefits 
 to thirty-four weeks, two to thirty-nine weeks and three to 
 fifty-two weeks. Ten funds provided convalescent homes, 
 and eight had day convalescent resorts. Twenty-one out 
 of these twenty -eight funds granted medical aid to the mem- 
 bers of the family, and twelve gave drugs as well. Seven- 
 teen funds have provided funeral benefits in case of death 
 of the wife, and of these, fifteen also paid the funeral 
 expenses in case of death of children."^ 
 
 T)Report of the Social Insurance Commission of the State of California, page 157. 
 
232 
 
 V — Organization of Medical Aid.^ 
 
 Medical as well as casli benefits are administered by the 
 funds themselves, and each fund has an absolutely free 
 hand in the method of remunerating the physicians. 
 Throughout Germany there exist official scales of medical, 
 surgical and dental fees, and in the absence of formal 
 agreements between the physicians and the funds it follows 
 that payment will be made by attendance according to the 
 minimum fees of the official scale. 
 
 The federation of sickness funds in Bremen is the only 
 large organization known to pay its medical staff uncondi- 
 tionally on this principle, however, the usual plan being 
 for the fund to contract with a number of physicians who 
 give their services in return for a fixed annjual salary, as 
 in Dresden, or for compensation according to a capitation 
 system. Under such a system, the physician may receive 
 a fixed fee per capita per year for all insured persons whom 
 he undertakes to attend, with or without certain special 
 services according to the terms of the agreement; he may 
 be paid a fixed rate per case of sickness attended, although 
 this is an uncommon practice ; on there may be a capitation 
 fund of a stated amount, divided according to services 
 rendered each patient, each service counting so many 
 points. This last is the method most commonly used. In 
 no instance is a charge based only on the number of visits 
 or prescriptions. Physicians are not required to furnish 
 medicines, but send the prescriptions to be filled by the 
 pharmacist of the patient's choice. 
 
 As a rule, the insured person has free choice between at 
 least two physicians, and may be permitted to change from 
 one physician to another for certain sensible reasons.^ In 
 Leipzig, 80 per cent, of the physicians are on the panel of 
 the Leipzig Fund and consequently a wide choice is pos- 
 sible. 
 
 Between 1896 and 1911 there was a marked increase in 
 the cost of medical treatment, due not only to the higher 
 fees paid to physicians, but to the broader scope of treat- 
 ment due to the progress of therapeutics, to the extension 
 of treatment by specialists, and to the increased recogni- 
 tion by the working classes of the importance of health and 
 their willingness to make sacrifices to obtain it. ' 
 
 The funds are usually disposed to give a very liberal 
 interpretation to medical treatment. The treatment by 
 specialists under most funds depends on the recommenda- 
 tion by the general practitioner first consulted, but in some 
 
 OAmerican Medical Association — Social Insurance Pamplilet No. 11, pages 24-40. 
 
283 
 
 towns, such as Munich, members are allowed to go directly 
 to any specialist on the medical list without previous rec- 
 ommendation. Specialists with whom the large sickness 
 funds conclude agreement are those for eye, ear, nerve, skin, 
 throat, stomach and women's diseases. Medical treatment 
 often comprises Roentgen-ray applications, electric treat- 
 ment and mechanical exercises. In 1912 the central com- 
 mittee of the sickness funds in Berlin coro'pleted the 
 equipment of an establishment for general use, including 
 Eoentgen-ray, hydrotherapeutic, electric and physical treat- 
 ment on a large scale, and in the course of tha first fifteen 
 months, 6,800 persons were treated. Some of the large 
 federations of sickness funds, like those of Leipzig and 
 Dresden, have well equipped rooms attached to their cen- 
 tral oflBices in which mechanical treatment is given in the 
 most approved methods. The large sickness funds in the 
 towns also provide their sick members with medical baths 
 of great variety. 
 
 Among all classes in Germany there seemfe to be general 
 satisfaction with the health insurance law. Standards of 
 living among working men and women have been raised 
 by its operation and loss of working time greatly decreased 
 by prompt attention to incipient illness. The testimony 
 of employers, employees, and public ofiScials is, so far as 
 is known, unanimously in favor of the system. 
 
 GREAT BRITAIN. 
 
 The National Insurance Act of Great Britain, providing for both 
 compulsory health and old age insurance, pas passed on December 16, 
 1 911, and became operative J uly 15, 1912. Unlike the German system, 
 which grew slowly as the result of experiments with state subsidies 
 and control of sick-benefit societies, the British system was all-in- 
 clusive from the beginning. 
 
 Before the passage of the law the bulk of health insurance was 
 handled by the powerful lodges and friendly societies and the trade 
 unions. More than 5,500,000 of the more thrifty British workmen 
 were voluntarily insured in this way, leaving about 8,000,000 workers 
 unprotected. The influence of the fraternals was strongly felt in the 
 formulation of the act, under which they remain the chief carriers 
 of insurance. The continuation of these national societies is one of 
 many striking differences from the German system, which has forced 
 the localization of all approved societies. In fact, except for the 
 underlying principle of compulsion, the two systems have so little in 
 common that they may well be taken as different types of state health 
 insurance. 
 
23i 
 
 I — Insured Persons: 
 
 a— AH persons between the ages of sixteen and sixty-five 
 years who are employed at manual labor, without regard 
 to income, and other employed persons earning less than 
 60 pounds (1778.64) a year, are compelled to' insure. A 
 person insured when under sixty-five remains insured if 
 employed until he is seventy. Exceptions are made in the 
 case of persons in the naval or military service, those em- 
 ployed by public authority, railway employees, teachers, 
 and other persons for whom provision has already been 
 made, and for a few casual and part-time employees, 
 b — Voluntary mpmbers include all persons who are employed 
 and are dependent on their earnings for their livelihood, 
 and whose total income does not exceed 160 pounds 
 (1778.64) a year. In addition those who have been insured 
 persons for five years or longer may become voluntary 
 members regardless of earnings, 
 c — No person who is sixty-five years of age or older may be- 
 come insured under the act, and no person may continue 
 to be insured after he reaches the age of seventy, when 
 he is taken care of by the old age pensions system. 
 II — Organization and Administration of Insurance 
 Unlike European systems of health Insurance, the British system 
 encourages the continuation of benefit societies by allowing them to 
 become the main carriers of insurance. Participation is open to all 
 sick-benefit societies, trade unions,, establishment funds and similar 
 organizations which can conform to the requirements for "approved 
 societies," the most important of which are that they must not 
 operate for profit and must be controlled by their members. In spite 
 of this last provision many "approved societies" have been organized 
 by industrial life insurance companies and are under very little demo- 
 cratic control. It is impossible to ascertain the number of persons 
 insured in various types of societies since 1914, but the following 
 table shows the situation just prior to the outbreak of the war. 
 
 MEMBERS OF APPROVED SOCIETIES. GREAT BRITAIN, IMMED- 
 IATELY PRECEEDING THE OUTBREAK OF THE WAR. 
 
 Men. 
 
 Women. 
 
 Total. 
 
 Friendly Societies with branches, — 
 
 Centralized Friendly Societies. 
 
 Industrial and Collecting Societies, - 
 
 Trade Unions, 
 
 Employers I^ovideat Funds, 
 
 Totals, 
 
 2,517,363 
 2,649,451) 
 3,136,766 
 1,267,064 
 95,917 
 
 711,230 
 1,021,601 
 2,168,068 
 
 225,149 
 30,252 
 
 9,666,560 
 
 4,156,298 
 
 3,228,593 
 3,671,051 
 5,304,832 
 1,492,213 
 126.169 
 
 13,822,858 
 
235 
 
 Technically, the insured person has unrestricted choice of his so- 
 ciety. This is unlike ^the German system where he must belong to 
 the society of his trade or locality. But the societies .in Great Britain 
 also -have the right to refuse an applicant for miembership, although 
 not because of age alone. Persons who thus fail to gain admission 
 to any society become "deposit contributors" by depositing their con- 
 tributions with the post office. They may draw benefits only up to 
 the amount of their individual balances and so are not incured in any 
 real sense. The failure to provide special institutions for the insur- 
 ance of such persons is generally considered a defect in the British 
 system. The provision for "deposit contributors" was intended to 
 be only a temporary one, but has been continued because of the war. 
 However, there were only about 352,000 persons provided for in this 
 way just before the war, as against 18,827,828 in the approved so- 
 cieties.^ 
 
 The 'administration of cash benefits for members of approved so- 
 cieties is left entirely to the societies, but the medical benefits are 
 administered by 238 local insurance committees, one for each county 
 or- borough. This separation of the> administration of the cash and 
 medical benefits was made necessary because the supplying of medical 
 care was distinctly a local problem and could not be handled by the 
 societies, which do not operate within geographic limits. The Insur- 
 ance Committees, which were instituted to secure some uniformity 
 in the medical benefits provided, consist of from forty to eighty mem- 
 bers, of whom three-fifths represent the insured persons, one-fifth (of 
 whom two at least must be women) are appointed by the county or 
 borough council, two members are elected by the medical practi- 
 tioners in the district, and the remaining members by the insurance 
 commissioners. Of the insurance commissioners at least one must 
 be a medical practitioner and at least two must be women. These 
 committees administer the medical benefits for members of approved 
 societies, both the cash and the medical benefits for "deposit con- 
 tributors," keep records, and promote measures for the prevention of 
 disease. They may inquire into the causes of excessive sickness in 
 any locality and may prosecute any persons responsible. To defray 
 the expenses of these committees, each society having members who 
 are insured persons, resident in the county or county borough, pays 
 two cents annually for each such member. 
 
 Both the approved societies and the insurance committees are under 
 the control of four National Insurance Commissions, one for each of 
 the four parts of the United Kingdom. These Commissions are ap- 
 opinted by the Treasury Department, and must contain at least one 
 medical practitioner. They may make rules to govern all insurance 
 administration. To insure uniformity, a joint committee for the 
 United Kingdom exists, representing the four Insurance Commissions. 
 
 (1) Beport of the administration of the National Health Insurance, '1914-17. 
 
236 
 
 An advisory committee has been appointed by each Insurance 
 ^^ommission, composed of representatives of employers' associations, 
 "approved societies" of employees, the medical profession and others, 
 at least two of whom must be women. 
 
 Ill — Contributions. 
 
 The cost of the system is born by payments from the employer, 
 the employee, and the state. Unlike the continental laws, which 
 provide for contributions on an assessment basis, the British law 
 fixes the rate of premium as well as the rate of benefits. The stand- 
 ard cost of insurance is fixed at nine pence per week for each male 
 insured and eight pence for each female, irrespective of age or OjCcu- 
 pations. This cost is divided between the three contributors, the 
 ratio of payment being determined by the wages and sex of the em- 
 ployee. 
 
 A — If the employee earns 2 s. 6 d. (61 cents) or more per day, 
 the payments are fixed as follows: 
 
 Employer, ' 3 d. (6 cents) a week 
 
 CMale, 4 d. (8 cents) a week 
 
 Employee | j^emale, 3d. (6 cents) a week 
 
 Government, 2 d. (4 cents) a week 
 
 B — If the employee earns between 2 s. (49 cents) and 2 s. 6 d. 
 (61 cents) per day: 
 
 {for male employee, . . . .4 d. (8 cents) a week 
 for female employee, ..3d. (6 cents) a week 
 
 Employee, 3d. (6 cents) a w^ek 
 
 Government, > 2d. (4 cents) a week 
 
 C — If the employee earns between 1 s. 6 d. (37 cents) and 2 s. 
 (49 cents) per day: • 
 
 (for male employee, . . .5 d. (10 cents) a week 
 Jimp oyer <^^^ female employee, . .4 d. ( 8 cents) a week 
 
 Employee, Id. ( 2 cents) a week 
 
 Government, 3d. ( 6 cents) a week 
 
 D — If the employee earns less than 1 s. 6 d. (37 cents) per day: 
 I for male employee, . . 6 d. (fl2 cents) a week 
 mp oyer | f^r female employee, .El d. (10 cents) a week 
 
 Government, 3 d. (6 cents) a week 
 
 In no case can the employer be made to pay more than 6 d. (12 
 cents) per cent, per employee, or the employee more than 4 d. (8 
 cents) per week. 
 
 The cost of administration is borne by the entire fund. 
 OoUectionsi are made by the sale of stamps through the post ofQce, 
 the proceeds of which go to the Insurance Commission. The em- 
 ployer p^ys both his own share and that of his employees, and is 
 authorized to deduct from wages the payments made for emplo/ees. 
 The stamps are placed on cards which are collected quarterly by 
 the societies, under regulations made by the Insurance Commis- 
 sioners. The societies in turn collect from the Commissioners pro- 
 
237 
 
 rata amounts for the purpose of paying benefits and covering the 
 cost of administration. The Insurance Committees also receive from 
 the Commissioners money to cover the cost of medical aid and ad- 
 ministration. 
 
 This flat rate contribution which is so different from the assess- 
 ment system used in Germany, is based on the cost of supplying all 
 the benefits to a person from sixteen to seventy years of age, and 
 'medical and sanatorium benefit throughout Ufe. The greater sick- 
 ness rate of later life has been allowed for by fixing the flat rate too 
 high for the low-age groups and too low for the high-age groups. By 
 this method a reserve is created to meet the increasing claims of later 
 life. A uniform contribution for the various ages insured at the 
 : inauguration of the system was made possible by crediting to the 
 { societies, for members over sixteen years of age, the amiounts which 
 would have accumulated to the credit of these members if they had 
 been insured from the age of sixteen. These "reserve values" made 
 an aggregate total of |432,000,000, w^ch appeared at first only^as 
 a book credit. About one-fifth of each week's contribution is de- 
 voted to converting this into cash and providing interest on the 
 capital sum, a process which it was originally estimated would take 
 from eighteen to twenty years. When the total amount has been 
 written off, the released one-fifth of the contributions may be used 
 for increasing benefits. 
 
 Serious criticism has been made of this flat rate of contribution. 
 Several errors were made in the calculation of the British sickness 
 rate, especially for women, and it has been found very difl&cult to 
 change the premjium rate, which the contributors regard as fixed. 
 It has been found equally hard to change the rate, even to proyide 
 more adequate benefits, and necessary additional expenditures have 
 had to be met by the government. The flat rate is especially un- 
 satisfactory when coupled with unrestricted freedom in the choice 
 of carriers, because of the possible segregation in separate societies 
 of persons by trade or sex, frequently resulting, in an isolation of 
 risk far below or above the average hazard for the entire insured 
 population' for which the . flat contribution was calculated. Since 
 the societies are financially independent of each other, and one is 
 unable to benefit from the surplus of another, it has been necessary 
 to set aside a portion of the reserve fund as a "special risk fund" 
 frqm which unfortunate societies may recoup themselves.^ 
 
 IV— Benefits. 
 
 Instead of establishing a schedule of minimum benefits which 
 approved societies must provide and may exceed, the British act 
 established a uniform system of services which are rarely extended. '' 
 
 (')Olga S. Halsey, "Compulsory Health Insurance In Great Britain." 
 
238 
 
 a — Medical benefits begin with the first day of illness and 
 include medical attendance and treatment, medicines, and 
 such appliances as may be prescribed under regulations 
 made by the Insurance Commissioners. These benefits are 
 much less carefully defined than in the German system, and 
 actually guarantee only treatment by an ordinary prac- 
 titioner. They do not specifically include obstetrical aid, 
 operations, hospital care or nursing, although several 
 Parliamentary grants have been made to provide these 
 services to a limited extent. Medical and dental care for 
 •dependents is optional with the societies. 
 
 b — Sanatorium benefit for persons suffering with tuberculosis 
 is provided through the insurance committees which make 
 arrangements with the local authorities. 
 
 c — The cash benefit is not based upon wages, as in Germany, 
 but is affixed uniformly at ten shillings (f2.40) a week 
 for men and seven shillings six-pence (|1.80) for women, 
 for a period of twenty-six weeks in each year, beginning 
 with the fourth day of incapacity. A disablement benefit 
 of five shillings ($1.2Q) a week is paid to both men and 
 women who have been insured for two years, when the 
 illness extends beyond twenty-six weeks. This payment 
 may continue for the entire duration of the incapacity, or 
 until the insured reaches the age of seventy. To be 
 eligible for cash benefit, the insured person must have 
 been insured for at least twenty-six weeks and at least 
 twenty-six weekly contributions must have been paid by or 
 for him. Provisions are made for paying reduced rates 
 of sick benefit to unmarried persons under twenty-one 
 years of age having no dependents ; to persons fifty years 
 of age and over who become insured within one year from 
 the commencement of the act and who at the time they 
 claim benefits have paid less than five hundred weekly 
 contributions; to certain persons of the age of seventeen 
 or more who become insured later than one year from the 
 commencement of the act, and to persons whose dues are 
 in arrears. 
 
 d — Maternity Benefits — In the case of an employed woman or 
 the wife of an insured man, a lump sum of 30 shillings 
 (|7.30) is paid for confinement. This payments is made 
 solely to help pay the expenses incident to confinement, as 
 no medical care is provided. If the mother is an insured 
 person and married, she is entitled to sickness or disable- 
 ment benefit in addition to the maternity benefit, but 
 except for such cases, no woman is entitled to sickness or 
 
239 
 
 disablement benefit during two weeks' before and fony 
 weeks after confinement, except for a disease or disable- 
 ment not connected with childbirth, 
 e — Xo funeral benefit is granted under the Act. 
 
 T — Organization of Medical Aid. 
 
 The Insurance Committees, under the supervision of the Commis- 
 sioners, arrange for medical care of insured persons and draw up 
 ^'panels" or lists of physicians. In making these arrangements, two 
 fundamental conditions must be recognized: the right of every- dxiljr 
 qualified physician who wishes to serve upon a panel to a place uponj 
 it, provided he has not been shown to be injurious to the service, trjact 
 the right of every insured person to choose his, physician from t&ose 
 on the panel. A minimum of |1.68 and a maximum of fl.SG' per per-^ 
 son, is annually set aside for the remuneration of physicians, regards 
 less of the amount of treatment given in individual cases. 
 
 ATTITUDE OF MEDICAL PROFESSION. 
 
 "About ten years ago it became evident in England' tILa.Ti tfis? «& . 
 cumstances under which the general practice of medicine eouEC tai» 
 place were rapidly becoming less and less advantageous t& tBe- pro- 
 fession."^ The reduction of infectious diseases through preventive* 
 medicine and public hygiene and the substitution of mi«Ewikes fort 
 physicians at confinement had done much to reduce the incomes of. 
 practitioners among the poor. It was well recognized that serel; prac- 
 tice meant very small fees with many bad debts, and that the^pooi- 
 could not pay for their medical care Avithout STrfFerfng; setioTiSr 
 financial embarrassment. Numerous clubs, and medical' assodatScmss- 
 had sprung up, and lodge practice and club practice had become' sfe 
 prevalent that in 1905 the British Medical Association made ais in- 
 vestigation of the situation. Their report showed" that IBk- usHal'! 
 method of payment was by capitatiion:, uesulting; often; in fnaxBa^aate 
 payment for excessive work, and poor medical return to tBiff paiSent 
 The average fee obtained per visit was about 21 cents, and e&ch clufe 
 tnember was attended on an average four times per yeari 
 
 Various plans for the establishment of medical associations to com- 
 pete with the lodges were under consideration w&en the Katiaiial 
 Insurance Act was proposed. The British Medical Associati«ni pint- 
 sented six cardinal points which it desired' to have incorporateKi'iiito* 
 the act. Four of these, providing for free- choice of physicfaiE^ tfife 
 patient subject to the consent of the physician to act; medlcaJTleiaefife 
 to be administered by the insurance .committees and no^ Sy tfie 
 societies ; adequate medical Tepresentation among the Instrraar«e CJbnu- 
 missioners and on the local insurance' committees, anti: statnto^ 
 
 (')-Ajner'<'fl^ Medical Asseciation^Social IiisitraoCG' EamEliltfc Noj 11, pag^es-- CfJiTT.. 
 
 16 
 
240 
 
 i-ecognition of a local medical committee representative of the pro- 
 fession in the district of each insurance committee; and an equitable 
 adjustment of differences regarding amount and method of remunera- 
 tibn of physicians were adopted and made a part of the Act. There 
 were Mumerous controversies between the Medical Association and 
 the government regarding the rate of capitation payment, but the 
 ■ majority of the profession at once, accepted service under the Act. 
 At present from 70 to 100 per cent, of the physicians in the various 
 districts are on the insurance panels. 
 
 "On January 17th, 1917, the Insurance Acts Committee of the 
 British 'Jledical Association decided to ask each Branch and Division 
 of the Association and each Local Medical and Panel Committee, or 
 such bodies acting in co-operation, to appoint a thoroughly represen- 
 tative Sub-Committee to consider the present system of N^tiotal 
 Health Insurance, so far as it affects the relation of the medical pro- 
 fession to the public health and the treatment of disease, and to make 
 suggestions for its improvement. The hope was expressed that all 
 possible steps would be taken to ascertain the opinions of as many 
 nien as possible on military service and certain questions were asked 
 dn order that attention might be directed to certain specifie points. 
 
 "The degree of unanimity so far disclosed is somewhat remarkable. 
 On a subject which five years ago was the most highly -controversial, 
 that had ever been before the profession, and which stiU in some 
 placas and everywhere in some of its aspects, excites argument, it is 
 'found (1) that many matters which at the beginning of the contro- 
 versy gave rise to most apprehension have assumed a position of 
 quite minor importance; (2) that the general system by which the 
 State provides medical advice and treatment under the- insurance 
 scheme is' in the main approved, and that criticisms have a tendency 
 to concentrate on a comparatively few points which, though of great 
 importance and indeed vital to smooth working, are, after all, matters 
 of detail which ought to be capable of adjustment; (3) that there is 
 a large body of opinion in favor of the extension of the health insur- 
 ance system both to kinds of treatment not at present provided for 
 and to classes of persons at present excluded therefrom."^ 
 
 The report of the Committee goes on 'to state that the medical pro- 
 fession, insured persons and government officials seem to be in accord 
 "with the principle of the Act, and that all elements unite in demand- 
 ing more adequate medical and surgical aid, as well as numerous 
 qlianges in the details of operation of the system. A long list of 
 suggestions for improvements have been formulated by the Insurance 
 Acts Committee of the British Medical Association to be presented 
 as possible amendments to the Act. 
 
 ,. (M British Mflrtical Aasociation, Insurance -icts Committee, Interim Report on tlie Future of 
 flie Insqrssce Acts, 191T. ' 
 
241 
 
 OTHER COMPULSORY SYSTEMS. 
 The-health insurance systems of Austria (1888), Ilungary (1891), 
 Luxemburg (1901), and Koumania (1912) are organized in the same 
 way as the German system and differ from it only in a few minor 
 details. The most important difference is the experiment introduced 
 in Hungary in 1907, when all the local funds were consolidated into 
 two national insurance societies. The Serbian law (1910) includes 
 only employees of establishments subject to the industrial act which 
 covers mining, transportation, trade, and certain other industries. 
 The Russian Act (1912) is also limited in its scope, covering factories, 
 mines, metallurgical establishments, inland navigation, street rail- 
 ways and some local steam railroads, provided that they employ at 
 least twenty hands, and use some form of mechanical power, or that 
 if they do not use mechanical power they employ at least thirty 
 hands. Only aJjout 20 per cent, of the wage workers are thus pro- 
 vided for. Cash benefits resemble those furnished by the German 
 system, but no medical care is provided, because by a law of 1866, 
 employers in factories and mines are required to provide free medical 
 care for employees. As very few sick benefit societies existed in 
 Russia previous to the passage of the Act, the administration of the 
 system was put exclusively in the hands of establishment or factory 
 fiands, controlled by boards of directors of which the employers elect 
 two-thirds of the members and the employees one-third. The Nor- 
 wegian law (1909) covers all industrial employees regardless of trade 
 and departs from German precedent in exempting persons suffering 
 from chronic diseases, making medical care for dependents com- 
 pulsory and introducing a definite money subsidy ffom the State. 
 The Netherlands passed a compulsory health insurance law in 1913, 
 - differing in two important features from the German law. No medi- 
 cal or funeral aid is provided, because of the already extensive pro- 
 vision of this care by mutual aid societies and by municipalities; 
 and the administration of. the system is in the hands of special 
 "labor councils," elected by employers and employees for adminis- 
 trative districts designated by the government. These councils pro- 
 vide a method of organization which more closely approaches com- . 
 plete state insurance than the ^methods' used in other European 
 
 countriesr. . 
 
 Sweden is reported to have adopted a compulsory system since tie 
 outbreak of the war, and Italy has appointed a Commission to draft 
 a compulsory Act, including other workers besides railway employees, 
 who are at present compulsorily insured. In May, 1914, the Belgian 
 Chamber of Representatives passed a bill for compulsery health, 
 invalidity, and old age insurance which was to have been referred to 
 the Senate in NoA^ember, 1914.* 
 
 -TT^haxnbre de. Uepresentants, -iiWles Parlementaires, page 2,031. 
 
242 
 
 It lias of course been impossible to secure extensive or detailed 
 information concerning the recent operation of any of these systems. 
 Their success or failure can at present only be judged by the testi- 
 aaony of persons who are familiar with the various countries con- 
 cerned. By far the largest volume of this testimony indicates a wide 
 ^reail endorsement of the principle of comiJulsory health insurance" 
 in Europe, and a desire on the part of all classes to liberalize benefits, 
 extend eligibility, and give greater stimulus to preventive health 
 measiires. -^ 
 
 In March 1914, Sidney and Beatrice Webb, the well known English 
 writers on labor problems, published a careful report of the results 
 «f an investigation which they had just made of the British Health 
 Insurance system. They spoke very frankly of the incompleteness 
 especially of the medical care provided, but said of the system in 
 general: 
 
 "We cannot pretgnd to measure the advantage, to individuals or to 
 the community, or the really gigantic provision thus made for periods 
 of incapacity — liowever far short of completeness or perfection the 
 j>roirjsJon may be deemed . 
 
 "We do not pretend in this survey, to give any vision of the social 
 results of llie National Insurance Act^to gauge the relief afforded in 
 sickness and poverty, or the advance in health and productive power 
 that Its truly gigantic operations can not fail to be bringing about.'' 
 
.'43 
 
 PART III. 
 SECTION III. 
 
 State Social Insurance Facilities in the United States. 
 
 The iBdustrial development of the United States, as of Europe, has 
 T^een accompanied by various efforts of employed persons, sometimes 
 Avith the cooperation of employers, to establish insurance systems 
 which would enable groups of workers to distribute such risks as 
 those arising from sickness, accident, old age and invalidity. Trade 
 unions, both national and local ; establishment funds for workers in 
 individual industrial or business operations; mutual societies, fra- 
 ternals and lodges ; and mutual industrial life insurance companies 
 are the best known representatives of this type of protection. 
 
 The extent of these different kinds of insurance, in so far as they 
 are concerned with the sickness risk, has been -outlined in Pai't TI, 
 Section III of this report. Their growth in this count) y has been 
 very similar to their progress in Europe befoie the enactment of so- 
 cial insurance acts, and they reveal here the same defects as we . 
 have already described in discussing the factors which led to the 
 .development of state insurance abroad. 
 
 A few interesting experiments are being made in different parts 
 of the United States wath voluntary state insurance in very limited 
 degrees. Massachusetts through its savings banks and Wisconsin 
 through the state government are attempting to provi<le industrial 
 life insurance at the lowest possible cost by eliminating profit and 
 the expense of solicitors and collectors, and by subsidizing the coat 
 of actuarial and medical departments. Indiana has for myany years 
 maintained a "hydrophobia fund," from which persons bitten by 
 dogs can have their w'ounds treated, and North and South Dakota 
 have just adopted from Canada a. plan for "hail insurance," main- 
 tained by the state for the protection of the farmer in case of de- 
 struction of his crops by hail storms. 
 
 However, the growth of Workmen's Compensation is the one im- 
 portant development of state insurance in this country so far. The 
 addition of Virginia in 191S made thirty-eight states, besides Alaska, 
 Hawaii and Porto Eico, which have compensation acts. The federal 
 government has also a law for the protection of its million civilian 
 employees, and war risk insurance has been provided for men in the 
 service. Thirteen of the state compensation law^s are compulsory, 
 and sixteen laws provide for insurance in a state-managed fund. 
 The rate of compensation varies from 40 per cent of wages in Wash- 
 ington to 66f per cent in Ohio and Xew York. Louisiana, Massa- 
 
244 
 
 chusetts, iS^ew York, Porto Eico, Kentucky, and Xew Jersey, ha\«e 
 improved their laws within the past year. The successful operation 
 of these laws has won general suppert of the principle of compensa- 
 tion, not only because of the relief afforded actual cases of injury ,^ 
 but even more because of the tremendous impetus given to preventive 
 efforts. The "Safety First" sign is now a familiar one, and is but 
 an indication of the general movement for safe working conditions, 
 properly guarded machinery, and educational campaigns among 
 employees. 
 
 STATE HEALTH INSURANCE PROI-'OSALS IN THE UNITED STATES. 
 
 Various plans for State Insurance have been proposed in this 
 country, differing somewhat in the number and type of benefits 
 provided. 
 
 The most comprehensive proposals aim to insure all employed per- 
 sons against sickness and accident not covered by Workmen's Com- 
 pensation acts, and to provide medical benefits during the entire 
 illness, including the necessarj^ supplies and hospital treatment, ex- 
 tending this care to the workers' dependents ; making special pro- 
 vision for maternity and death benefits; supplying cash as well as 
 medical benefits, the cash benefit amounting to a proportion of the 
 employee's wages, but with a maximum limit. It is proposed to con- 
 duct- the system under state supervision and to support it by contri-. 
 bution from the employees, the employers, and the community, in 
 varying proportions. 
 
 The other proposed plans are usually modifications of tke above, 
 differing from it principally in the regulations as to (1) whether in- 
 sured persons shall include all employes, or be limited to a group in 
 receipt of not more than ascertain yearly income; (2) whether bene- 
 fits can be extended to the dependents of these employees; (3) methods 
 of organization and provisions for medical benefits; (4) degree of 
 supervision and type of insurance carriers; (5) detail in types of 
 benefits conferred. 
 
 There are two standards by which any proposed health insurance 
 plan must be tested as a state or national policy: -; 
 
 First: Whether it will lessen poverty and destitution. 
 
 Second: Whether it will lessen disease and promote health. 
 
 As Dr. Warren of the United States Health Service states, "State 
 Health Insura.nce should have two definite objects: (1) to distribute 
 the cost of sickness among those responsible for conditions causing 
 sickness and thereby lighten the burden upon the individual and (2) 
 to give a financial incentive for the prevention of sickness to those 
 who are responsible by dividing the premiums among the responsible 
 groups." 
 
245 
 
 Because of the attention paid to the exact number and land of 
 losses occurring and the financial incentive to prevent as many as 
 possible of these losses, we find, that invariably all kinds of insur- 
 ance stimulate prevention. Life insurance companies find it worth 
 their while to care for the health of their policy holders ; to make in 
 short, every effort to prevent death and the consequent loss to the 
 company. Fire insurance companies stimulate in every possible 
 way means of fire prevention. A certain number of losses — deaths,, 
 fires, accident — are bound to occur. As a business proposition, how- 
 • «ver, it is worth the while of the insurance companies to reduce 
 the number of these losses to the minimum. So far as we are able 
 to judge from the information available, every European country 
 which has in operation a state health insurance system has felt the 
 impetus to preventive effort. Better hospital and nursing facilities 
 liave been provided, prompt attention to minor illnesses has lessened 
 the proportion of serious and chronic diseases, and educational 
 health propaganda among the employed classes has been greatly 
 fitimulated. 
 
 The interest in State Health Insurance in the United Statfes is 
 witnessed by the innumerable private bodies representing the or- 
 ganized employers, employees, medical profession, social agencies 
 and research bureaus studying health insurance questions, in addi- 
 tion to the official commissions created by nine State Legislatures 
 find charged with the duties of investigating the sickness problem 
 among employed persons, tlie economic results of this sickness, and 
 the different plans in force in this and other countries, looking to- 
 ward a more equitable distribution of the sickness burden among 
 those responsible for it — the individual, industry, and the State. 
 
2J:0 
 
 PART III.— SECTION II.— TABLE I. 
 
 PRINCIPAL EUROPEAN COUNTRIES- HAVING HEALTH AfsS^RANCB: 
 WITH DATE OP ORIGINAL ADOPTION. I Q iQ 
 
 Compulsory General. 
 
 Germany, '-:l_._; 188.'. 
 
 -Austria., ^_^.. 1S88 
 
 Hungary, __.^_ 1891 
 
 Luxemburg, i ;____ 1991 
 
 Norway, 1909 
 
 Servi.1, 1910 
 
 Great Britaia, 1911 
 
 Eussla, __ 1912 
 
 Roumania, 1912 
 
 .Netherlands, , 191.3 
 
 Belgium, '1 1914 
 
 Sweden (reported), 1917-18 
 
 Ten cantons of Switzerland, . 1914 
 
 ...■»S,'S:fg»,.:' .. 
 
 Compulsory Partial. 
 
 _i 
 
 France: 
 
 Miners, seamen, railway employees,. 1894- 
 Denmsrk: 
 
 Allen seasonal employees, I90a 
 
 Italy: 
 
 Maternity cases, 1910 
 
 Volyntary, Subsidized by State 
 
 Denmark, ISei 
 
 France, -'kr^ l^lcy- 
 
 Switzerland, .'^,: - 1914- 
 
 
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Cornell University Library 
 HD7102.U5P4 1919 
 
 Report of the Health insurance commissio 
 
 3 1924 002 407 744