are small to direct the latter not only to make provision against his death, but likewise against disease.

Can this be done? As has been stated, in Germany the State recognizes not only its duty to the citizen by appropriating from its treasury a portion of the funds for the support of the invalided workmen, but it compels the employer and the employe to assume their respective responsibilities, so that should the latter become incapacitated, he will not become a charge upon the public. It is doubtful, in fact probably impossible, to institute any such compulsory system of insurance in the United States, but there is a strong possibility that an insurance organization which can intelligently present to the working classes the advisability of protecting themselves against tuberculosis, can depend upon the voluntary cooperation of the intelligent workman to bring such an organization to a successful financial basis. It is more than likely true that Mr. Hoffman's point of view is correct. Industrial insurance companies working on general lines may not have the power to divert their resources to the consideration of any special class of their policyholders. But this does not invalidate the belief that it might be possible for an assurance society to take tuberculosis risks or that a new society, with the special purpose of insurance against tuberculosis, or as will probably be necessary, against disease in general, could not be successful. It would be an assumption on my part to attempt to discuss this question in detail. The ability to determine what an insurance company can or cannot do must be left to those qualified in the complexities of insurance to decide. I wish to present, however, a few of the data of the Landes Versicherungs Anstalt Baden, the state insurance company of that province, to demonstrate that an insurance society whose only purpose is to insure against disease and invalidity can be financially successful. In the year 1891 the receipts of this society from premiums were 2,662,978 marks, and from interest on investments, 26,696 marks. In the year 1900, the receipts

from premiums were 4,120,458 marks, and from interest account 924,781 marks. Its expenditures for the year included 419,204 marks for old age pensions, 1,118,434 marks for invalidity pensions, and 484,820 marks for treatment in sanatoria, hospitals, etc. Its capital account at the end of the year 1900 was 27,591,146 marks. In other words, after paying all obligations, the capital account had so increased that the interest on investments rose from 26,000 marks in 1891 to nearly a million marks in 1900. This society, during the year 1900, gave treatment to 1,315 men and women afflicted with tuberculosis, and to 732 men and women afflicted with other diseases. On the basis of the Trade Census for the year 1895, 362,553 people are liable to the Insurance Law. If these figures are correct we have the conclusion that .5 of 1 per cent of the insured were cared for in sanatoria, etc., during the year by the Insurance Society at an expenditure of practically 10 per cent of the receipts.

It must be remembered, however, that of the amount received by the Insurance Society, half has been contributed by the employer. In other words, if the employer cannot be considered, the cost of caring for the society's sick would be 20 per cent of the receipts instead of 10 per cent.

In an earlier part of this paper mention was made that some of the smaller societies found it impossible to meet their obligations owing to the limited membership. It is possible that the report of the Badische Society is not a fair test of the results actually accomplished throughout the Empire. It will answer, however, for purposes of illustration, and to indicate that if a sufficiently large membership can be obtained, the probabilities of financial success can be demonstrated. Whether it is possible among the working classes in the United States to arouse the sense of personal responsibility in large numbers of men, and to make them realize the necessity of making provision against sickness and for inaugurating proper treatment should they be

afflicted, is a question that can be determined by experiment only. The numbers of sick benefit organizations, etc., which are in existence would indicate that the workman is fully alive to his duties. Of even greater import is the fact that the employer is realizing his responsibility to the employe by voluntarily contributing to the latter's support in case of sickness and old age. How far the State could coöperate is an open question. If the insane are fit subjects for State supervision and State care, it will be but an extension of this idea that the State should care for the bodily sick as well as for the mentally sick and to contract with organizations created with such a specific purpose, in order that the best possible treatment can be given. Such is the principle on which all hospitals are subsidized. It is fair to assume that an insurance society organized on a philanthropic basis with the sole purpose of inculcating habits of thrift in the workman so that he shall make provision against possible sickness, and in particular against tuberculosis, might have the right to seek State aid and State coöperation. Finally, if requisite financial support cannot be obtained from the above sources, such a plan is always within the province of private philanthropy.

To sum up, it may be safely stated that a compulsory plan of insurance against sickness which shall include proper provision for the treatment of tuberculosis, as conducted in Germany, is not feasible in the United States.

On the other hand, we are justified in believing that an insurance society against sickness which shall make special provision against tuberculosis, and if necessary create proper sanatoria for its treatment, would receive the voluntary support of the workman who would contribute his share of his earnings; of the enployer, who would see in such a plan an economic measure; of the philanthropist, who would find a useful field for charitable endeavor; and of the State, which would recognize that in aiding such an institution it would be progressing along the lines of

wise and sound policy. From the standpoint of the charitable in particular, the proposition is an alluring one, since it would be charity in its most useful form, the charity, namely, which inculcates the principles of self-help. If the workman can be made to realize his share of responsibility, and to make proper provision for insurance against disease, it will relieve the community of a burden which it is at present compelled to bear for lack of such provision.

Dr. Pryor has told us that of the 7,000,000 people now living in New York State, 600,000 will probably die of consumption, and that approximately one of every five over twenty-one years of age suffers from it. The enormity of the problem is so thoroughly indicated by these figures, that it need not be further dilated upon. Not only would such an assurance society help in the solution of this great problem by giving treatment at the proper time, and thereby materially lessening the death rate, but through its very existence, through its very efforts to interest the laborer and the workman, it would make propaganda that would enable its policyholders to take proper steps against infection. It would teach the advantages of proper housing, of good sanitation, of necessary sunlight and fresh air, and in this way materially reduce the numbers who would eventually apply for treatment. It is the last phase of the question in particular, that places the subject above the plane of a purely business venture, and makes it distinctly a question for the philanthropist.

DISCUSSION ON 66 COOPERATION AND HEALTH INSURANCE FOR CONSUMPTIVES."

The discussion was opened by Ignatius Rice, of New York.

Mr. RICE. I have listened with appreciation and interest to the able and learned paper of Dr. Frankel and have been called upon to make a few remarks on the possibility of applying similar methods in this country.

attract general interest

It has been made clear

The subject is one that is bound to in proportion as one studies the matter. that tuberculosis is the chief disabling factor in our industrial world, and that the victim himself is not the only sufferer, but that his disability involves disaster to his entire family and the community.

Any methods that we can employ to alleviate the economic distress occasioned by this and other diseases will be of incalculable advantage, and one that estimated in dollars and cents alone would show surprising results.

I agree with Sir John Burdon Sanderson that some voluntary insurance against tuberculosis must be regarded as the best substitute for the compulsory system. Compulsory insurance by the State seems to me to be out of the question in this country, as the word "compulsion" is obnoxious to all the inhabitants of this hemisphere, and I am strongly inclined to believe that a system of insurance which has the confidence of the people, and can convince the working classes of the necessity of protecting themselves against all diseases, particularly tuberculosis, will have the coöperation of every thinking workingman.

It is, however, not the workingman alone who must carry out this plan. The employer also must lend a helping hand. The employer should lead the good and noble canse and show the employes that their welfare is also his.

The working people should be informed of the well-known fact, that over one-tenth of the deaths in this State are caused by tuberculosis, and it may open their eyes to the advantage of insuring against sickness and thereby protecting their family against

want.

We should have no difficulty in persuading employers and philanthropists to assist in furthering the common weal. The coöperation of the trades' union would be a very material assistance in establishing this form of benefit.