NRLF B M bl7 7bl Medical Problems of Legislation Being the Papers and Discussions Presented at the XLI Annual Meeting of the American Academy of Medi- cine, held at Detroit, Mich, June 9-12, 1916. Easton, Pa.: American Academy of Medicine Press 1917 ^l)ec^1 The Medico-Social Problems Library, VII. The American Academy of Medicine is not responsible for the sentiments exprest in any paper or article presented to it. PREFACE. The boundary between legislation and medicine is extensiv and extending. With each succeeding session of the legislatures these problems become more varied and complicated. It begins with prescribing the requirements for entering upon the practice of medicine, continues in regulating the practice in important directions after the student has become a physician, as shown by the laws regulating criminal malpractice, prescribing of narcotics and, more recently, by the various forms of welfare insurance. Thus the contact between the physician himself and legislation is important and intimate. Then there are the regulations grupt together under public health laws and the medical ques- tions to be determined in legislating for the care of defectiv classes, which are additional examples of the intimate relation- ship between medicine and legislation. This volume presents and discusses some of these problems, being the transactions of the forty-first annual meeting of the American Academy of Medicine. The papers have already appeard in the official organ of the Academy, the Journal of Sociologic Medicine, and are gathered together in a single volume for the convenience of those who may desire to refer to these papers apart from other articles appearing in the Journal. 366673 TABLE OF CONTENTS. Our Social Readjustments and the Relation of the State to Mother- hood and Children. By George A. Hare, M.D., Fresno, Cal. {President's Address.) 7 Legislation Affecting the Entrance upon the Practice of Medicine: Legislation Regulating the Practice of Medicine, Preliminary and Medical Education. By N. P. Colwell, M.D., Chicago, Secretary of the Council on Medical Education of the American Medical Association 24 Examinations for License to Practise and Hospital Interneship. By John M. Baldy, M.D., Philadelphia, President of the Bureau of Medical Education and Licensure of the State of Pennsylvania. 37 Legislation Affecting the Status and Duties of Physicians: Legislation Creating Civil Positions for Physicians. By John B. McAlister, M.D., Harrisburg, Pa., President of the Medical So- ciety of the State of Pennsylvania 46 Social Insurance against Accidents (Workmen's Compensation Laws). By Frederick L. Van Sickle, M.D., Olyphant, Pa 54 Health Insurance. By John B. Andrews, Ph.D., New York City, Secretary of the American Association for Labor Legislation .... 77 Unemployment Insurance. By Hon. Rufus M. Potts, Springfield, 111., Insurance Superintendent, State of Illinois 90 The Relation of Medical Benefits of Health Insurance to Existing Health Agencies. By B. S. Warren, M.D., Washington, D. C, Surgeon U. S. Public Health Service iii The New York State Sanitary Code, How Enacted— Its Scope and Legal Status. By Hermann M. Biggs, M.D., Albany, N. Y., State Commissioner of Health 125 Interstate Sanitary Relations. By William Colby Rucker, M.D., Washington, D. C, Assistant Surgeon-General, U. S. Public Health Service 131 The Drink Problem and Legislation. By John Koren, A.B., Boston. 140 Legislative Protection of the People from the Evils of Patent Medi- cines and Medical Fakers. By F. F. Lawrence, M.D., D.Sc, LL.D., F.A.C.S., Columbus, 154 Industrial Legislation: Standards Applicable to Child Labor. By Helen L. Sumner, Ph.D., Washington, D. C, Assistant Chief, U. S. Children's Bureau. . . . 164 Women as Wage-earners. By Mrs. Florence Kelley, New York City, General Secretary, National Consumers' League 176 Housing Reform Through Legislation. By Lawrence Veiller, New York City, Secretary, National Housing Association 179 Medicine and the Industries. By George M. Price, M. D., New York City, Director, Joint Board of Sanitary Control 183 Legislation for Care of Exceptional Cases: The Physically Defective. By B. O. Otis, M.D., Boston 189 The State and the Insane. By Richard H. Hutchings, M.D., Ogdens- burg, N. Y., Superintendent, St. Lawrence State Hospital 209 The Necessity for Medical Examination of Prisoners at the Time of Trial. By Paul E. Bowers, M.D., Michigan City, Ind., Physician to Indiana Hospital for Insane Criminals 220 OUR SOCIAL READJUSTMENTS AND THE RELATION OF THE STATE TO MOTHERHOOD AND CHILDREN. By George A. Hare, M.D., Fresno, Cal. We have met this evening to celebrate the forty-first anni- versary of the founding of the American Academy of Medicine. I will not attempt to recount our achievements, for society has moved so rapidly during the past forty-one years that should any one have had the temerity to have outlined our progress he would have been classed as a dreamer of dreams. It was Morse who tried to forecast our progress in 1819 by teaching school children in his Universal Geography issued in that year that "All settlers who go beyond the Mississippi River will be forever lost to the United States." And again it was tried in 1840 by no less a person than Daniel Webster who, in one of his eloquent speeches before the United States Senate, exprest his belief that the Mississippi River formed the Western boundary of modern progress beyond which American civilization could hope to make no substantial headway for he askt, "What do we want with that vast and worthless area — that region of savage wild beasts, of deserts, of shifting sands and whirling winds, of dust, of cactus and of prairie dogs?" "To what use could we ever hope to put those great deserts and those endless mountain ranges — what could we ever do with that western coast — a coast of three thousand miles — ^rock- bound, cheerless and uninviting." Even Webster had no dream that the children of his day would see a Lincoln Highway unite the undisputed center of the commercial world with the un- rivalled paradise of the Pacific. As an illustration of our rapid progress take the interesting problem of intelligent quarantine. Suppose that New Orleans, during a scourge of yellow fever fifty years ago had had a really intelligent health officer, who would have considered that physical contact with a person dying of yellow fever involved no danger whatever, and who would have considered green peas, cu- cumbers and water melons as deliciously harmless as they really are, and permitted them freely in the open market, and should have directed his energies and authority toward the extermination of the stegomyia mosquito. Such intelligence would have caused him to be considered the victim of hallucinations and a fit sub- ject for the insane asylum. But when society gave sufficient study to the problem of control of infectious diseases it found the adoption of this apparently insane idea a practical necessity. Yellow fever, malaria and bubonical plague have remained un- changed, but society has had to change its viewpoint, and to con- sider them no longer questions of green vegetables, foul air and evil spirits, but rather of mosquitoes, of fleas, and of bedbugs, no longer questions of dietetics but questions of entomology. But I hear some one say, we had to change our view point in the treatment because doctors had not discovered the bacterial .cause of these diseases. All right then, let us illustrate the changed view point of society by citing another instance. We have done a wonderful work in controlling the ravages of tuberculosis. We certainly have discovered its bacterial causation, never was conformation to Koch's postulates more rigidly demanded. We have educated the public until its bacterial cause is the common knowledge of every school boy. We have demonstrated be- yond a question that this is a preventable disease and should no longer be the white plague of an intelligent civilization. We have lowered the death rate some, but the real problem of its control and its eradication is yet before us. All we have done has only brought us face to face with the stern truth, that the control of tuberculosis must no longer be considered a medical problem, but a social problem. And as a social problem it can never be cured until we treat it socially. And society will treat tuberculosis in a social way only when it treats all sickness in a social way, by means of social insurance. And when society treats all sickness by insurance, it will find that the suggestion made by Chester Rowell is true that it is cheaper, it costs less cash, to supply all those condi- tions necessary for keeping people well enough to earn their living, than it is to support them and their families when they are sick. Then and only then will the problem of tuberculosis find its real solution. Is this an insane idea? Well we must squarely face it, for social insurance is the problem of to-day, and is by all odds the largest problem before the medical pro- fession. We are in a transitional period, the individualistic system with its individual doctor, its individual patient, is passing; and in its place we will soon find the coUectivistic method as is shown by the present tendency to social insurance which has for its object the prevention and cure of sickness on a coUectivistic plan, just as society now prevents and cures ignorance by means of our public schools, the expense of which is a coUectivistic and not an individualistic obligation. In a democratic form of government the ignorance of one is the menace all, hence the education of each at the expense of all. This principle applies with as much force in the control of all infectious diseases as it does in the control of ignorance. The infection of one is the menace of all, hence the care and pro- tection of each should be at the expense of all; and protection of society against tuberculosis means that each must have enough food, clothing, shelter, rest and recreation to keep his vital re- sistance above the invading level of tuberculosis. This means employment, wages, reasonable working hours, and proper care when ill from accidental causes. It means that society, as in- dividuals, demands that society, as a whole, distribute the causes lO of poverty and suffering by intelligent prevention, rather than by our present method of treating the end results, suffering, sickness, poverty and a large amount of crime, at an enormous and wasteful expense, or by a heartless and wicked neglect. Hence we have the foundation of social insurance laws against sickness and unemployment. It is just as sound in principle and just as profitable to keep people well, at public expense, as to keep them educated at public expense; it is quite as much in the interest of public welfare to cure sickness as to cure ignor- ance. Doesn't this idea of curing sickness at public e^tpense sound like socialism and if so, is it not dangerous? Socialism is a term we all dislike, but in using it as a label to hinder every movement in the interest of the people we have rather worked it overtime. A railroad commission which compelled the railroad to work for the interest of the public as well as for private gains was social- istic. The assumption by the state or municipality of the right to control the building of tenement houses for the poorer classes so that every man, woman and child, shall be given by every owner of rented property sufficient light and air for good health, is socialistic. The compulsory education of every child for its own good and the good of the state at the expense of the public, is socialistic. The control of public utilities such as gas, water and telephone companies, depriving them of the power to charge one patron more than another, or to make in any cases more than a reason- able charge, is socialistic. Who could have foreseen that the same progressive forces which called the American Academy of Medicine into being would compel us to consider in such rapid sequence the topics just men- tioned and many others, and bring us face to face with such popu- lar movements as industrial insurance, health insurance, mothers' insurance and other national movements which add to the peace and prosperity of our commonwealth. These efforts at social readjustment, based on the principle II that every industry should share the losses as well as the gains of its development and maintenance are so sound in their phil- osophy and so practical in their results that since 1883, when they were recognized by Germany, they have found expression on the statute books of almost every civilized nation. Social insurance is so important to the medical profession that the American Medical Association recently appointed a special committee to study this problem. The State Medical Society of California at its meeting in April last appointed a state committee on social insurance and re- quested every county society to appoint a similar committee to work in co-operation with a state instu-ance commission ap- pointed last year by the governor, to the end that with the aid of physicians proper legislation might be constructed. I use that word constructed advisedly for much of the legislation with which we are afflicted was never constructed, it just hap- pened and the fact that it just happened is not the only resem- blance it bears to some of our other misfortunes. Even our legislators as well as our physicians seem slow to learn that so- ciety is readjusting itself. Any attempt to establish such social insurance as will secure to the wage earner and his family protection from the disastrous efifects of sickness pre- sents as its most difficult problem any form of adjustment satisfactory to the medical profession. ^ The British Health Instu-ance Act differs decidedly from that of other European countries in frankly recognizing this difi&culty by way of a com- promise between the interest of the physician and the interest of the insured.* And why not recognize both interests? In all countries insur- ance laws are formed to protect not only the insured but also safeguard the interest of the insurer. Is not the world indebted alone to the medical profession for its wonderful progress in preventive medicine? And is there any good reason either in logic or morals why the progress of pre- ventive medicine should be retarded by allowing the interests of the medical profession to be ignored or over-ridden? The 1 Rubinow. » Rubinow, Pamphlet, p. 345. 12 Academy would do well to urge on the part of the profession of the United States such co-operative consideration of these conflicting interests as will safeguard the future progress of pre- ventive medicine. Social instu-ance has not yet accomplished its mission. It is firmly established in almost every European country; in our American commonwealth it has just begun but it has already made of the questions of industrial insurance, health insurance, insurance against unemployment, the relation of the state to mother and children, definite problems that demand solution. While the great movements for social readjustment have swept society like a mighty cyclone, the medical profession has had something of the attitude of the man who was visiting his friend on the broad prairies of Kansas and seeing for the first time a tornado he inquired of his friend, "Say, Jim, you have had some experience, can you tell me how I can stop that tornado?" "Yes, we have had some experience and we don't stop 'em ; we find we are more successful to just go with them." The medical profession not only of the United States but throughout the world, by its open opposition to, or its aloofness from this movement for social insurance, is failing to render to humanity that service which is due in this period of social reconstruction. One of the newest and most interesting phases of social insur- ance is that which touches on the relationship of the state to motherhood and children. In 1 89 1 a society was developed in France known as the Mutual- ite Matemelle. Although formed on the co-operative plan, its treasury received but a small amount from its members, most of the funds being supplied by the state and by private philan- thropies. Its members were entitled to forty-eight francs at confinement and ten francs for nursing. This society was so successful that it stimulated the formation of many similar socie- ties throughout Europe. To-day we find maternity insurnace in at least fourteen countries of Europe. These are all or nearly all co-operative, the employer, the employee and the state each contributing a definite proportion to a common fund. 13 Australia and France have a system of maternity insurance under which the state pays all the benefits. The British laws provide for a benefit at confinement for the wives of all insured men and to all insured women, whether mar- ried or unmarried, and an additional sick benefit is paid to all insured women, provided, however, they are married. The British laws contain another very remarkable clause which states that "Medical benefit shall not include any right to medical treatment or attendance in respect to a confinement." The British medical profession stuely was not in evidence when that law was enacted. The first city in the United States to extend definite aid to mothers was San Francisco, in 1908; while Missouri must be given the credit for enacting the first mothers state pension law in 191 1. Since then mothers pensions laws have been en- acted in twenty-three states.^ California, Oregon, Washington, Idaho, Utah, Nevada, Arizona, Colorado, South Dakota, Minne- sota, Nebraska, New Hampshire, Iowa, Missoiu-i, Wisconsin, Illinois, Michigan, Ohio, Pennsylvania, New Jersey, Massachu- setts, New York and Tennessee. In all these countries, with the exception of Germany, and in all American states as far as I can learn with the exception of Colorado, the only recognized relationship existing between the state and motherhood and children is poverty. Some one has said that "The first test of eligibility of mothers to state recognition is poverty." Is it? Or is it motherhood? The state recognizes poverty as poverty and relieves it in every condition of life. Whether or not the state should recognize and foster motherhood on the quality of which the existence of all free government depends is a question which will be discussed in the near future. Italy recognized motherhood and not poverty as the first test and enacted a compulsory maternity insurance law in 19 10, although she has no health insurance laws. This maternity law covers only working women who are employed ; it is co-operation in that the employer, the employee and the state each contributes 1 Mothers' Pension, p. 2. to a common fund. This law asks not whether she has a com- petence or is in poverty. The fact of motherhood alone gives her access to this fund. Colorado recognizes motherhood as well as poverty a sufficient test for recognition. The Colorado law expressly states that:^ This act shall be liberally construed for the protection of the child, the home and the state, and in the interest of public morals, and for the preven- tion of poverty and crime. In commenting on this law Judge Lindsey says: It is a recognition by the state that the aid is rendered, not as a charity, but as a right as justice due mothers whose work in rearing their children is a work for the state as much as that of the soldier who is paid by the state for his services on the battlefield; it is a recognition for the first time by society that the state is responsible in a measure for the plight of the mother, and acknowledges its responsibility by sharing the burdens of her poverty that is created largely by the conditions that the state permits to exist. In Colorado, where wife and child desertion is growing with alarming rapidity, the deserters are generally sent to a very comfortable county jail, where they are fed up, and the wife and children starve outside. The detail as to the payment of the earnings for the support of the cases mentioned in the act was intended to put a premium on motherhood in favor of the women who bear children. ^ The state owes an obligation to every mother. This obliga- tion rests not on the chance of financial rating but on the fact of motherhood and the state recognition of this obligation should not be expressed in terms of charity, which it is not; neither as relief of poverty which is humiliating, but, as a recognition of motherhood which by right it is. Germany, which at the outbreak of the present war passed an act August 4, 19 14, relieving all her insurance societies of their obligations to pay maternity insurance, soon found it was in the interest of public policy to recognize the relation of motherhood to the Empire in a very tangible manner, and only fom* months later, December 2, 19 14, she re-enacted a maternity benefit law. This law, which applied only to soldiers and the wives of insured men, was rapidly modified by a further enactment in January, 191 5, and again in April, 19 15, by which its maternity benefits * Judge Lindsey in "Mothers' Pensions," p. 23. * Mothers' "Compensation Law of Colorado," Ben B. Lindsey, Survey, %9, 714-16. 15 were made to include women in domestic service, in the pursuit of agriculture and in other occupations. Under the terms of this law each mother was provided for both before and after confinement; she w^as given free treatment, in- cluding medicines, midwives, physicians' care, and the child is cared for till it is fifteen years old. Or in lieu of free treatment and care the mother is allowed a cash benefit to the amount of 133 marks or $31.65. In this decree, as pointed out by Frankel, "The expression of small means" (minderbemittelt) is employed instead of "needy" or "indigent" (bedurftig) in order that the aid might not bear the stamp of poor relief.^ It is very significant that this law eliminates every feature of co-operative contributions, the entire expense is borne by the Empire. The war opened Germany's eye to the dependence of the state on mothers and children, for she says, "The enormous sacrifice of human life which war demands makes it the imperative duty of the state to take proper care for the preservation and strength- ening of the coming generation at the very moment of entrance into this world." In monarchial governments the perpetuity of the state depends mainly on the ability of the ruler, and the future ruler is reared and trained for the purpose of ruling. In a free government the children are the future rulers, not one child, but the majority of children are rulers, hence the relationship of the state to parent- age is quite different in a free government from that which ob- tains under a monarchy. Stability of democratic forms of government depends on an intelligent citizenry, hence the duty of the state to make every citizen intelligent, not only to give them the opportunity to be- come intelligent but to make the use of the opportunity compul- sory, hence the justice of our compulsory school laws. Now the stability of the state depends no more on an intelli- gent citizenry than does the perpetuity of the state depend on a vigorous posterity and thru a vigorous posterity alone can 1 Frankel, Maternity Insurance, p. 15. i6 our civilization and the institutions it represents be preserved in its integrity and pass unimpaired to the control of those who follow us. I wish to emphasize this duty of the state in its relationship to motherhood because there has been altogether too common a feeling that the state should concern itself only with the more important matters of tarriff and commerce and finance and not concern itself with such small matters as motherhood. It is considered as an unwarranted meddling in domestic affairs. Of course, it is all right to appropriate money to pay the cost of maintaining poor houses or of biuying people because people just have to be buried, but, the inference is that people don't just have to be bom, at least if they do it doesn't cost anything. I want to say with emphasis that there are few questions before the American people which so vitally effect our future welfare as the problem of motherhood and children and the recogni- tion of the obligation of the state to foster their well-being. And I shall recommend that these problems receive careful study on the part of the Academy. Now as to the matter of jtu"isprudence. Has the state the right to recognize any obligation or relationship between the state and motherhood and children except the duty to relieve poverty? The right of the state to legislate in behalf of the health of growing children by forbidding their employment at hard labor (during the early years of their growi:h) and to restrict the hours of labor for women and forbid the employment of mothers for a period before and after confinement is unquestioned. All will concede that the state has the right to enforce such legislation on the child and the mother whether they wish it or not. This is a plain recognition on the part of the state of her responsi- bility to provide for the physical growth and well-being of her mothers and children regardless of poverty. Almost every nation of Europe has by law protected mothers from labor by forbidding their employment for a stated time both before and after confinement. Austria, Holland, Norway, Great Britain and Germany prohibit work for two weeks before 17 and four weeks after, Italy for seven weeks, Belgium, Portugal and Spain for four weeks, Sweden for six weeks. Laws enforcing a period of rest before and after confinement have been enacted in: Massachusetts, enforced rest period of two weeks before and four weeks after. Vermont, enforced rest period of two weeks before and four weeks after confinement. Connecticut, rest four weeks before and four weeks after con- finement. New York forbids employment of women for four weeks after confinement. These all recognize an obligation on the part of the state to care for both mother and child, a relationship not based on pov- erty, but on the physical well-being of the mother and child. In any comprehensive study of the relation of the state to mother- hood will be involved the study of the American home and its preservation. To-day the trend of society is decidedly away from the home idea; women are no longer trained in the idea that the development of a happy home, around the fireside of which is reared a group of healthy, joyous children, is infinitely the greatest achievement within the range of her possibilities. To-day she is being educated to compete with men along lines which God ordained should be an adjunct of fatherhood, that of providing for the maintenance of the family. It was Timothy who said "He (not she) that provideth not for his own and espe- cially those of his own household hath denied the faith and is worse than an infidel."^ I am a believer in the rights of women, especially the right of mothers and their political emancipation and while I quite fully endorse the words of Dr. Helen C. Putnam that ** Political domi- nance of sex is wholly an evil, and to both sexes; that the only right dominance is wisdom; that "law made by men not based on biologic law which women are learning ends in disaster. "^ Yet among men and women who are thinking deeply on social prob- 1 I Tim., 5 : 8. a Bulletin A. A. M., 133, p. 59. i8 lems there is a well-founded belief that this tendency away from the home deas bodes no good to the future stability of the state and that there is no question more vital to the perpetuity of our civilization than the fostering of all those interests which center in the American home and make possible the raising of better children. There is no real home except that which clusters about the thought of mother and children, yet there are people who honestly question whether or not the state has the right to aid in bettering the conditions of mothers and children. But they do not question the right of the state to spend large sums of money to better the conditions of some other things that cluster around some rural homes such as chickens and cows, horses and sheep, pigs and potatoes. No one questions that it is the proper function of the government to aid, foster and improve these com- mercial factors for they represent money, but with the mother and children it is different. The preservation of dollars as the chief function of government must yield to the preservation of human beings. Our mad scramble for the elusive dollar so permeates our minds that we are like the Scotchman who, witnessing the excavation of some ancient city, saw some old ruins on which was a placard "Library 4000 B. C," was asked by a friend "What does that 4000 B. C. mean"? "Hoot, mon, that means $4000 By Carnegie." Let us see if the home idea cannot be expressed even in terms of cash. It was stated in the report of the public health service presented last month at the tuberculosis association in Washing- ton, D. C, that "One-fourth of all cases of tuberculosis developed not in homes but in lodging houses, where men are deprived of home care." That means an annual loss of 25,000 lives of a monetary value of $25,000,000. In the city of Cincinnati the average monthly income of 19 17 families was $57.00. This imposes a condition under which the maintenance of a home or the raising of a family of children is difficult or impossible, race suicide is the logical solution. From a commercial view-point the state is amply justified in fostering the home idea. And Dr. Pratt states that the Emanuel Church of Boston, at 19 an expense of $15,000, increased the earning capacity of tuber- culosis cases $50,000. The greatest rival of our American home is modem apart- ment houses which are happily eliminating the question of ser- vants but they are also eliminating the American home and the most substantial class of American babies, for all applicants for up-to-date apartments are told in blunt language that children are not wanted and among our most valuable class of people when children are not wanted such accidents as children do not occur. I believe it was Joseph Newton who said, "The hope of the world is in the child, in whose dirty, chubby, candy-stained hands lies the future of the human race. In him we live again, if in no other way in memory of God who does not forget." And some one else has said that "We should keep that man," be he landlord or porter, "Three paces distant who is not charmed with the beauty of flowers, the song of birds and the prattle of children." Viewing this question from the standpoint of the permanency of free government, just in so far as modern apartment houses can induce oiu: better class of citizens to select them as a place of permanent residence and yet maintain an unwelcome attitude toward children, thus decreasing the flower of the coming genera- tion and committing to an inferior people the maintenance of our democracy, just in so far are they a menace to free gov- ernment. Any place where children are unwelcome is not a fit place for married Americans to establish a home, however heavenly it would be for the solution of the problem of the feeble-minded. This social and commercial feeHng against children, so destruc- tive alike to broad principle of service to humanity and the future safety of our democracy, has become so common to-day that it is almost a social crime to raise babies. This fetish of fashionable society to have childless homes, like the fetish of wealth must inevitably pass. The time was when the mere possession of millions was a social passport unques- tioned, society next demanded of the possessor of millions, how did you get them? Both these ideas were thrown into the scrap 20 heap of a passing civilization and to-day society demands of the man of great wealth, what are you doing with it? So likewise modem democracy is demanding of every social selfish jelly fish that they be transformed into dependable human beings whose progeny shall develop spinal columns stiff enough to insure the perpetuity of free government. Our national success and national permanence depends to a very large degree on the attitude of public sentiment toward parent- age. The hope of our free government lies not in her standing army; neither great leadership nor a few great men; for genuine democracy will not long tolerate great leadership, for when any man rises much above the average in genuine leadership we Americans demonstrate our personal freedom by hitting him on the head suflGlciently often to keep him much closer the level of the average man. Without hope therefore in the leadership of great men our only hope lies in eliminating the feeble and raising the level of the average. This again emphasizes the vital relationship of the state to motherhood and children, for so sure as our citizenry is recruited by the propagation of inferior stock so sure will our democracy terminate in total disaster. The fact that birth rate among the inferior classes is relatively increasing from year to year is so patent to all that it is super- fluous to offer proof of it. This increase of our population from inferior stock is due to several factors: It is increasing among the lowest classes because of a lack of ap- preciation of responsibility and the ability to exist on very small income. But among the laboring classes of the better grades we find very many mothers who cannot afford to raise babies because their incomes are not sufi&cient to supply what they consider the necessaries of life. While among the higher classes, who are the most pros- perous and in some things the most intelligent, the demands of club life and other social duties so obscure that larger view of life that real patriotism and oiu- obligations to humanity are lost sight of. 21 Can the state offer any remedy to this condition? Should the state in any manner give encouragement to the raising of chil- dren? Why not? Is it not the duty of the state to devise a remedy for any evil that threatens its permanency? Then why is it not just as much the duty of the state to reheve the wants of a mother both before and after birth of the child and while she is nursing and rearing it as it is to educate that same child? Is it not better economy to educate a strong and healthy child than a weakling? And recognizing this obligation of the state, to see that her children are properly cared for, make the raising of children a greater honor to her, on whom the state is depen- dent, and thus change the trend of public sentiment which is stead- ily making headway against the raising of children. How much has the state ever spent to foster our most funda- mental bulwark, the American home? We spend a large sum of money each year (relatively a most insignificant pittance) for the care of children in institutions where initiative is crushed in childhood and the inspiration for doing the great deeds of life are never fostered by the reciprocal love of father or mother, the helpfulness of brother or sister, the inspiration of pets and flowers, of childhood freedom and childhood conquests. Why not take those children we incarcerate in rule ridden, motherless, homeless institutions and develop them at the same expense or at any reasonable expense in good homes, where chil- dren would be welcome and where they would be rounded out into men and women with an experience that would fit them for the conflicts and the conquests of after life and fit them for a better fatherhood, a better motherhood and a better home builder? The facts presented by Judge Pinckney warrant the statement that New York State at the close of 19 lo was caring for 34,530 children in institutions; she was caring for ten-fold as many children in institutions as was Illinois with only two-fold her population.^ Does it mean that the social influence of New York's "400*' has made homes where children are welcome five times less com- mon than they are in the state of Illinois, or does it mean that 1 Child 1, No. 5. pp 43-50. 22 the progressive state of Illinois has been doing five times more child thinking and home thinking than has New York? Is it significant that in 191 1 Illinois passed a state wide mother pension law, while New York defeated the enactment of a similar measure? If the state owes an obligation to the child to see that it has food, clothing and freedom from suffering, then it should restore as far as possible a home environment and a mother's love, for every child's sense of justice demands this right to a mother's love and therefore much of the work done by our juvenile court in committing children from the care of a home to the care of a motherless institution is wrong and much of our so-called charity and philanthropy is hard-hearted cruelty. It was a wise Rabbi who said that "God could not be in every place, therefore he made mothers." The following from Judge Pinckney's experience will illustrate my thoughts : Meanwhile^ is the baby of a widowed mother to be sent to a foundlings' home, the twins under four years to a home-finding society, a boy of six and two girls of eight and ten years to a training school, industrial school, respectively? And then, after you have quietly, but firmly, broken up the family circle and distributed the little ones among the foiu" institutions, al- lotting to each the proper quota in accordance with the age rule, there still remains the mother. What of her? A woman, mentally, morally and phys- ically sound, the victim of circumstances and conditions for which society and the state and not she are responsible, too great a burden apparently for organized charity to care for; what is to become of her? Heartbroken, alone, her husband dead, her children widely separated not only from her but from each other, weakened physically, mentally and morally by the ruthless tearing of maternal heart-strings, where will her footsteps tend to lead this pitiable object to a state's ingratitude? Will she survive the test and continue to lead the honest upright life or will she drift along the lines of least resis- tance, ending in the brothel or in the mad house? It was just such a problem as this some three years ago that first challenged my attention. Such cases have multiplied since then and have made me realize the need of this new law. The picture is overdrawn, say you? Words cannot express a child's fear or a mother's agony at such a time. Watch as I have for nearly four years, children clinging to a mother's skirts or sobbing in a mother's arms; see the affrighted look on the mother's face, a look akin to that seen only in the eyes of a dumb animal when torn from her young, and you will not say the picture is overdrawn, and you will come to believe with me that society and the 23 state should encourage, cherish and not destroy this most sacred thing in human life, a mother's love, and should guard, protect and foster the grand- est institution of our social and political life, the home.^ Shall the state in any manner recognize its dependence on an intelligent motherhood? Shall the state give any encouragement to the building and preservation of our American homes? Shall the state continue to destroy that which is best in her dependent children by committing them to institutions or shall she rear them to patriotic citizenship under the influence of home environment and the love of even foster parentage ? What should the state do to foster good motherhood? What is the state paying annually for bad motherhood? These are problems worthy of our best thought. You ask what have I to offer by way of solution. It is my purpose to-night to present to you some facts and ask if in your judgment they do not constitute a problem worthy of solution. If they do, as I firmly believe, then the solution should be worked out by a careful study of their many details. We have altogether too much law making and too little law thinking. There is no greater service the Academy can render to both the medical profession and to society than a constructive solu- tion of the present polyhedral question of social insurance and the relation of the state to motherhood and children. The rapid development of these questions constitute one of those great tidal waves of society against which opposition is futile. The only way to meet it is by an intelligent solution. For this solution I recommend : That a committee be appointed to be known as the Social Insurance Committee whose duty it shall be to make a special study of the whole problem of social insurance and the relation- ship of the state to motherhood and children, for the purpose of enabling the Academy to render such aid in the final adjustment of these problems as will best conserve the interest of the state, the demand of society, the interests of medical profession, and the needs of the individual. I recommend that the report of this committee be given in the form of a symposium for the meeting of 19 18. 1 Mothers' Pensions, p. 142-143. LEGISLATION REGULATING THE PRACTICEOF MEDI- CINE, PRELIMINARY AND MEDICAL EDUCA- TION. By N. P. CotwELL, M.D., Chicago, 111., Secretary of the Council on Medical Education of the American Medical Association. INTRODUCTORY. On this important topic it is difficult to present anything new to this audience composed, as it is, of those who are famiUar with the conditions underlying medical education and licensure. The only hope, therefore, is to present the already familiar facts in such manner as to emphasize those which are most important, and possibly to enable you to view them from a new standpoint. Minimum Qualifications Necessary to Guarantee Competency on the Part of Those Who Are to Treat the Sick, All in this audience are doubtless familiar with the phenomenal changes which have been made in medical education during the last ten or twelve years. Instead of 162 medical colleges in the United States, only four or five of which held entrance require- ments of one or more years of college work, we now have 95 medical colleges, 83 of which hold the higher entrance standard. In brief, quantity has given way — largely through the merging process — to quality; an abnormal supply, mostly of poorly equipped, low-standard institutions, has given way to a more normal supply of higher standard and better equipped medical schools. But this amazing change does not seem so remarkable when one considers the two distinct processes which have been at work during the previous thirty or forty years. Following the Civil War, with the rapid settlement of the central and western parts of the country, there was an unusual but actual demand for physicians, and the teaching of medicine became a profitable business. This was the stimulus which led to the rapid increase in the number of medical colleges which gave this country over half of the world's supply. Because of the profits, however, this increase continued long after the real 25 demand for physicians had been satisfied. But during the same period the very forces were also at work which were eventually to demand an entirely different type of medical school. Prior to that period medical knowledge consisted largely of clinical observations and theories based on them, but during the last three decades of the nineteenth century there was an increase of medical knowledge unprecedented in the history of medicine. At the beginning of that period Virchow estabHshed his system of cellular pathology and demonstrated the cellular origin of dis- ease. It was dtuing that period that Louis Pasteiu' demonstrated positively the r61e played by bacteria in natural processes such as fermentation, decay and putrefaction. Pastetur's researches marked the beginning of bacteriology, which, in tiurn, has revo- lutionized the practice of medicine. Pasteur's work was followed in 1876 by Koch's researches in regard to anthrax, and in 1882 Koch's invention of solid culture media and methods for the isola- tion of single species of bacteria. You all know how, from that time on, discoveries of the germ origin of numerous diseases were made in rapid succession, so that within a few years' time the specific origin of many of the common diseases was positively known. Not only were positive methods made available for their diagnosis and treatment, but also the spread of each disease has been prevented and numerous immunizing or opposing sub- stances, in the form of vaccines and antitoxins, were discovered. The researches of Pasteur and the discoveries since his time practically revolutionized the conception of disease. The old ideas of etiology of diseases gave way to an absolute knowledge regarding their bacterial origin, and the old empirical methods of treatment gave way to more scientific methods — methods based on a study of the habits of the specific germ causing each disease. The victories of medical research have emphasized the importance of an adequate training for those who are to care for the sick. They have emphasized the importance also, not only of the premedical sciences — ^physics, chemistry and biology — but also of the fundamental medical sciences — anatomy, phys- iology, physiological chemistry, pharmacology, bacteriology and pathology. The advances have demonstrated how firmly mod- 26 em medicine is based on these sciences and how decidedly il- logical and unscientific is any system of healing which is not based on them. A medical college is no longer able to furnish a satisfactory training unless it possesses thoroughly equipped laboratories in these fundamental sciences. Nor can these sciences be taught — as they formerly were — by busy practitioners, who gave only their spare time to teaching. These sciences must now be taught by salaried experts who devote their entire time to teaching and to research. Again, a grammar school education no longer constitutes an adequate preliminary training for those who are to study medi- cine. The student needs a knowledge of physics, of chemistry and of biology, in order to better understand the more complex medical sciences. He needs to study anatomy and pathology so he may differentiate between normal and abnormal structures and conditions and note the changes produced by disease; he must study bacteriology so as to understand the diseases caused by such micro-organisms; he needs physiology and physiological chemistry so he may understand the function and composition of the various secretions and substances of the body; he must study pharmacology so he can note the physiological action of various chemical and medicinal substances; he needs to study the various types of disease in dispensaries and at the bedside in hospitals, and while still under supervision he should further develop skill and reliability and round out his course of medical training by at least a year's experience as an intern, or resident physician, in a good hospital. A student who has followed this routine course will usually be a safe, efficient and successful practitioner of medicine. If he desires to specialize in any particular class of disease or in any particular method of treatment, the course thus outlined should be followed by one or two years of study devoted to the desired specialty. The educational standard now enforced in all leading nations, and which should be adopted in every state in this country, as the reasonable minimum requirement for those who are to treat the sick, includes: (a) A secondary school education equal to that obtained in an 27 accredited four-year high school and in addition two years of work in an approved college of liberal arts, including courses with laboratory work in physics, chemistry and biology of at least eight semester hours each. (Educationally, the quantity and quality of the work in these two years should be no whit less than that required in the first two years for the Bachelor of Science degree.) (5) A medical training provided by a four-year course in a well-equipped medical college, including two years of laboratory work in anatomy, physiology, physiological chemistry, pharma- cology, bacteriology and pathology, and two years of clinical instruction in dispensaries and hospitals, and (c) The practical experience obtained in a fifth year as an in- tern in a good hospital. In brief, anyone who is to undertake the repair of delicate life processes of human beings, which are rendered doubly sensi- tive in times of sickness, should have had such a training as will enable him to differentiate between normal and abnormal condi- tions and to determine what particular disorder is present; to be acquainted with all the approved methods of treatment so as to apply the particular treatment which will best meet the needs of the patient. To safeguard the interests of the public, no educational training less than this should be countenanced in any state, and the legal provision for the strict enforcement of such a requirement should be provided. No other department of education needs to be so strictly supervised as medicine, since in no other calling does the practitioner assume the responsibility for the lives of human beings and in no other profession can bun- gling or ignorance work such havoc. The failure of any state to assume responsibility in these matters is shown to be all the more serious since the discoveries following Pasteur's work have added so much to the positive knowledge by which diseases and epidemics may be prevented or eradicated. State Control of Physician's Educational Qualifications — Medical Licensure. A legal provision for the licensing of those who are^ to treat the sick, therefore, is a matter of vital importance to the public. 28 Such provision is necessary to protect the public against those who, for educational, mental, moral or other reasons, are unfit to be entrusted with the lives of sick human beings. On the other hand, a license granted by legal authority to anyone who assumes the r61e of the physician should be a guaranty — and the public have the right to so look upon it — that the holder is a safe and competent person to furnish medical care in times of sick- ness or injury. As to the responsibility for the licensing of physi- cians, much has been said in recent years in regard to the police power of the individual state as the only source of authority for the control of medical licensure. The statement has also been frequently made that this agreement is provided for by the Constitution of the United States. A noted student of that docu- ment, however, states that the Constitution is entirely silent on the subject. Sufi&cient be it to say, that instead of being con- trolled by the national government, as is the case in most other countries, the responsibility for the licensing of physicians has been left with the fifty individual states. This responsibility has been fully assumed and excellent measures adopted in some states ; in others, the seriousness of the responsibility has not been recognized, and in those of a third group so many conflicting laws have been adopted, or so many different boards and stand- ards provided, as to make a ridiculous botch of the whole affair. In the majority of states the matter is too closely interwoven with politics to permit the adoption of the most efficient control. In the fifty states there are now fifty different medical practice acts, providing for sixty-two separate and independent boards, no two of which entirely agree in the details of the methods fol- lowed or of the standards enforced. Even in the individual states there is not always a single authority over these matters. In some states the authority is divided between two or three en- tirely separate and independent boards. Instead of a single simple and efficient authority vested in a national body, as found in other countries, therefore, the regula- tion of the practice of medicine in the United States, from a na- tional point of view, is most confusing, complex and, as a result, ineffective. There is no legal provision for uniformity or action, 29 or for cooperation between these boards. We have every grade of standard, from the few states in which educational require- ments are reasonably high and well administered, down to the states which still do not provide for or do not enforce any stand- ards. While in a state having an adequate and effective control of these matters a seriously incompetent applicant may be re- jected, he promptly goes to another state — perhaps merely cross- ing a state line — ^where he seldom fails to obtain a license. Should he happen to fail in the second state, he goes to a third, or to a fourth — he has fifty chances! In any other country, after one careful investigation of his credentials or after one examination, such an applicant would have to obtain further medical training and show adequate qualifications or he could not obtain the legal right to treat the sick an3n\^here or by any method. Since there is no national control of medical education and licensure, there is all the more reason why an effective control should be established in each state. To prevent confusion there should be but one body or board in each state, made up of the most competent physicians available. This board should be given full authority to license all those who are to treat the sick. It should be given power to prescribe and enforce reasonable standards of preliminary and medical education, as well as to verify and test the qualifications of every candidate seeking a license to practice. The best guarantee of satisfactory qualifica- tions comes through the duplex requirement of (a) graduation from a reputable medical college, and (b) the passing of an examina- tion. Where the board can refuse to admit to its examinations all but those who have graduated from high-grade medical schools, then the public will have fairly adequate protection against un- trained and incompetent physicians, even if the examination is not made long and severe. But where the board is limited to an examination as the only means of determining an applicant's qualifications, then indeed that examination should be especially thorough and comprehensive and should include practical labora- tory and clinical tests. Otherwise the examination could be passed after a few weeks in a quiz class, by those who may never have performed or witnessed an experiment in the laboratory, who 30 may never have attended a clinic, or who may never have ex- amined a patient in a dispensary or hospital. Preliminary Education. There are now sixteen states in which the boards have definitely adopted as a minimum standard of preliminary education, in addition to a four-year high school course, two years of collegiate work. These states and the years when the requirement affects all applicants are: Minnesota 1912 New Hampshire, 191 9 New Mexico. ... 1922 New Jersey 192 1 North Dakota.. . 191 2 Oklahoma 1921 South Dakota. . . 19 15 Virginia 192 1 Washington 1922 Wisconsin 1919 Alabama 1919 Arizona 1922 Colorado 1914 Indiana 1915 Iowa 1915 Maryland 1922 In four of these states — Arizona, Maryland, New Mexico and Washington— the increased requirement is automatic, since the practice act calls for the standards of the Association of Amer- ican Medical Colleges and that Association has adopted the higher requirement. Under the Association's standard these states now require a four-year high school education; in 19 18 they will require, in addition to the high school course, one year of college work, and in 1922 two years of college work will be required. The medical practice act of Nevada also provides that the stand- ards of the state shall be those of the Association of American Medical Colleges. The Attorney-General of Nevada is said to have decided, however, that the standard in the state is not automatically raised by changes made by the Association of Amer- ican Medical Colleges. The opposite view has been taken by all the other states named. There are seventeen states in which the boards have adopted the requirement of one year of collegiate work in addition to the high school education. These states and the years when the requirement affects all applications are: Arkansas 1919 Louisiana 1919 CaHfomia 1919 Michigan 1918 Mississippi. ..... 1919 North Carolina . . 1 9 1 8 Pennsylvania.... 191 8 Rhode Island — 19 18 Connecticut 19 14 Illinois 1919 Kansas 1914 Kentucky 1918 Tennessee 1919 Texas 1918 Utah 1 91 7 Vermont 1917 West Virginia. . . 1921 Maine Nevada Missouri New York Nebraska Ohio 31 The higher requirement has been adopted by the regular board in Arkansas and Louisiana. There is nothing to indicate that their example has been followed by the other boards in those states. There are nine states in which a standard four-year high school course is the minimum standard of preliminary education. These states are: Delaware Florida Georgia The standard has been adopted by the regular board of Florida, but evidently not by the eclectic and homeopathic boards. In one state, Montana, the board appears to have the authority to adopt a standard of preliminary education, but as yet has not done so. In five states the authority is too limited, or there are two or three independent licensing boards, some of which evidently have not established standards of preliminary education, or the standard is less than a four-year high school education. These states are: Arkansas Idaho South Carolina Florida Louisiana There are now only three states — District of Columl)ia, Massa- chusetts and Wyoming — in which the practice acts do not pro- vide for preliminary education. Authority to Determine Reputability of Medical Colleges. There are now forty -four states in which the applicants are re- quired to be graduates of "reputable medical colleges" as deter- mined by the board. This gives the boards of those states the authority not only to fix educational standards but also to refuse to recognize medical colleges which do not adhere to these stand- ards, or which are lacking in teachers or equipment. In some states recognized colleges are referred to as "in good standing," in others they are considered as "reputable," and elsewhere they are "registered," while in other states, as in Michigan, they are divided into groups, only those of the first group having 32 full recognition. Of the forty-four states having this authority, thirty are making more or less use of it, each having ceased to recognize from three to thirty colleges. These states are: Alabama^ Minnesota 1 Oklahoma! Colorado 1 Mississippi Pennsylvania Delaware Missouri Rhode Island Georgia New Hampshire 1 South Carolina Illinois New Jersey 1 South Dakota^ Indiana 1 New Mexico Texas lowa^ New York Vermont Kentucky- North Carolina Virginia^ Maine North Dakotai West Virginia Michigan Ohio Wisconsin 1 In five states the authority to refuse recognition to inferior medical schools rests with two or three separate boards, but so far as indications show, only one board — the regular — is making use of that authority. These states, and the number of separate boards in each, are: Arkansas, 3 Connecticut, 3 Florida, 3 Louisiana, 2 Maryland, 2 The confusion from the division of authority has repeatedly resulted in a practical annulment of educational standards. As an example, an inferior medical college in Kansas City, which is not recognized in Missouri or in thirty-three other states, has for several years been sending most of its graduates to the Eclectic Board of Arkansas, where there is seldom a failure to pass. In nine states the boards are evidently not making use of the authority given them to refuse recognition to inferior medical colleges. These states are: Arizona Montana Oregon California Nebraska Tennessee Kansas Nevada Washington In Tennessee the power not only to fix standards of preliminary education but also to determine what medical colleges are "reputa- 1 These twelve states will not accept a diploma from any college unless the holder of it, in addition to a four-year high school education, completed two years of college work before entering on the study of medicine. 33 ble" rests with the recently estabhshed Board of Preliminary Examiners. This board, however, has not as yet established a list of recognized medical schools. In five states the practice acts do not give the boards the author- ity to insist on any standard of medical education, but they must admit to their examinations the graduate of any legally char- tered "medical college," no matter how low its entrance qualifica- tions, or how lacking it may be in teachers, laboratories or clin- ical material. These states are: District of Columbia Massachusetts Wyoming Idaho Utah There are fourteen states in the last two groups, therefore, in which all applicants are admitted to examinations, regardless of the character of the college from which they obtained their credentials. And in no one of them does the examination re- quired for the license compare in severity with those required in England and in the various countries of Europe. Further- more, since the graduates of thirty-one medical schools are no longer admitted to examinations in from 13 to 35 states, those graduates will pour into the states which continue to admit them. These fourteen states, therefore, will literally become the "dump- ing ground" for those candidates who are not considered accepta- ble elsewhere and the examinations as held at present are scarcely such as will prevent their obtaining the right to practise. Recognition of Foreign Credentials. It has not been many years since credentials from almost any foreign medical college were more worthy of consideration by state licensing boards than those from the average medical college in this country. That was true when less than ten (less than 5 per cent, of aU) medical schools in the United States, in admission requirements and in teachers and equipment, were on a par with the medical colleges of Europe. Now, however, there are at least 60 (or over 60 per cent, of all) medical colleges in this country which can stand the comparison. The time has come, therefore, when more care should be exercised by state boards in the verification and evaluation of credentials from abroad and 34 only those of unquestioned excellence should be accepted. It appears that some state boards are still unusually generous in recognizing such credentials, even when they come from medical schools, the very existence of which is doubtful. Interstate Reciprocity in Medical Licensure. Candidates are frequently registered without examination on presentation of satisfactory credentials, which include the license issued by some other state. This method of registration is com- monly referred to as "reciprocity," which conveys the idea that the state which accepts the license of one state will in return be granted the same courtesy by that state. The term does not always apply, however, since some boards — ^for example, Cali- fornia and Colorado — accept the physician's credentials if satis- factory, no matter whether the state board issuing the original license returns the favor or not. The arrangement for reciprocity is a matter of justice to physi- cians previously licensed in some other state who, perhaps, for many years have been engaged in the reputable practice of their profession but who for good reason desire to move to other states. As usually administered, however, reciprocal relations tend to lower rather than to elevate educational standards. Such relations exist in numerous instances between states having not only decidedly unequal standards of preliminary and medical education, but also decidedly unequal methods of examination. It is clear, therefore, that no candidate coming from the state having a lower educational standard should be accepted by the other state unless, in addition to this license, he holds educa- tional qualifications which meet the requirements of the other state. It can be seen, therefore, that a loose administration of registration through reciprocity would provide an open door for numerous unqualified candidates. It is evident that every board should reserve and exercise the right to reject any candi- date who does not possess satisfactory credentials, even though he is registered in some state with which it has reciprocal rela- tions. Again, a board should require that the applicant, before he is 35 eligible for reciprocal registration, should have been in the actual and reputable practice of his profession for at least a year in the state in which the original license is granted. Without this pro- vision a candidate may be tempted to obtain his original license in the state giving the easiest examination. Naturally, a state should retain the right to refuse to register by reciprocity candi- dates who have failed to pass their own examinations. At present forty states have established reciprocal relations with from one to thirty-two other states. The nine states which do not reciprocate with others are: Alabama Florida Oregon Arizona Massachusetts Rhode Island Connecticut Montana Washington Progress in Medical Licensure. Information shows that until about forty years ago only one or two states had secured laws regulating the practice of medi- cine and that until after 1900 very few had adopted definite requirem^ents either in regard to preliminary or medical educa- tion. It was when the supply of medical colleges had reached such amazing proportions, and the securing of a diploma had become such an easy matter, that the necessity for licensing boards was recognized. That diplomas had come to have a questionable value as a qualification for the license is evidenced by the fact that the first requirement given general adoption by the majority of boards was that of an examination. All states but one — New Mexico — have adopted that requirement for every candidate, and the action in all states was taken during the twenty-five years betw^een 1882 and 1907. In the recent campaign for an improved medical education the changes in medical colleges were more rapid than those by state boards. This was to be ex- pected, since the obtaining of improved legislation was neces- sarily a slow process. Within the last few years, however, the changes for the better by state boards, and particularly the adop- tion of improved standards of preliminary education, have been so remarkable as to parallel the advances made by medical col- leges. It is noteworthy that the improved standards of prelim- 36 inary education came largely as a voluntary movement on the part of medical colleges, since their adoption of the higher stand- ards preceded the action taken by state boards. Nevertheless, these boards are now supporting the better class of medical col- leges, which make it certain that reasonable standards of pre- liminary and medical education are to prevail in the United States. This action by the state boards, furthermore, induced other col- leges to adopt the higher standards which for financial or other reasons were not willing to do so voluntarily. Only a few more states need to secure legislation providing for better educational standards. Then — and the time is not far distant — all medical schools will have to adopt reasonable standards or cease to exist. Then also every medical school graduate will be better equipped not only to present more acceptable qualifications for the license to practice medicine, but also — and this is far more important — he will be able to render better care to his patients. EXAMINATIONS I^OR LICENSE TO PRACTISE AND HOSPITAL INTERNESHIP.i By John M. Baldy, M.D., Philadelphia, President of the Bureau of Medical Education and Licensure of the State of Pennsylvania. Examinations for License to Practise. It has always appeared to me that State Boards have greatly misconceived their duties as regards the function of examina- tions for license to practise medicine. Educationally, we have primary and secondary school work, followed by college work, as preliminary; this is followed by the work in the medical school, and finally by the interneship in a hospital, prior to the state examination. Each one of these sub-divisions begins and ends as an entity and each one is competently taught and competently passed prior to entering upon the succeeding one. In passing from the high school to the college, it is assumed on the presenta- tion of properly certified credentials that the detail of the high school work has been competently performed, the teachers have been of proper competency and the result has been passed on competently; the same may be said of the college work which follows, on entrance to the medical school ; and the same ought to be said of the work done in the medical school, on entrance to the state medical examination. No State Medical Examining Board thinks, when examining an applicant for the practice of medicine, of re-examining him in the A B C's nor in reading, writing or arithmetic. No State Examining Board thinks it necessary to pass upon his qualifications in history, geography and the higher branches. Physics, chemistry, biology and lan- guages are not taken into consideration in state medical examina- tions. If this be true of the work up to the medical school work, and can be done safely, then why should it not be applied equally well to the work done in the medical school itself? Some years ago, when there was no supervision whatever over the medical schools, when there was no standardization of medical schools and when State Boards well knew that the majority of 38 medical schools did not teach medicine properly, the situation was an entirely different one. At the present time medical schools are standardized. The weaker ones are rapidly elimi- nated. Proper departments with proper equipment are well in hand; competent teachers with competent and sufficient num- bers of assistants are engaged; the State inspects the schools and assumes responsibility as to their curriculum and teaching force. This being true there is no more reason that the details of their work should be reviewed by the State Examining Board for Licensure than there is that the State should review the pre- liminary work of the primary or the secondary schools or the college. The function of the State briefly stated is to determine whether or not the applicant wishing to practise medicine is competent to begin to do so. In determining this it is none of the function of the State to test whether or not the applicant knows all the details of all the various fundamental sciences necessary for the preparation for graduation. An applicant having been graduated from a competent and standardized med- ical school may fairly be presumed to know the facts of the basic sciences. The point the State should demand to know is whether or not he can correlate these facts sufficiently to make him a safe practitioner: not a finished practitioner but sufficiently safe to be allowed to begin practice. This to me is the entire function of the State in these matters and beyond this there is no necessity to go. It is utterly impossible for any student to learn in the short time devoted to the study of medicine all the facts of all the funda- mental sciences. It is equally impossible for him to carry in his mind all of the facts that he does learn in order that they may be available at an examination at some indefinite time in the future. I may state further that it is not even desirable that he should remember them all. Study does not predicate the remembrance of everything one has studied. The value of study is the training it has given the mind and the learning of general principles and principal facts which have a practical applicability to future work. Many men perfectly competent to begin the practice of medicine have been rejected and unfairly 39 handicapped by a non-recognition of these plain and fundamental facts. Consequently I am a strong believer that the State in its licensing examinations should not examine in the fundamental sciences directly but that it should confine its tests in regard to the knowledge of these sciences to practical questions of prac- tice, which questions cannot be answered unless the applicant understands the general principles and main facts of the under- lying sciences. For instance, I am strongly opposed to asking pure anatomical questions, physiological questions and questions on inorganic and organic chemistry. The examiner who cannot formulate his pathological questions so as to demonstrate the knowledge of physiology of the one answering them, is an incompetent examiner and has mistaken his calling. The examiner who cannot put his surgical questions in such a manner as to demonstrate the knowledge of anatomy of the one answering the questions, is similarly disqualified as an examiner. No man uses organic or inorganic chemistry in the practice of medicine. The chemistry which is in daily use by him and which he should understand thoroughly is physiological chemistry and the examination questions should be confined to this subject. It is perfectly fair to presume that the man who can answer his surgical questions, his pathological questions, his biochemical questions, under- stands a sufficiency of the three underlying sciences for all prac- tical and theoretical purposes. If the State is to go into the de- tails of all these subjects then there is no reason why it should not reach further back and test out the applicant as to whether or not he understands all of the intricacies of physics, of geography, of reading, writing and arithmetic, and even of the A B C's. There must come a point when it is perfectly safe to cease testing a man's knowledge of elementary subjects and from the State viewpoint I am very emphatic in my belief that that point is reached as indicated above. Hospital Interneship. To demand a year or more of time of a young man just leaving the medical school after having undergone all the sacrifices neces- 40 sary to his medical education, is a serious matter, especially when we consider the age at which the average medical student leaves the medical school. Consequently, when the State de- mands an interneship of a period of time in a hospital it is bound to see that the hospital providing this interneship is capable of returning to the interne a competent quid pro quo for his time and his sacrifice. This means the standardization of hospitals just as medical schools have been standardized and are still in process of being standardized. It is not the intention to discuss in detail the organization of all departments of a hospital; this has been done many times by others well qualified so to do and a fair understanding ob- tains as to these matters. Rather is it the intention in a general way to call attention sharply to those departments which really go to make up a true hospital but which, in the course of a systematic and fairly exhaustive inspection of over two hundred hospitals, including State-owned hospitals, the Pennsylvania medical authorities have found to be very generally ignored; or, if in existence at all, were in such a large number of instances found to be so poorly developed as to be worthless for the pur- pose of proper and efficient scientific work, either as aid to proper and accurate diagnosis or as useful for instruction of an interne. The question then primarily arises, what is a hospital? From the viewpoint of the interneship it is utterly impossible to con- sider many institutions at the present time calling themselves hospitals, under this designation. In constructing a true hos- pital certain scientific departments should first be provided for; the balance of the hospital should be built around these depart- ments. Principally these departments are: the pathological and clinical laboratories, the X-ray department, the anesthetic department, the morgue and the autopsy room, and a competent system of record-keeping throughout the whole institution. These things are as necessary as is a kitchen, a laundry, a super- intendent's office, a boiler house, the medical and surgical wards or any other essential department and no institution should be dignified with the name of hospital without each and all of them being competently provided for. It were supererogation to 41 state that medicine cannot be competently practised or taught to-day without the aid of these departments, and if this be true then it follows as a matter of course that the interne cannot be competently educated in an institution which does not provide these facilities, nor can the patient submitted to its care receive the full benefits possible from modern medicine. In attempting to do so an institution does not give either the interne or the patient a fair and proper service. For an institution to have these departments within its walls is not sufficient. Their es- tablishment and equipment carries with it the supposition that they must be administered by a proper personnel. By a proper personnel it is not meant that figure-heads be appointed for this work but that men and women with a full technical knowledge of the work of the various departments, aided by competent assistants, be in control ; that these heads be active in their duties and that they be of such a type as to be able to impart a knowl- edge of the work as well as perform the work of their several departments. It further does not mean that these departments should exist in the hospital and not be used by the medical and surgical staff. It is perfectly patent that in many hospitals the staff, in many instances, is composed of men unfitted for the work assigned to them; unfitted not only as teachers of the interne but unfitted to give that service to the patients submitted to their care which should be given, in accordance with the possibilities of modern medicine. The efficient handling of the scientific departments means team work on the part of every one throughout the whole institu- tion. Staff men who neglect the opportunities offered by the scientific departments should be promptly retired and should be no longer tolerated in the hospital's service. Team work in- volves not only the co-operation of the staff men with the labora- tories but involves also the co-operation of the superintendents and boards of managers. If a sufficiency of budget is not pro- vided competent work cannot be done in the scientific depart- ments for lack of means in the doing. Consequently boards of managers should include in their budget ample funds for carrying on the work of these departments. 42 Superintendents should so arrange the details of their superin- tendency that certain routine work goes daily to the laboratory, whether or not the staff men make the request. For instance, all tissue removed in the operating room should be sent routinely to the laboratories for investigation ; certain ward material should be taken routinely to the laboratories for examination; the milk and water used in the institution should be investigated system- atically and periodically; it should be a matter of routine that all vaginal secretions of children, smears from throat infec- tions, sputum from possible tubercular cases and various other conditions should be carefully studied. If staff doctors do not care for the information derived from these sources, the patients are nevertheless hospital patients and the hospital should secure the proper data for their own uses and records. The staff man who does his duty and is worthy of appointment will use the laboratories freely in many ways. Without this no hospital is doing its full duty to its patients and it is entirely neglecting its duty to its internes. The hospital function involves the proper scientific treatment of its patients, and the education of the interne as its principal functions; this to be supplemented by the investigation of new remedies and by research work in the larger institutions. X-ray department: No institution in these days of workmen's compensation acts can do justice to its clientele, if he be a work- man or employer, without the full and competent use of the X-ray apparatus. It is not sufficient that the function of this depart- ment be confined to primary diagnosis. Diagnosis is, of course, one of its principal functions, but there follows immediately thereafter the great importance of record-keeping. To illustrate : for the hospital to assume in the case of a fracture or dislocation that its duty is fulfilled when the picture of the injury is recorded, is erroneous. The condition of this injury at the time of dis- charge and supposed cure is equally as important and should in every instance be recorded, and the records, in the shape of the radiograph, should be properly filled and preserved for a period of years. The education of the interne in the matter of correctly reading 43 plates and interpreting them is equally a function of this labora- tory. And no such laboratory is complete which is not equipped for and actively engaged in treatment work. Records of all departments of the institution are a requisite of a properly standardized hospital. These records should cover at a minimum, alphabetical admission card, a record card according to diseases, history sheets, temperature charts, order sheets, bedside records, operating and anesthetic records, labora- tory request and finding sheets with card index in the laboratory, request and finding sheets with card index in the X-ray depart- ment, and follow-up cards, all carrying the house number. The laboratory and X-ray number should appear on their respective request sheets. In addition to this, in the laboratory there should be filed seriatim, with the laboratory number attached, all slides and paraffin blocks. In the X-ray department all plates, having attached the X-ray laboratory number, should be filed seriatim. It should be essential in every hospital that these records be not only in existence, but that they be systematically and fully recorded and then properly filed. Here again, without compe- tency in the superintendency the situation becomes hopeless. Records properly kept are a source of education to those making them; are a source of the utmost value to future diagnosis and medico-legal matters; are a source of demonstration of the effi- ciency of the work done in every department, and of those in control of the work ; and are a fund of information for the boards of managers as to the competency of superintendents, internes and of members of the medical and surgical staff. By reference to the laboratory records filed in the office any board of managers can tell promptly which members of the medical and surgical staff are engaged in the scientific practice of medicine and which are mere "prescription writers," and consequently which should be retained on their staff. The interne cannot receive a competent service in an institu- tion which is manned by a staff whose members walk through their wards, spend a few minutes with their patients, make few or no scientific investigations, do not discuss their cases and merely prescribe drugs. Such a service is worse than useless to the in- 44 terne and in nine cases out of ten it is equally useless to the patient. The interne is entitled to a fair measure of instruction and the authorities should demand that its staff members explain their cases to the interne in the course of the rounds and that the ser- vice be made a real educational one. It is rare that the interne will receive any competent service in the hospital which opens its doors to all the doctors in the com- munity in which it exists. A standard hospital should have a staff carefully picked for its competency in all departments and the work in the wards of the hospital should be confined to this staff. The interne should receive a rotary service through- out all departments, the service being so arranged that he will receive a maximum of time in each. In a year's service in a hospital he should have a minimum of two months in the labora- tory alone without any other service whatever complicating; and the better time for this service is in the early part of his in- terneship. During this service he should be at the command of the pathologist alone and his full time daily should be spent in this department. If it be necessary that this service, because of the number of internes employed in the hospital, be cornbined with, for instance, out-patient work or siurgical dressing work, then the time in the laboratory should be increased to three months or more in order that the interne shall have received the equivalent of a full two months' service, as a minimum. It goes without saying, it is desirable that the laboratory service be complicated with no other service whatever. The anesthetic department should be under the direction of a member of the staff, this member to have at least one trained full-time individual, preferably a woman, as assistant. During the service of the interne in this department, which should be a distinct and definite service, there should always be a watchful hand kept over him diu-ing each administration of anesthesia, throughout his full term. To simply instruct a new interne, fresh from college, for a week in the giving of anesthesia and then to allow him to administer it for the next two months without supervision is not competent for the safety of the patient, for the comfort of the surgeon, or for the education of the interne, 45 and should not be tolerated. One or more full-time individuals in this department is a necessity in a modern hospital and should be insisted on. The work of the anesthetizer should be to admin- ister anesthesia in certain cases and to educate and supervise the interne when giving the anesthesia, throughout his full ser- vice. A physician living out of the hospital and practicing med- icine is not competent to undertake this work; few hospitals can afford a physician on full time for such work. A reasonable solution is the woman anesthetist, preferably a former trained nurse especially instructed in these matters. In small hospitals a very competent and economical arrangement may obtain by which the laboratory technician and the anesthetizer may be com- bined in the same individual; the responsibility of seeing that the records throughout the hospital are properly recorded and filed might in some instances be properly placed in the same hands. The lack of interest in autopsy work in America is usually attributed to the difficulty in obtaining material for this purpose, but as a matter of fact is largely due to indifference on the part of the hospital authorities. An effort should be made in every in- stance, especially in an institution with educational pretensions, to obtain this material ; the pathologist might obtain many a consent if he be given an opportunity to do so. It is plainly evident that the less work of this kind performed the less efficient the staff, the less reliable the records and the less vital instruction is received by the interne. This indifference is one of the greatest defects of the American hospital and a supreme effort should be made to rectify it. LEGISLATION CREATING CIVIL POSITIONS FOR PHYSICIANS. By John B. McAlister, M.D., Harrisburg, Penna., President of the Medical Society of the State of Pennsylvania. One of the best signs of the medical times is the awakening of the medical profession to the importance of its interests. Med- ical journals throughout the United States are publishing edi- torials and articles by leading physicians in which the question is asked "What is the matter with our profession?" The query differs slightly in the method of the asking, but recurs so contin- ually that clearly enough something radically wrong exists be- tween the profession we represent and the public. The answer to the question: "What is the matter with the medical profession," is of vital moment for more than one hundred thousand physicians in the United States. They are all agreed that they do not receive adequate pay for the services they give the public — be that service rendered in the family, hospital or dispensary; whether they treat, investigate or prevent, not only the ordinary ills flesh is heir to — but contagious or epidemic diseases. In both hospital and private practice the physician is the chief ally of the Board of Health and other departments of the state to which he has to report all communicable, epidemic or industrial diseases, births and deaths, under a penalty of a fine for neglect; he is called upon to assist in the investigation of the various causes, treatments, and prevention of disease; to present his practical experience thus gained in recitations before his medical society, or to publish them in journals devoted to medical lore. Finally, he is expected to disseminate his accumulated knowl- edge among his patients for their use and benefit. He is a store- house of scientific and useful information in health or sickness, which belongs to the public merely for the asking. He thus literally serves the state, but, unhke all other servants of the state, receives nothing for his services. On the contrary, every effort 47 he makes to prevent disease or to remove disease conditions helps to diminish his income. As soon as a physician receives his coveted degree he becomes an interne in a hospital or an assistant in a dispensary. At the same time he becomes an altruist and a philanthropist, although these latter titles are not commonly recognized. Upon entering into practice, he begins his own destruction and annihilation, for in this age of preventive medicine whereby disease will ulti- mately be eliminated, the physician will be superfluous and the necessity for him will no longer exist. Until that happy era for the public be attained, the physician may be excused if he be permitted to look a little to his interests, be they professional or legislative. It is doubtful if the public ever would have had its attention called to the threatened plight of physicians, or if the physicians themselves had fully realized the precipice toward which they were trending had it not been for the fact that half of the total number of physicians in the United States had not organized themselves into the great and influential body known as the Amer- ican Medical Association. This organization has been carrying on a campaign of education in order that the public may better understand what the modern physician is trying to do for human- ity's sake and how he is hampered personally while earnestly trying to prevent and cure disease. It is estimated that probably twenty to twenty-five per cent, of a physician's work is done for charity, either directly in dis- pensary or hospital work, or in private practice for which he is not paid. Thus it is that to-day the living to be made from the practice of medicine is a precarious one, due to the diminution of disease and the enormous amount of medical charity, expected and demanded from the physician. If more civil positions with adequate remuneration were open to physicians, one of the greatest evils against our profession would be removed — the doing of work gratuitously for which patients are able to pay. Why should not physicians be com- pensated as are other employees of hospitals and dispensaries? Since the time of Hippocrates the physician has been trained 48 t to become an altruist, to treat fees with indifference, if not with contempt. This legendary custom, this noble but impractical idea, does not seem to square well with the 20th century needs. Every community owes to the doctor more protection than it bestows upon him. Instead of giving him such protection, the laws of many states put him on an equal footing with quacks and clairvoyants. If the present indifference to the educated physician's rights continues, the profession of medicine will cease to attract men of noble ideals and good preparatory training, for in this work-a-day world compensation must be obtained to meet the physical wants of the individual. Conscientious folk will soon be forced to say to every young man or woman who has a hankering after medical study, "Don't." There are lots of other ways of making a comfortable living beside medicine. While it is the noblest of professions it is the meanest of trades. It must be admitted that the public obligations to physicians are constantly disregarded in the unjust discrimination against them by our lawmakers. Power to remove this stigma rests with the people. In ordinary times and for ordinary matters, the people delegate the law-making functions of the national, state or municipal legislative bodies: the administrative to ad- ministrative bodies similarly divided; and the judicial functions to the judicial machinery. In time of great emergency, how- ever, such differentiation is swept aside, and action lies solely with the people. Is it too much to hope that through the cam- paign of education put forward by the American Medical Asso- ciation, by its series of lectures given in many County Medical Societies, besides lectures to Women's Clubs, Mothers' and Teachers' Organizations, Young Women's Christian Associa- tions, Church and Settlement Clubs (10,000 such lectures since 1909) will bring its reward, leaving the physician's case to be acted upon by the people whom he has always so self sacrificingly served? Medicine is more and more becoming a function of the State and physicians soon must look to the State for their support. Who is to teach the people the great truths of preventive medi- cine except they? Are they asking more than their just rights 49 that the State who depends so largely upon them should pay them a living wage? Public health is a science and one to be carried on by scientifically trained minds. To handle the vital problems of public health, to wage the battle against the powers of disease, and the pain with which they torture mankind, physi- cians and surgeons must take their places in the forefront. They are the captains who order the fights, discover the vulnerable points, map out the campaigns and lead the forces on to the battle- field. Men must be trained for this important work, and having been trained, have a moral and legal right to be placed in posi- tions where they must serve mankind by applying this training they have so expensively and painstakingly acquired. The important point of contact between the Law, Medicine, and the State is the Public Health Service as supervised by State and Local Boards of Health. In order to meet the new conditions this entire system needs change, enlarging and strength- ening. It is a significant fact that although local and State Boards of Health are so dependent upon and so closely allied with the medical practitioners of the City or State, yet but 6 per cent, of those employed by such Boards of Health are regular physi- cians. Can war be waged successfully upon disease until the whole medical profession is under control of the State? Until such a consummation be reached, it is vain to hope that every individual in the community can be subjected to proper medical inspection or receive adequate medical treatment. Heroic measures are necessary if the health of the State be- comes the important part of the State administration it deserves. One of the first and most important requisites is the immediate organization of every medical institution and clinic in every city under one head. This head should preferably be a State Health Commissioner and a strong executive. A Board, or Committee, or Bureau, or whatever any aggregate or individual may be called, is never as successful in executive work as one person to whom much power is granted, of whom much is expected. He may be called anything the State desires, but his province should be to appoint his subordinates, who, as far as possible, should be efiicient physicians trained in public health, and then pay them 50 salaries adequate to permit them to give their entire time to the service demanded of them. The only obstacle in securing such an executive is the part politics plays in the appointment of civil positions. If anyone can devise a plan whereby politics be removed from civil posi- tions, especially those with fair salaries attached — what seems an impossibility will become an easy probability. It remains for the people to waken up to a realization that their executive should work for the State and not for any political party. Several states have minimized political complications by giving the organized medical societies an important place in the admin- istration of their Health Department. It must be admitted that satisfactory health work has been accomplished in some of these states and under such a system, but it must also be recognized that equally good work has resulted from other forms of organ- ization in other states. At present the head of the State Health Department is ap- pointed by the Governor in less than a third of the States. This seems a good plan in that responsibility is thus centered upon one man ; and on the other hand, every time there is a new gover- nor the executive of this important Health Department may be removed — an unfortunate possibility, for surely he gains an added usefulness to the people every year he holds office and should not be removed except for personal derelictions or manifest un- fitness for the office. A Board of Health exists in every State in the Union except one. The State Health Officer is elected by this Board, a custom which prevails in thirty states. Such selection of the State Health Officer does not entirely remove the office from politics, but it does lessen its chances of becoming part of the patronage sys- tem. Local health officers and their subordinates must be good men, trained by the State in all that pertains to their positions. How they are selected is of great importance and their selection should be decided by each State by carefully drawn-up legislation. Such legislation should be intelligent, uniform and accurate. Legislation should take notice of the fact that even the best 51 men cannot work without just and fair compensation. This compensation should be fixed by the State. Appointments of health officers, whether federal, state or local, should depend entirely upon professional qualifications, and tenure of office be based absolutely upon efficiency. Such ser- vants should not be permitted to engage in any duties other than their regular official ones. Stirely the services of the guardians of the public health are as important as those of county sheriff or attorney. When such provisions are recognized and enforced by law, organizations which care for the public health will become more highly standardized and win a higher respect from the people at large. Their next step in attractiveness will be that regular physicians will prepare for and desire to be appointed to the many positions which now are dubbed civil ones, but will gradually evolute until they are held absolutely by professional physicians, carefully educated and especially trained. Stop talking — stop criticising the health organizations of your State and pull together until you have forced a more satis- factory state of affairs. You have more power than you have any knowledge of. I am appealing to your self-interest, you see. You have the power to demand and enforce wise legislation. You can raise efficiency to a high level and standardize it. You can keep health legislation and health administration out of politics. To accomplish these Utopian conditions, you must co-operate with, and stand by, the health officers the State now supports, if you desire to lend a hand in advancing the health work and health organization of the State you call your own. The organization of the public health of a State must not neglect providing for the training of workers it requires for its own ser- vice. Outside institutions may train men for the higher posi- tions but the masses of workers in any State system must be trained in the State where they later expect to be employed. As long as the State neglects to provide for this training it will be weak in one of the most vital links in the chain it is endeavoring to forge. This training can be obtained nowhere so well as in the uni- 52 versities which are maintained by the State. In Germany, all universities are under State control, and nearly all medi- cal instruction gained in such universities; therefore the State has recognized its duty in educating the physicians who later save the lives of its people. In Austria, Hungary and Switzerland all the universities are State ones, and in Holland with but one exception. In Great Britain originally all its universi- ties were private ones, but they have gradually passed to those of State control except Oxford, Cambridge, and a few others. When our physicians are trained in universities supported by the State, it will seem but one step forward for them to be placed in hospitals and institutions for caring for the sick and dependent classes. ' All such institutions, including insane asylums, should be in conjunction with State universities whose graduates, upon completing their courses, should find their way into State insti- tutions where they will receive a fair compensation for their services, and thus more closely cement the bonds between public health and the medical profession. How may such reform be obtained? In a democracy, where people govern themselves, there is one way and one only. By legislation which should voice the desires and the needs of those who are most intimately concerned. In all medical legislation the interest of the physician has been singularly, and almost hopelessly, disregarded. It is due to this fact that the question is being asked, "What is the matter with the medical profes- sion?" It remains for the doctors themselves to cure such condi- tions. How may they do it? By associating themselves with the medical societies of their State and by organization, co-opera- tion and determined efforts, force their, rights before the public, which, after all, is fair-minded and remembering the great debt of gratitude it owes to the physician, will exercise all the power it has to insist that doctors receive fair treatment at the hands of the legislators. This the public will do when once it under- stands the true conditions under which we suffer. To facilitate the bringing about of such a desired improvement, bills relating to public health must be carefully drawn by men with practical knowledge of the legislative needs as far as public 53 health is concerned. This has not been so in the past. Out of one thousand bills upon health matters, introduced into 42 legisla- tures last year, most of them came under the head of fads. We need fewer laws carefully framed, and so critically considered before adoption, as to avoid the trouble and confusion that care- less legislation entails. While many of these laws introduced were unimportant, yet several were passed and enforced which have done much to ad- vance the medical health of the nation. It is not too optimistic to hope that when physicians have roused themselves to an ap- preciation of their power, they will enforce legislation, which will raise their economic status, so that they may reap a fair reward for their arduous and oft-unrequited labors in behalf of humanity. With civil positions offering legitimate compensation open to physicians, with an assurance of his continuance in same as long as he makes good — ^with reasonable chance of promotion — with services in hospitals, dispensaries and institutions open to the graduate of our medical colleges, fair salaries being attached thereto; with the years of his unrepaid labor lessened by the two or three he was expected to serve as an unpaid interne before he dare hang out his shingle — with the cost of his medical education reduced from $10,000 to $1,000 — his charity work paid for by the State which directly benefits by it — then I dare to hope that my profession and yours may retain the high ideals for which it has always stood, and for which it will ever fight instead of being al- lowed to sink to the depths of sordid commercialism. SOCIAL INSURANCE AGAINST ACCIDENTS (WORK- MEN'S COMPENSATION LAWS). By Frbdbrick L. Van Sickle, M.D., Olyphant, Pa. "THE FAITHFUL LABORER IS WORTHY OF HIS HIRE." Workmen's Compensation. In studying the evolution of incomes and of means whereby the people of the world are supported, either by hand or brain, it is well to make some investigation as to the changes which have taken place in the past twenty years, whereby a gradual evolu- tion of wages, salaries and earnings has been granted to the working and middle classes of the people of this and foreign countries, which is evidenced by the present state of wages with their increase, as compared to those paid in times gone by. It is very difficult to get a table of comparisons from which each section of a country as large as the United States can be workt out, because there enters into such estimates many fac- tors that deal with local conditions, with the sale of commodi- ties and with the general standing of prices of all things entering into the cost of living; but it is well known from statistics gathered by industrial organizations, that in cases where the wages of a 55 daily laborer twenty years ago ranged from $i.io to $1.25 per day of ten hours, the present wage would not be less than $1.95 to $2 . 25 per day of eight hours for similar labor. Again, comparing the wages of a higher grade, for instance — mechanics, carpenters, bricklayers and masons, the wages of twenty years ago would run from $2 . 00 to $2.25 per day of ten hours, whereas in 19 16 the earnings of most of the states would give us an average of from $3.00 to $4.00 per day of eight to nine hours, for the same grade of labor. Again, taking a higher class, a more skilled workman or men in salaried offices, we find that whereas $50 to $75 per month was a fair income some years ago, the same work to-day brings from $100 to $150 per month. It is unnecessary for us to go into detail regarding the reasons for giving these advances, as they are too well known for dis- cussion. A most vital reason, however, is the greater considera- tion for labor by capital, as a necessary part of its equipment and a greater coming together of the two units, thru which greater concessions are granted in time of working hours, in vacation periods, and furnishing means which afford not only the necessi- ties of life, but aiding in supplying the comforts and pleasures which up until the present decade were almost deprived to a large class of the working people of the nation. In considering this featiure of the workmen of the world, we must realize what has entered into this problem from the various influences which have cemented the closer relationship with labor and capital and that another means of rendering aid has been brought about by the passage of various laws in foreign countries and in the United States, whereby in time of injury- compensation was granted, making the path of the injured more easy, the trials and hardships of the family more tenable, the pain and suffering — while not abolisht — ^rendered more bearable, with the thought that the wage earner was not without means of sustenance for himself and family in the dark hour of trouble. For the most part these liberal laws have been termed "Work- 56 men's Compensation Acts," in which we find capital with a de- sire to promote the best interests of that unit of their organiza- tion, namely — ^labor — not only paying for part of the time lost, but furnishing the workmen with a more prompt, rapid and sys- tematic course of treatment and relief for their injuries. It cannot be said that these laws were past with any idea of placating or relieving the responsibihty which labor placed upon capital, but with an eye single to promoting the best interests of the working world, bringing to the people to whom it was most needed a beneficial system of conducting the treatment of in- jiured persons, whereby correct data might be obtained as to the kind of injury, the method of treatment, the length of time necessary to restore health, the value of trained observation and the greater availability of statistics which bring to the en- tire world that which in previous times and previous methods was of unknown quantity and of little value. The tedious and cumbersome acts which were first produced have been repeatedly modified, amended and altered, so that at the present time the thirty-two states of the Union having these meastues, represent a vast step forward toward perfecting a system of workmen's compensation that is doing an immense amount of good. In the United States we find on investigation of the various tables of comparisons in most of the states having compensation laws that among the working people the annual income of the employe is based at $1000 a year, and from that figure has been workt out a scheme of indemnity liberal to what was in vogue in times past. The principle of workmen's compensation universally adopted is a reversal of the previous employers' liability acts, under which the employer paid damages only when the accident was due to his fault or the fault of his fellow-servant, etc.; whereas these new laws place the financial burden of all industrial accidents which happen to its workmen upon the industry and the com- modity produced and the workers who happen to be the victims of particular accidents are not subjected to the financial drain which existed under the former condition. 57 In computing the cost and fixing the price of the finisht product, capital computes its industrial losses due to accidents as those of other fixt charges, namely — wages, machinery, etc., etc. We are appalled at the awful sacrifice of life in the European war, but the condition of the industries of the United States furnishes us with an unwelcome parallel of fatalities in the indus- trial world, as given by the industrial accident commissions of the United States. In California dining the year 19 14 there were 62,211 industrial accidents, of which 678 were fatal, 1292 permanent injuries and 60,241 temporary injuries. In Michigan during the year 19 15 the number of fatal accidents was 332 ; number of accidents causing loss of member, 972 ; num- ber of accidents causing disability for more than two weeks, 12,188; number of accidents causing disability for less than two weeks, 26,289. In Pennsylvania from January i, 1916, the date upon which the new Workmen's Compensation Act of Pennsylvania went into effect, up to May 10, 19 16, there have been more than 800 working men and women who have lost their lives in the course of their employment; 21 mine workers were killed in three coun- ties of the anthracite coal fields and over 80,000 injmies were in- flicted upon the workers of the state. Similar reports from all other states might be quoted were space permitted. The time has arrived when the humanitarian feeling has per- vaded the public mind and public opinion has so imprest capital that there is an increasing consideration for the man who works with his hands. The Michigan Industrial Accident Board in carrying out the theory of Workmen's Compensation Law, says: The law should be supported to the end: — That the injured workmen may receive justice. That employers may have fixt liabilities and escape the embarrassment and expense of damage suits. That the courts may be relieved of the time of trying damage suits. That the public treasury may be relieved of the expense of these damage suits. 58 That the public may be relieved of the expense of caring for the victims of industrial accidents. That more harmonious relations be promoted between employers and employes. It further says that the cardinal principles of a compensation law should be: Reasonable compensation at minimum cost for all accidents except the result of wilful fault. Certainty of amount. Certainty of payment. Payment without litigation. Prevention of accidents. We may draw the inference from the attitude taken by com- pensation commissions that there is a most liberal desire on the part of these boards to pay what the tariff of the industry can afford, relieving thereby the public from previous burdens borne in the name of the so-called charity; hospital abuse in its various forms to be relieved and overcome; the ambulance chasing at- torney caused to seek legitimate fields; the typical medico-legal expert ( ?) in liability suits relegated to the dim past, and the many evils attendant upon a system of payment for industrial injuries which never reacht the ideal of modem times. We can well understand, therefore, why workmen's compensa- tion or industrial insurance has attained such wonderful promi- nence in legislativ halls, lawyers' gatherings, among sociological workers and professions of all kinds, whose aim it is to bring about the modern scientific plans for relief and the growth that appears the more phenomenal when we reflect upon the miserable failure of liability statutes and the earlier compensation acts when subjected to the microscopic eye of the supreme tribunals. The operation of the compensation laws in the states has natur- ally encroacht upon the business of the legal profession; has altered the relationship of court procedure; has in its effect to systematize its application; made changes in relation to the patient and the medical profession, but its principles are right and all of us who are influenced by its various provisions must take the bitter with the sweet; must realize the upward tendency, no matter what the cost may be to personal interests; and we and all pro- 59 fessions and all sociologic workers must lend our support to an object which is to preserv the safety, the happiness and the peace of mind of the people of the states and the Union, and we should urge hearty support in all states having compensation acts and prevail upon legislatures in states not having these mod- ern measures to cause them to be enacted as soon as possible. I can no better illustrate the thought in relation to the working classes of the United States in my feeling toward compensation laws than to quote the language of Chief Justice Winslow, of the Supreme Court of Wisconsin, handed down in case of Driscall vs. Allis-Chalmers Co., who has the following to say: It gives me no pleasure to state these long establisht principles of the law of negligence. I have no fondness for them. If I were to consult my feelings alone I would far prefer to let the case pass in silence. No part of my labor on this bench has brought such heart-weariness to me as that ever-increasing part devoted to the consideration of personal injury actions brought by employes against their employers. The appeal to the emotions is so strong in these cases, the results to life and limb and human happiness so distressing, that the attempt to honestly administer cold, hard rules of law which either deny relief entirely or necessitate a new trial, make draughts upon the heart and nerves which no man can appreciate who has not been obliged to meet the situation himself. If it be said that some of these rules are archaic and unfitted to modem industrial conditions, I do not disagree; in fact that has been my own opinion for long. Upon reflection it seems that this could not be otherwise. Principles which were first laid down in the days of the small shop, few employes and simple machinery could hardly be expected to apply with justice to the industrial conditions which now sur- round us. In those earlier days the laborer ordinarily knew his fellow work- men, workt with simple machinery and ran comparatively small risk of injury. The genius of our present remarkable industrial development re- quires that he carry on his patient toil in company with veritable armies of fellow men, many of whom he can neither see nor know; it surrounds him with mighty and complicated machinery driven by forces beyond his control, whose relentless strength rivals that of the thunderbolt itself; and it re- quires him to labor day by day with faculties at highest tension in places where death lurks in ambush at his elbow, waiting only a moment's inad- vertence before it strikes. The faithful laborer is worthy of his hire in these latter days as never before, but is he not entitled to more, and are not those dependent upon his labors entitled to more? When he has yielded up life, or limb, or self in the service of that marvelous industrialism which is our boast, shall not the great public for whom he wrought be charged with a duty of securing from want the laborer himself, if he survive, as well as his 6o helpless and dependent ones? Shall these latter alone pay the fearful price of the luxuries and comforts which modern machinery brings within the reach of all? These are burning and difficult questions with which the courts can not deal, because their duty is to administer the law as it is, not to change it; but they are well within the province of the legislativ arm of the govern- ment. Happily the Legislature has seen the need and now has these ques- tions under serious consideration. If it shall solve them justly and equitably within constitutional limits, or even make a substantial advance in the direction of such a solution, it will be entitled to the gratitude of all citizens. Confidently, I can say that none will welcome such a solution more heartily than the judges of the courts. Physicians' Compensation. The history of medicine from the days of Aesculapius and Hippocrates, placing medicine on so difficult a plane with the question of recompense, or in other words, the question of work- man's hire, has shown it to be the most difficult, irregular, irre- sponsible business asset that any class of men could have ac- cepted in any walk of life. Recompense for services rendered has been almost the last thought for many generations, of men, and later women, engaged in the healing art. This early training and moulding of thought has had much to do with the stagnant and apathetic condition pervading the great mass of the profession, so much so that business matters failed to receive the attention or discussion that has been so markt in almost every walk of life and business profession, other than ours. It makes it very difficult, therefore, to enter into a discussion of the business side of the profession, even as it relates to the mod- ern assets of our business, to the newer fases that have been thrust upon us by the kaleidoscopic change in the business world. We have ever been loathe to discuss the question of wages, or income, or salary, or fees, with that serious, solid, business sense that should have received a much earlier consideration at our hands, and as a result the condition of the medical profession this day is almost at the same ebb as that of our forefathers. Many of the things that have occurred to us in a business way have been thru oiu: own lack of interest in the financial side of the work and much can be laid at our own doors from our own apathy. 6i When we consider how Httle attention has been paid to the various legislativ acts during their discussion in the pubHc press, in public assembHes and in legislativ halls, we cannot but agree with the statement made February 24, 1916, by Harry A. Mackey, Chairman of the Workmen's Compensation Board of the State of Pennsylvania, when he says: If the medical men feel that the Pemisylvania Act is somewhat restrictiv upon their profession, it might be well for them to remember that probably they did not take the same care of their interests that the employer and employe did at a time when their advice would have been very welcome and most instructiv. He also gives us this advice: But we are in a period of experimentation and if the next twelve months' experience with this law proves that your (medical) profession has any real grievance, the Board will feel itself especially commissioned to present those results to the next Legislature for the purpose of correction. The same thought should be capitalized by medical men in every state, should be a stepping stone upon which to advance their interests, financially and economically, when new acts are to be framed under workmen's compensation laws. As a comparison of increase it was stated by the late Dr. Bris- tow in an address before the New York Academy of Medicine, about 19 13, that of the annual income of male adults in the United States 90 per cent, is less than $600, and fully 50 per cent, is less than $500, with 20 per cent, as low as $200 per annum. As a comparison to this, it was stated somewhere about the beginning of 19 10 that the average earning of the medical pro- fession of the United States was $750 per annum. Taking this as a basis of comparison, we find that the working classes have an income which was not so much less, proportionate, than that of the medical profession. Since 19 13 there has been a gradual increase of wages and income in the United States among the working classes, whereby from 10 per cent, to 20 per cent, of an increase has been obtained and in some cases more than that amount, while we cannot, from any data on hand at present, find SLnywhere as great an increase as 20 per cent, in fees in the medical profession. 62 The Judicial Council of the American Medical Association, in its report June i6, 19 13, among other things, had this to say: The fees therefore of the physician have lagged behind those of the surgeon and the worldly rewards in internal medicine are not as great as those of surgery. More than that, the rewards given to physicians are on the average given more grudgingly than to the surgeon. The surgical fees are enormously greater than they were twenty-five years ago; medical fees still remain prac- tically the same, and except in a few large centers have hardly advanced at all. Oftentimes, especially in smaller communities, physicians giving their time, draining their personalities, giving of all that is in them, find that the sense of obligation to reward them for their service diminishes in direct ratio as a feeling of friendship from their patient increases, with the result that they cannot collect a fee for an honest, difficult, scientific diagnosis which results in the life-saving operation for their patient, while the surgeon who does the mechanical operation readily collects a relatively large fee. In our discussion, therefore, of the physician's compensation as applied to workmen's compensation acts, we feel there is not a just increase in fees obtained as compared with the ordinary surgeon's work done in private practice. Murray N. Hadley, M.D., in correspondence to the Indiana State Medical Joiu-nal, February, 19 16, regarding fees under the Workmen's Compensation Laws, had this to say: Anyone giving the matter unprejudiced thought will soon be made aware that certain questions effecting physicians have arisen under the Workmen's Compensation Law that are very difficult of solution. As might be expected the question of fees has occupied most prominently the attention of physicians. This is entirely proper, for unless the question can be amicably settled it will seriously interfere with the proper working of the Act. He further says: It is said that the fees are too small and without doubt in some instances they are and should be revised, but no one has said what they should be. We have no data on which to base a schedule. It would require a con- siderable amount of research work to get accurate facts relativ to the average specific fees for specific services rendered the industrial class, as the law provides this shall be the basis of charge. If the medical profession will produce this data and then submit it to the liability companies and they re- fuse to accept it, then will the time have arrived to demand it. Let no one be surprised, however, to find as a result of such research that a considerable amount of minor surgical services rendered the industrial class under the system of the patient paying for his own services is done at a smaller figure than most of the liability companies' schedules call for. 63 To the above we must in the main agree that antiquated fee bills of twenty years ago are still the rule and are in vogue in the great percentage of medical societies and units in the United States. It is also without dispute that fees charged to patients receiv- ing injuries, which now come under the compensation laws have been paid for only in part in the great majority of instances by the laboring classes; while under the present business arrange- ment the payment is a positiv one and within a reasonable time. The suggestion also made in the above quotation would offer an incentiv for medical societies to get busy, become more prac- tical business men, reduce the long list of obsolete fees previously charged to a modern fee basis, proportionate to the services and sufficiently intelligible, so that it can be a basis upon which lia- bility companies, industrial boards, insurance companies and the like may meet us upon common business grounds. In a California case it was stated that the reasonable value of medical and surgical services will be determined with refer- ence to reasonable and usual charges by physicians for services rendered to persons of the earning capacity of the average em- ploye affected by the Compensation Act, namely, an employe with an average earning capacity of $1000 per year. The report of the Industrial Accident Commission of the State of California on medical payments for temporary injuries, says: In the cases of temporary injury it seems that medical organizations run a little better than dollar for dollar; $615,706.24 were paid out for temporary injuries alone, or an average of about $19.06 per case considered. (For year 1914.) During a comprehensiv review of the laws in the 32 states submitted (as shown by a revised table of amended laws, attacht), relativ to the application of workmen's compensation, one cannot help but be struck with the small consideration allotted to the medical profession in their application, when large space is alloted to almost every other department, amplifying in concise terms the various minute and often valueless instructions, as compared to the vital importance of medical, surgical and hospital aid to 64 the injured person. We cannot help but enlarge upon this point when we feel the enormous responsibility placed upon the medical and surgical profession in relation to the injured and the endeavor to restore to normal physical condition the individuals in whose behalf workmen's compensation laws have been framed. Many of the present boards in various states assume that no fee bill is necessary, as they base the charges upon what is usually askt by physicians and surgeons in the treatment of injuries when the individual is required to pay the same in general practice. While in the main the charges of the average physician would be legitimate, honorable and just, unless some system is adopted whereby these charges shall be uniform, as well as equitable, it is evident that there will be a great diversity of charges sub- mitted for similar service, together with the length of time re- quired to produce a cure and return to work, persons receiving the benefits of the compensation treatment. An illustration is shown by a chart in the report of the Industrial Accident Commission of the State of California, which chart shows the average time lost per case by character of medical treatment, thus: Private doctor paid a specific fee 20 days Medical fees not specified and amounts unknown 17 days Company hospital or contract doctor 15 days No medical fees reported as paid 12 days This shows that there is a tendency at times on the part of the doctor attending patients in private capacity to carry along the individual past the time when he might return to his occupation and especially if he were directed under a system of workmen's compensation as carried out under systematic medical regulation. It is quite probable that in cases of men of higher calling and receiving a larger salary than that determined by the law, viz., $1000 per year, would desire more expensiv medical, siu-gical and hospital treatment and attention on the part of the surgeon, but the law fixes the compensation, basing it only upon one fixt income; therefore employes desiring more expensiv hospital and surgical services should consider that any additional expenses must be borne by themselves. 65 From a composite view-point of the laws in all the states now having workmen's compensation and fee bills submitted by com- pensation boards, we find that the minimum fee as usually charged in the community i the basis of payment to physicians doing compensation work; and in most of the cases, while the fee is often below that which may be at times obtained in a like com- munity were the patient paying for such services, there come times when every reasonable medical, surgical and hospital treatment could not be afforded on the part of the surgeon for the amount granted in the law, as many cases of severe nature re- quire extraordinary care, attention and skill; and as a result we would make this observation when new legislation is contemplated, in our capacity as recommenders — that states should amend their various acts and give more discriminary power to the com- missioners, boards, or different executiv departments applying the law, in extraordinary conditions of the patients that the sur- geons might be allowed to expend more for medical, surgical and hospital treatment, thereby rendering greater aid in these serious cases. In nearly all of the compensation acts reference is made to hospitals, as well as to medical and surgical aid. We feel that this combination, while necessary to work in conjunction with each other, should be separated so far as compensation is con- cerned, as many of the laws make such statements in the applica- tion of the remuneration that it is difficult to separate medical and surgical treatment from the hospital fee, thereby offering an opportunity for disagreement and argument as to the placing the fee. Many of the commissioners in their discussion of the applica- tion of stu-gery to injured employes, make reference to the X-ray and it is the consensus of opinion that the X-Ray Department is separate from compensation granted for medical and surgical attention. It is wise that this is so, as it is found that X-Ray charges would materially eat up the amount allowed in any case, leaving but little for the surgeon to receive at the expiration of the one, two or more weeks, according to the various laws. A point of advantage, it would seem to us, in conducting a 66 surgical case due to traumatism and coming under workmen's compensation laws, is the fact that the patient in the majority of the laws is placed directly under the charge of the attending surgeon and must submit to what is deemed proper treatment in a given injury. The employe's refusal to obey the advice given by the surgeon vitiates the employe's chances to recover only such compensation as he would be entitled to receive had he submitted to treatment and had the treatment proven normally successful. As a result of this submission on the part of the em- ploye the recovery is more prompt, as instructions are carried out in a more definit and efficacious manner. The question of operation as recommended by the surgeon en- tails a point of personal submission on the part of the employe and a necessity to submit to a reasonable operation when a chailce of recovery is thereby considered. If, however, the employe is advised to submit to a serious major operation, which would vitiate his chances of recovery, or be a risk of life were he to sub- mit, the Supreme Court of Michigan has held that the employe's refusal to submit to an operation of that kind is not unreasonable. In the application of the medical, surgical and hospital sec- tions of compensation acts, the question has been raised that surgeons working under compensation laws endeavor to over- charge. These statements have been proven false in the greater majority of cases. The report of the Judicial Council of the American Medical Association, among other things, has this to say: That a few of the profession have greedily endeavored to obtain more than they deserved, is undoubtedly true, and any referee board of physicians or surgeons to which these claims have been referred, has been the first to con- demn the excessiv amounts claimed. There is no question that public opinion among the medical profession condemns overcharging the state or overcharging for this industrial work as severely as it condemns any other dishonest practice perpetrated by the members of the profession. It is a well-known fact that there is a tendency for all corpora- tions and industrial insurance companies, when a state begins the operation of workmen's compensation laws, to make application to members of the profession in every industrial locality, whereby they may obtain medical and surgical service for injured workers, 67 and that contracts are requested of these men, many of them at the lowest rate that can be obtained, and as a consequence doctors will engage in contract services and such service is over- workt, with the result that economic conditions are against the best interests of those who employ such contract surgeons, by reason of hasty method of treatment, carelessness in following aseptic methods, limiting the time to each individual patient, bringing such results as are stated by the Judicial Council, thus : It is often noticeable that pus and politics go together, and he who shaves the medical fee piles up compensation expenses, A stingy man hires a poor surgeon and begets many infections and much disability. Workmen's compensation acts have raised a new question that, while not from the view-point of income to the surgeons, is one that must be rated as a commercial asset in applying the provi- sions of the compensation acts, namely, the new standards of surgical and hospital efficiency, as they apply to the recovery of the patient and his working economic value. We are quite sure that a patient coming under a compensation act, when treated by a competent surgeon, with the end in view to place back into the industrial world such patient, with the least possible effect of injury, as far as working ability is concerned, gives a new impetus to that sm-geon to do for his patient all that human flesh and blood can do, and to this end the question of relationship of surgeon and hospital is very pertinent. It is this question of hospital service and attending physician that has stirred much comment in many of the states having compensation acts for many years and we doubt not that revised plans for compensa- tion, proportionate to work, will soon follow, as it is very conclu- siv that cheap work and cheap service do not bring good results. The underpaid hospital, so far as workmen's compensation acts are concerned, is brought out very nicely in the first annual re- port of the Board of Compensation Commission of Connecticut, which says : If the spirit underlying this act is to make each industry carry the expense of the casualties that occur in the conduct of that business, it fails to do so when the hospitals and physicians are forced to care for them at a loss or as charity cases. It costs the hospitals from $io to $15 per week to care for cases. If the compensation cases are placed in public wards at $7 per week. 68 the balance has to be made up by contributions that are made for charity, and physicians should not be askt to treat these cases for nothing in hospitals any more than they are askt to treat them outside for nothing. Advantages of Social Insurance against Accidents under Work- men's Compensation Laws. First. — To Workmen. The benefits of workmen's compensation laws as applied to the working classes of the United States cannot be measured in dollars and cents. These laws were never made with the idea of compensating disabled workmen or working women to the extent that they shall be supported entirely from these funds while dis- abled by accident, but it is to be supposed that they are for the purpose of tiding over a most difficult time in their lives when, in an unguarded moment, an accident befalls them, suddenly removing them from their daily toil and the income which it brings. Any social insurance scheme which would be sufficiently large to maintain the injured employe would be too great for in- dustry to bear and it would be the basis of much trouble among this class of our people, as we often find a great tendency to seek even greater benefits than the law gives, whether it be partial indemnity or a sufficient amount which would render it attractiv ; consequently every law in its application takes into considera- tion the immediate relief of the physical fault by supplying "seasonably," or as some term it "as and when needed" medical, surgical and hospital services. Another benefit which these laws give to the working classes, is that prompt service is rendered them and in the great majority of cases we doubt not that the best service possible to be ob- tained is rendered, thereby giving them the advantage of speedy return to normal health, where such a thing is possible. Under ordinary conditions, the average person in the working world delays in sending for a medical attendant, hoping and trust- ing that kind nature will repair the damages, thereby saving them an additional expense. Often this delay is the most serious thing which they could have attempted, as traumatism destroy- ing continuity of structure, allowing infection to take place. 69 renders the treatment and cure of the injury many-fold greater than where prompt scientific surgical principles are applied. Further, workmen's compensation acts, after the waiting period, give to those people that which in former times was denied them except by process of law, namely, a sufficient amount of money to enable them to live without starvation or fear of absolute want. Industrial communities in years gone by were frequently destitute of modern hospital facilities, but with the ever-growing idea of humanitarianism which now pervades the minds of those who govern the financial world, modem hospitals have come into existence and opened their doors, first to the poor of the community and later to those who come under the compensation provision. In these modern homes for the care of the sick and injured, quicker restitution of health in a great majority of instances is obtained. Every law, so far as we have been able to observ, specifically states that injuries caused thru intoxication are barred from com- pensation, and it would seem that if there is a benefit to be ob- tained the moral effect of this law to render sober the working classes is by no means a small item. We are often prone to consider personal liberty a great factor in selecting competent medical attendance and our conduct during sickness or injury in relation to the advice of physicians who are caUed to render aid. Applied to the working people this often is much to their detriment, because they are not always competent to judge who are best fitted to treat them, especially in cases of injury, and when treated as private patients take ad- vantage of the medical attendants' directions, doing many things which deter their chances for prompt recovery to a much longer period than were they under direct supervision of competent surgical service, which holds them directly responsible for every act in compliance with carrying out the directions for their relief. Many of the laws distinctly state that while it is the employer's duty to furnish "reasonable medical, surgical and hospital treat- ment," it is equally as necessary that the employe submit strictly to the advice given by the physician or surgeon in the treatment of his injury, and it has been proven that the time to reliev and cure has been reduced materially in this manner. 70 Malingering can never be entirely overcome, but it is much easier to reach and remove when the patient is observed by- physicians who receive"" their compensation thru insurance asso- ciations, rather than from the individual himself, and in that manner the wheels of industry are not prevented from turning by the loss of the worker, who would make himself a drone rather than the busy, energetic individual whom we so much admire. Second. — To Physicians. While it is necessary for us in this discussion to consider the features of workmen's compensation acts largely in their effect upon the physicians' recompense, yet we believe that there is a sense of satisfaction in watching a patient, who has been injured, respond to treatment and rapidly recover his usefulness thru our efforts, when we have carried out every wish in his behalf, so far as treatment is concerned, and the pleasure which the medical profession has so often taken unto itself, that of restoring the broken and injured human frame. We certainly should con- sider workmen's compensation laws as applied to siu-geons in that branch of work as a great advantage. We cannot deny the fact that workmen's compensation laws do not allow of any ex- travagance in the nature of supplies and yet when we look back in the past and realize what many of the earlier pioneers of surgery used in the treatment of the injured and with a fair degree of success, we must often consider our methods as somewhat ex- travagant. Another advantage to the physician in the treatment of acci- dent cases under workmen's compensation laws is the well ac- knowledged fact that those who employ us as surgeons for their work are prompt in paying for our services. In contrast to this, we find a somewhat varied percentage of amounts collected in the average practice, basing the loss of collections from lo per cent, to 50 per cent., and it has been stated that in Massachusetts it has been found that after two weeks when the industrial acci- dent board ceased to pay hospital fees for the injured workmen, it was impossible to collect from patient or friends any further monies for hospital services in from 50 per cent, to 90 per cent. 71 of cases. It is doubtful if the experience of physicians has varied much from this experience of hospitals. This condition of affairs without doubt exists thruout the coun- try and the greatest trouble experienced by the average medical man in his every day work, especially in surgical work of the ac- cident type, is recovering legitimate fees. It has been stated that there is a tendency to criticize the cost of medical services under the compensation laws in the various states and that the income of physicians is in some instances "dollar for dollar" paid to the employe in compensation ; while in others it is variously stated from 35.4 per cent, to 58 per cent, of what would have been the fee under the regular charge for a like case in general practice. Another item of importance relativ to the collection of fees under compensation acts is one that is somewhat diversified in the thirty-one states considered. In the Bulletin of the Industrial Commission of Ohio, October ist, 19 14, is the following: Against whom is the physicians' account? It should be remembered that the law implied specifically that all awards were to be paid to the in- jured workman. This impliedly respects the right of the workman to select his attending physician and the allowance to be made therefor from the fund cannot be logically a question of dispute between the commission and the physician, the physician making his charge against the injured workman with the idea of collecting it; the employer paying his premium based on an industrial accident basis, and industrial conditions, with the idea of the premium being for the purpose of paying it, etc. It would seem that this feature of applying the method of payment is much that would be in favor of the compensation boards and the employer and, while in the main the fee earned by the surgeon would reach its particular destination, yet we cannot doubt it would in many cases lead to a controversy, when some time had elapsed after the case had been settled and the employe forgetting or neglecting to pay his bill. A business feature of compensation acts is essential, whether the bill is paid by the employer or employe and the suggestion is made that on several occasions commissions have commented on the poor business ability of our profession in not rendering prompt accounts for services rendered. We cannot help but see 72 the necessity of placing the payment of all compensation directly up to the employer or insurer. The question of the limit of aid often involves the question of first aid and subsequent attendance and it has been my ob- servation that a difference has arisen in the minds of many com- missioners as to the necessity of too frequent visits and too fre- quent dressings. Obviously the time is not far distant when the siurgical instruc- tion and experience in industrial cases must be brought to a higher standard of proficiency and that surgeons undertaking this branch of work must study the economic side from the view of the compensation laws, as well as the nature of income which he is to receiv from such compensation work. Over-zealous ap- plication to the patient in the nature of too frequent dressings, too frequent visits and over meddlesomeness, while they in- crease the number of visits and proportionately the income, must be criticized to the extent that such bills are frequently re- duced when presented to commissioners or insurance companies for final payment. The joint relationship of major surgical operations, which are smaller in number in accidental surgery in comparison to minor surgery, suggests the observation that laws in some states give the fee bill in major surgery as including the operation and sub- sequent treatment, while in minor surgery it offers the first aid and subsequent dressings, and that some commissioners would be pleased to have the entire matter arranged under operation and subsequent attendance included on a flat fee basis. It can readily be seen that no matter how much we argue pro and con we, as medical men, must come to some definit understanding thruout the entire Union as to a better basis of charging for our work. Summary. Workmen's compensation laws are here to stay. They are of immense benefit to the industrial community when properly drawn and properly applied. To the medical profession, from the point of effecting the physicians' recompense, they have the advantage of certainty of payment, a fair degree of continued 73 service thniout the year, offering an opportunity to take indus- trial accident work and at the same time carry on the usual every- day practice, especially in smaller communities where not under specific contract by corporations. This method of compensation under industrial laws tends to offer the opportunity to specialize and become more proficient on the part of those desiring to under- take this class of work. A better understanding of the law in each individual state, under which the physicians and sm-geons are working, will have a tendency to make possible a better compliance with the law and as a result have harmonious work establisht between the commission or board applying the law and the physicians of that state, and wherever unity among the physicians of the state is establisht legislativ co-operation must and will be brought about. Compensation Laws as Applied to Medical, Surgical and Hospitav Service. Revised Table as Obtained from Amended Laws from Report of Commissions Obtainable to May, iqi6. Medical and surgical compensation is paid only if employe dies, leaving dependents. If workman leaves no widow, children or dependents, reasonable expense of medical attendance shall be paid. No provision is made for medical, sm-gical or hospital payment under the law. Such medical, surgical and hospital treatment, includ- ing nursing, medicines, medical and surgical supplies, crutches and apparatus as may be reasonably required at time of injury and within 90 days thereafter. Must furnish medical, surgical and hospital treatment, medicines and surgical supplies, crutches, and apparatus for a period not exceeding 30 days and $100 in value. Employer, as soon as he has knowledge of injury, shall provide a competent physician or surgeon to attend the injured employe, and in addition shall furnish such medi- cal and surgical aid or hospital service as such physician or surgeon shall deem reasonable or necessary. Charges limited as prevail in community to similar treated persons of like standard of living when such treatment is paid for by the injured persons. Arizona. California. Colorado. Connecticut. 74 Illinois. Indiana. Iowa. Kansas. Louisiana. Maine. Maryland. Massachusetts. Missouri. Michigan. Employer shall provide necessary first aid medical, surgical and hospital service for a period not longer than 8 weeks, not to exceed $200. The period of medical and surgical aid is extended for 30 days. No data obtained as to amount of compensation allowed. At any time after an injury and until the expiration of two weeks, the employer, if so requested by the work- man, or any one for him, or if so ordered by the court or Iowa Industrial Commissioner, shall furnish reasonable surgical, medical and hospital services and supplies, not exceeding $100. Compensation paid only if employe dies, leaving no dependents, not to exceed $100, which shall include burial expenses. Medical and surgical aid fumisht for first 14 days, not to exceed in amount $100. Maximum $30 for first two weeks, which includes reasonable medical and hospital services and medicine; in case of major surgical operation additional cost is arranged between employer and employe. Such medical, surgical or other attendance or treat- ment, nurse and hospital services, medicines, crutches and apparatus as may be required by the commission, not to exceed $150. If employe leaves no dependents, reasonable expense of last sickness, which shall not exceed $200, (Burial expenses included in this amount.) Massachusetts has no fee bill, the amount being paid as is usual for case of like condition when paid by employe. Liability of the employer for medical aid unlimited and in case he fails to furnish or tender the same, the employe, or some one for him, may make the employer liable therefor. Requires employer to pay for hospital service in public institution. Limits all charges for medical aid to such as are reason- able. During first three weeks after injury the employer shall furnish, or cause to be fumisht, reasonable medical and hospital services and medicines when they are needed. Minnesota. Montana. Nebraska. Nevada. New Hampshire. New Jersey. New York. Ohio. Oklahoma. Oregon. Pennsylvania. 75 Medical and surgical treatment, medical and surgical supplies, crutches and apparatus, not to exceed 90 days, to the amount of $100, except by order of court upon necessity being shown, shall furnish additional service not to exceed $200. Medical and surgical compensation paid to amount of $50 for period of two weeks. During first 21 days, reasonable medical and hospital services and medicines, not to exceed $200, If employe leaves no dependents of any kind, expenses of his last sickness and burial shall be paid, not to exceed the sum of $125. None. Compensation adjusted between employer and em- ploye. First two weeks reasonable medical and hospital ser- vices and medicines as and when needed, not to exceed $50 in value, unless employe refuses to allow them to be fumisht by the employer. Medical, surgical and hospital service, nurse, medicines, crutches and apparatus fumisht during 60 days after injury; fees and other charges for treatment regulated by commission and limited to such charges as prevail in the same community for similar treatment of injured persons of a like standard of living. Medical, nurse and hospital services and medicine, not to exceed the sum of $200 in any instance. The Board has power to regulate the furnishing of medical nurse and hospital services to injured employes entitled thereto and for the payment therefor. The period of compensation granted is 15 days. Amount granted for medical, surgical and hospital ser- vices not obtained. Medical and surgical attendance and hospital accom- modation, not to exceed $250 in any one case. Surgeons' industrial fee bill regulates charges to be made. Medical, surgical and hospital services provided for first 14 days after injury, not to exceed in amount $25; except if major surgical operation is necessary, when $75 is allowed. 76 Rhode Island. Texas. Vermont. Washington. West Virginia. Wisconsin. Reasonable medical and hospital service and medi- cines when needed provided for period of 2 weeks, but Rhode Island has no law fixing fee bills for physicians under Workmen's Compensation Act. During first week of injury, Association shall furnish reasonable medical aid, hospital services and medicines when needed, and if it does not furnish these immediately as and when needed it vshall repay all sums reasonably paid or incurred for same. Medical, surgical and hospital services fumisht for first 14 days, not to exceed in amount $75. None. First aid bill will be voted on at the next general elec- tion and if bill passes a fee bill will undoubtedly be adopted. At present no first aid or medical attention provision in the Washington Workmen's Compensation Act. Such sums for medical, surgical and hospital treat- ment as may reasonably be required, in any case not to exceed $150; provided in case of permanent disability that said disability can be reduced by surgical or medical treatment, the amount expended for medical, surgical or hospital treatment shall not exceed $300. Medical, surgical and hospital treatment, medicines, medical and surgical supplies, crutches and apparatus for period not to exceed 90 days. HEALTH INSURANCE. By John B. Andrews, Ph.D., New York, Secretary American Association for Labor Legislation. Medicine has progrest far since doctors taught that the in- flammation from a burn could be reUeved by holding the af- fected part near a hot fire, and that the bruised head of a viper would cure snakebite. Knowledge and technique have abund- antly progrest, but the pivotal change, I take it, has been the development of the scientific spirit. When Vesalius refused to hark back to authority for his theories, but appealed directly to the facts, guesswork and traditionalism lost respectability, and genuine research took their place. In the difiicult field where medicine and sociology meet, the American Academy of Medi- cine has well upheld this ideal. I feel at home in meeting you for this discussion because the organization I represent also approaches its problems in a scien- tific spirit. We endeavor to apply scientific methods to the sub- ject of labor organization. We endeavor to base our action on careful study of experience. The scientific attitude also im- plies that we must consider the welfare of the whole country, for the future as well as for the present. Perhaps the best evidence that we have succeeded in main- taining a scientific attitude toward labor problems is that we are occasionally criticised by employers as being too friendly to trade unions and again just as roundly condemned by certain representatives of labor as being too friendly to the employers. The subject of our discussion is Health Insurance, with special reference to the model bill prepared by the Association for Labor Legislation. Perhaps I cannot do better in the beginning than explain to you why and how we drafted this legislation. About seven years ago, you will remember, we began to give serious attention to workmen's compensation for industrial accidents. Investigations indicated that no fewer than 25,000 human lives were sacrificed each year in American industry. 78 The list of serious injuries, incapacitating for a period of four weeks, or more, totalled about 700,000. Bach year of productiv endeavor yielded as an incidental product some 45,000 widows and orphans. This truly was a social problem worthy of our best remedial efforts. The coming of workmen's compensation, which in the short space of six years swept over 35 of our 50 states and territories, and over the federal government for its own employes, was revolutionary in its effects. Accident statistics suddenly be- came something more than a sorry joke. Information accumu- lated almost automatically. Millions of dollars, formerly spent in wasteful and contentious methods, were now available to care for the victims of accidents on a systematic, scientific basis. Even those who in the beginning opposed workmen's compensa- tion as a legislativ proposal are now loyal adherents of it in prac- tice. Both employes and employers as well as society in gen- eral have benefited. And perhaps the chief gain has been the continuous economic pressure toward accident prevention. Many employers, in cooperation with their employes and the agents of the state, are now preventing from one-half to two- thirds of their accidents which six years ago they regarded as inevitable. The coming of workmen's compensation gave im- petus to the great movement for "Safety First." As early as 1912 it had become evident to many people that this social insurance method of dealing successfully with indus- trial accidents would be extended before many years to another and no less serious contingency in the life of the worker. At the annual meeting of the Association for Labor Legislation, held in Boston that year, a national committee was provided to in- vestigate the subject of workingmen's sickness. The members of that committee include leading authorities of the country on statistics, medicine, nursing, and social insurance. EXTENT AND COST OF SICKNESS. The committee found that about 3,000,000 persons in the United States are sick at any one time, and that each of our 30,000,000 wage-earners loses an average of approximately 79 nine days' work from this cause yearly, while the resultant yearly wage loss totals $500,000,000 and medical treatment costs an additional $180,000,000 annually. This estimate of nine days' illness for each wage-earner is sub- stantiated b}^ the recent community sickness surveys carried out by the Metropolitan Life Insurance Company in Rochester, N. Y., and Trenton, N. J., which revealed an average of 8.5 days of disability a year for men and 9 . 4 days for women. The enormous expenditure of $180,000,000 a year for med- ical care cannot be met by our industrial sick. An analysis made by the Boston Dispensary showed that only 17 per cent, of the families with which the institution was in touch received incomes from which they should be expected to pay for medical treatment beyond that necessary in childbirth and acute illness in the home. In the Rochester survey it was found that 39 per cent, of those who were sick had no physician in attendance; of those who were ill but able to work, 54.7 per cent, had no physician. In New York State, out of 300,000 patients cared for by 185 hospitals, 46 per cent, were taken as public charges or as free patients. In New York City alone, forty-six hospitals cared in one year for 69,000 patients, or 57 per cent, of their total, who paid nothing for their treatment. Yet the United Hospital Fund states that: "At present only one in ten persons seriously ill or injured in this city now gets treated in any hospi- tal. For lack of proper treatment thousands lose their health and efficiency and become a burden to their friends and the com- munity." Even the dispensaries of New York, with their 4,500,000 treatments yearly, fail to reach all of those who require their services. Wage studies, furthermore, show that the slender savings of workingmen are inadequate to meet the wage loss due to sickness. A recent investigation of 700 sick wage-earners by the Russell Sage Foundation disclosed that in addition to using up savings the deprivation of income was met (i) by relief socie- ties, (2) by relatives and friends, who were undermining their own health and strength in order to help others; (3) by employers and trade unions, and (4) by borrowing money, taking in lodgers. 8o sending the wife to work, committing children to institutions, and moving to cheaper quarters — all of which tend to reduce the standard of living and to multiply sickness. In 75 per cent, of the applications for aid to the New York Charity Organization Society, sickness was directly or indirectly responsible. About eight-tenths of the relief expenditure of the New York Associa- tion for Improving the Condition of the Poor is made necessary by sickness. In short, sickness was found to be a factor in seven times as much dependency as is industrial accident. The economic loss due to the impaired vitality of wage-earners, and to that of ill-nourisht and ill-cared-for children when they come to working age, cannot at present be accurately measured, but it must be considerable. Moreover, altho much of it is prevent- able, there are no signs that sickness in America is diminishing. On the contrary, deaths in middle life, due to degenerativ dis- eases, have increast in the United States 40 per cent, during the last twenty-three years. Until some means is found to pre- vent illness, and to distribute its cost, sickness will continue to produce destitution, dependency, inefficiency, waste, and death. RKSPONSIBIUTY FOR SICKNESS. The committee also found that responsibility for sickness may with justice be divided among three parties — the employer, the workman, and the state. While not to the same extent as for industrial accidents, the employer is nevertheless largely responsible for the sickness which assails his workmen, and interferes with the stability of his working force. Every new man broken in, every man transferred from his regular work to take the place of a worker who is absent, represents a definit financial loss, and much of this loss is but the employer's chickens coming home to roost. Often by conditions common to his trade, such as monotony of work, speeding up, and a work-day of unhygienic length, and also by payment of wages inadequate for proper food, clothing, shelter, and recreation, he undermines the vigor and resisting powers of his workpeople, so that the omnipresent bacteria of 8i disease find the ground well prepared. Not infrequently, also, improper heating, inadequate dust removal, or the presence of lead, arsenic, mercury, wood alcohol, or any other of fifty-four well-known industrial poisons, cause illnesses whose occupational origin is even more direct and unmistakable. "A great many of our own industries," reports the New York Factory Investigating Commission, "are at present carried on under such abnormal conditions that they unduly increase the morbidity and mor- tality rate of the workers." The experience of the Leipsic health insurance fund shows a variation of from 20 to 65 per 1,000 in the sickness rate for different occupations. This does not absolve the workman, however, from all com- plicity in his own ill health, particularly if he nails down the win- dows in his home on October ist, or in the workroom refuses to use the respirators provided for him. An amusing story is told of some workers in a dusty white lead plant who would not use the shower baths until they were forced to run stript thru a wall of water in order to reach their street clothes. In the selection of food and of living quarters, in personal care and habits, the man who must bear the physical brunt of illness falls in many cases far short of utilizing to the full the facilities for health which are at his hand. The state also is responsible for much of om- sickness. Inade- quate supervision of the water or milk supply may mean an epi- demic of typhoid. Thus George A. Johnson, engineer, estimates that properly purifying the water of American cities would pre- vent about 45,000 cases of typhoid and 3,000 deaths annually, at a saving of $22,500,000 in the vital capital of the nation. Failure promptly to discover and isolate foci of contagious dis- ease, as in the present threatening outbreak of infantile paralysis, endangers a whole community. Protection of the people's physique thru pure food laws is yet in its infancy. Unregulated housing conditions lead to the unsanitary slums of our large cities, and backward methods of garbage and sewage removal spread pestilence in their train. Towards encouraging and ele- vating standards of industrial hygiene the state has done much, but much more remains to be done. 82 The need of the hour is for some method of bringing persistently- home to each of these three parties — the individual employer, the individual workman, and the state — a due sense of responsi- bility for the common burden of sickness, and of enlisting the eager services of each in a thoro-going campain of prevention. INADEQUACY OF EXISTING HEAI.TH AGENCIES. A careful survey, furthermore, convinced our committee that existing health agencies were woefully inadequate to meet the demands upon them either for cure or for prophylaxis. Fortu- nately the vast body of medical service is far above the level indi- cated by a recent advertisement in the Los Angeles Times, which ran: "PERSONAL— ARE YOU SICK? IF SO, BE made well by Chiropractic in exchange for ladies' or gentlemen's clothing. All kinds of diseases successfully treated. Phone SOUTH 5532." Nevertheless it remains regretably true that the medical pro- fession as a whole is not yet organized for the maximum of social service. The tremendous development of medical science, in bulk, in variety, and in elaborateness of technique, has made possible cures which a generation ago were unthought of. But it has also brought about an era of specialization. It now often takes as many physicians to tend a patient as it takes tailors to make a man. One family has been known in the course of a year to engage the services of a laboratory worker, an X-ray man, a general physician, an oculist, a dentist, an orthopedic surgeon and a throat specialist. Such specialized service is expensiv. It can be secured by the wealthy, to whom strict economy is not an object. It can also be secured, free or at merely nominal cost, by the very poor, in the clinics and dispensaries which, in spite of uncertain finan- cial support, have multiplied seven-fold in the past decade and a half. The great bulk of the people, however, between these two extremes, are in the main cut off from the elaborate resources 83 of modern medicine. Some method is needed of placing these re- sources upon a sound financial basis and of throwing them open to the masses of the people. POSSIBILITIES OF HEALTH INSURANCE. Insurance against sickness has been successfully tried out in many older countries. Germany, Great Britain, Austria, Hun- gary, Russia, and five other European nations have for years been reaping the advantages of this method of meeting their sickness risk. Thus, after three years' experience with compulsory health insurance, the British physicians confess that only since the passage of the national insurance act of 19 ii have they been able to treat anemia among the working class. In Great Britain, also, the act has stimulated a powerful national crusade against tuber- culosis. The first effect has been to increase the availability of hospital beds already in existence but previously inaccessible to workingmen; the second has been to increase the actual ac- commodations. Within two years after the initiation of the act in England there were 3,000 beds in process of construction, 150 tuberculosis officers had been appointed, 150 new tuberculosis dispensaries had been opened, and nearly 1,000 shelters for out-of-door sleeping had become available. During the initial eighteen months, 19,400 insured tuberculous persons were treated at home, 8,800 thru dispensaries, and 19,900 in institutions, making a total of 48,000 insured tuberculous persons who received treatment. In Germany, where similar measures have been in operation twenty-five to thirty years, markt results have been achieved. There the health insurance law has placed within reach of the working people "resources of healing never dreamt of before." The invalidity funds, also, which afford benefit in case of pro- longed disability, are empowered to prevent the impending in- validity of an insured person by requiring the member to undergo treatment. In addition the funds may promote general mea- sures for the prevention of invalidity or for the improvement of the general health conditions of the population subject to insurance. 84 Under the provisions of the law, generous accommodations have been provided, so that, in 1910, 47,000 insured persons were cared for in sanatoria for an average of seventy-three days. In addition to the actual care of disease undertaken by the funds, they have been activ in a campain of prevention, in part thru health lectures and in part thru the promotion of improved hous- ing. Because of the causal relation between housing and sick- ness, the invalidity funds have invested large sums in improved housing schemes. Moreover, while life has recently lengthened in other European countries at a rate equivalent to five, ten, or even seventeen years a century, in Prussia it has lengthened in twenty-three years at the rate of twenty-five years a centmy for men and twenty-nine years a century for women. No small proportion of this increase must be attributed to the impulse toward the dis- covery and application of scientific medicine given by the health insurance law of 1883. HISTORY OF MODKlv BII.Iv FOR HEALTH INSURANCE. In June, 19 13, the committee's work led to the calling of the first American Conference on Social Insurance in Chicago. Gov- ernors of the main industrial states appointed delegates, and the discussions were participated in by government and labor bureau officials, economists, employers, and commercial insurance men. During the summer of 19 14 the committee issued a tentativ statement of the essential lines which it proposed to follow in drafting a model health insurance bill. The importance of having people with medical training and experience cooperate in perfecting the medical features of the bill was early recognized, and by November, 19 15, the Amer- ican Medical Association had offered its assistance and appointed a cominittee of three. May I suggest that no more valuable service could be rendered to the cause of health insurance by the American Academy of Medicine at this meeting than the appointment of a similar committee? In tentativ form 18,000 copies of the bill have been distributed thruout the country, and during the winter of 19 15-19 16 repeated 85 conferences were held for its final shaping before introduction in the state legislatures. Meanwhile words of encouragement came from all parts of the country. Almost simultaneously the measure was introduced in New York, Massachusetts, and New Jersey, and legislativ hearings early in March in the two former states lifted health insurance from the seclusion of aca- demic discussion into the realm of practical politics. The Massa- chusetts campain has just resulted in the creation of a legislativ commission, similar to the social insurance commission appointed in California in 19 15, to study the question and to report at the forthcoming session, and in at least twenty states preparations are under way for the introduction of this legislation in 191 7. PRINCIPAL PROVISIONS OP THE MODEL BIIvL. The bill that we have workt out, as Professor Seager has con- cisely stated, contemplates compulsory health insurance, on the ground that experience ever3rwhere has shown that voluntary insurance will not reach the classes which need it most. Those who are intelligent and foresighted enuf voluntarily to develop plans are not those over whom we need feel most concern. For others the system must be made obligatory if it is going to render the large social service of which it is capable. The obligation to insure imposed by the bill is to apply to all manual workers, and also to all other employes earning not more than $1,200 a year. In addition, provision is made for the volun- tary insurance of persons who desire to benefit by the economies of this great cooperativ plan and who are not included among those who must insure. ''' The benefits proposed are of five types. First, there are med- ical, surgical, and nursing benefits, medicines and surgical sup- plies, beginning on the first day of illness and continuing, if neces- sary, thru the twenty-six weeks in any one year during which cash benefits are to be paid. "* The second chief benefit is the cash benefit, which the bill proposes as two-thirds of wages, beginning on the fourth day of illness and continuing during disability up to twenty-six weeks in any one year. 86 ^ A third type of benefits is hospital or sanatorium care, where this is prescribed, or desired, with the consent of the physician. In that case the cash benefit to the dependent members of the family is to be reduced to one-third of wages. , A fourth benefit is the maternity benefit, which is to consist of medical care for the mother, and, in the case of insured women, of a cash benefit, for not more than eight weeks, on the ground that this is a kind of disability from capacity to earn wages, comparable with illness, and that the need for support during this period for wage-earning women is as great as in the case of ordinary illness. Indeed, this need is especially great because of our legal situation, since in some states we prohibit women from gainful employment for a certain period of time before or after child-birth, and therefore deprive them, if they are wage-earners, of their usual source of income. !t Finally, there is provision for a funeral benefit of not more than $50. Funeral benefits, as a matter of fact, are the benefits most eagerly desired by our wage-earners. The working men and women of New York State alone, for instance, paid in 19 15 to four commercial insurance companies more than $29,000,000 for industrial insurance, which practically amounted to mere burial benefits. The requisite funds for the proposed benefits are to be contrib- uted two-fifths by the employer, two-fifths by the employe, and one-fifth by the state. In view of what has been said re- garding the occupational factors in illness, it has been thought that this contribution of two-fifths from the employer is not ex- cessiv. Moreover, as Professor Seager has well pointed out, it is justified by the importance of enlisting the employer's in- terest in the whole program and his intelligent cooperation in the administration of the insurance fund. Our experience with workmen's compensation acts shows how much can be accom- plisht when we make it financially profitable. If we are to start a "Health First!" campain comparable with the "Safety First!" campain that is now so well launcht we must make health a paying investment for all in a position to promote it. It would not, however, be just to require the employer to pay 87 all of the cost of health insurance, as he now rightfully does of accident compensation. The employe's personal habits are responsible for much of his own illness. Thru financial interest the workman himself must be aroused to exercise more care for his own health, to discourage malingering, and to cooperate intelligently in the fair and economic administration of the funds. Unless the worker contributes to the fund, it is hard to see how he could be given voice and vote in its administration. It is believed also that the state should bear about one-fifth of the financial burden, which is probably not much more than it is already paying in crude and uncoordinated attempts at public health work, in public hospitals and sanatoriums, and in charitable relief to the destitute victims of unprevented disease. The administration of the plan, as proposed by the bill, is to be vested in local mutual insurance societies, to be supervised by a social insurance commission for the whole state. These local insurance societies are to be governed by representatives elected in equal number by the employers and employes con- cerned. Employer and employes are to select members of a large committee, the same number from each side ; this large com- mittee is to select a smaller board of directors for the insurance society. As you will observ, this is practically the German plan, and our confidence that it will operate well in this country when establisht is based upon observation of its success in Germany. We see no reason why in the administration of such a system there should be anything but the most cordial cooperation. The em- ployer would have no motiv for hampering the efficiency of the plan. On the contrary, we believe that his advice and assistance will aid it. This is to be the general type of administrativ organization. To supplement it, provision is made for the organization of trade societies in localities where there are enuf individual employes in particular trades to make that administrativ unit of sufficient size. Then there is provision for voluntary organizations, such as we have at present — labor unions, establishment funds, and the like — provided that they meet at all points the requirements of the law, comply with regulations of the social insurance com- 88 mission designed to hold them up to the standards which the law prescribes, and that they are financially sound. The details of the social insurance commission, the central body to have supervision over the whole system, are left rather shady in the provisional draft bill, because we think this must be adapted to special conditions in the different states that adopt the system. It is proposed, however, that the commission shall consist of three members ; that their position shall be non-politi- cal as far as possible, and that their tenure of office shall be long enuf to insure continuity of service and the right type of commissioner. OBJECTIONS TO MODEL BILI.. < Objections to the model health insurance bill have come in the main from three groups. A few employers have objected on the ground that the addi- tional burden would "drive industry out of the state." Care- ful calculations show, however, that the employer's contribution will equal but a little more than i per cent, of pay roll, and so slight an expense need not jeopardize any industry. Moreover, this is the same argument which was made a few years ago against workmen's compensation, and we have yet to learn of a single industry which has left any state because of the burden of com- pensation payments. In fact, under the New York State com- pensation law, the most liberal in the world, it has been found that the total cost to employers is actually less than it was under the old liability system. Few would go back to the old system; and on the other hand many are already in favor of health in- surance. Certain representatives of trade unions have entered protest, usually not against the purposes or principle of the measure, but against the provision that the workers contribute to the insurance funds. In other words, they are willing to receive the benefits, but are unwilling to bear their share of the expense. Needless to say, a system supported solely by the state and by the employers cannot be as liberal or as efficient as one in which the injured persons themselves meet a just portion of the ex- pense and participate in the management. 89 From a certain element of physicians, also, dissent has been heard. These practitioners, largely "lodge doctors," agree with the principle of universal health insurance and, in common with the leaders of the profession, recognize it as inevitable within the next few years. Their opposition is directed at minor administrativ details in which they fear that their inter- ests may not have been sufficiently safeguarded. As the movement for health insurance develops they will be given full opportunity to present their concrete suggestions, and there is no doubt that as is now the case in Germany and in England, the medical men of the country will soon stand as a unit in sup- port of this twentieth centiuy device for cooperation within the profession. CONCI.USION. This, then, is the situation : For oiu* present waste and suffer- ing thru uncheckt disease there is a threefold responsibihty, shared in by employer, employe, and the state. Each of these three has a compeUing interest, perhaps only dimly glimpsed as yet, in the prevention of preventable disease and in the prompt succor and relief of that which cannot yet be prevented. For the attainment of these purposes the three interested parties must be welded together in a progressiv, educational, health movement, and such a movement can be called into being only thru a comprehensiv plan of health insurance with its bturdens equitably distributed. UNEMPLOYMENT INSURANCE. By RuFus M. Potts, Springfield, 111., Insurance Superintendent, State of Illinois. The branches of insurance which your association has under consideration this afternoon, are now collectively termed "social insurance," but were formerly called "workingmen's insurance." The latter term, however, dropt out, of use, being inappropriate, because such insiwance was used by many other classes than manual workers. I believe the name social insurance is unsuitable also. The association of ideas causing its use is rather far-fetcht, but worse, it has, for the general public at least, an unfavorable and erroneous association with the name of the political party called Socialists. The effect of this in producing a hostile initial attitude in the minds of most members of other political parties, is as bad as if it were called Republican, Progressiv, Democratic, or Prohibition insurance. For these and other reasons, I believe it highly de- sirable to have a new collectiv name of these branches of insur- ance, and I propose "Welfare Insurance." This name is ac- curate, for it describes fully and correctly the aim of all of the kinds of insurance included. Neither has it any hurtful association with the name of any political party or doctrine. Welfare in- surance, then, is the use of insurance principles and methods for the purpose of supplying pecuniary resources necessary to main- tain each citizen of the United States, in a state of well-being, thruout the various misfortunes and emergencies of life which would otherwise destroy his well-being and cause in its place destitution and suffering. I believe that the substitution of the name welfare insurance for social insurance would be of immense service in bringing about its favorable consideration by the people in general and its ultimate adoption which can only be secured thru their ap- proval. Turning to unemployment insurance, that branch of welfare insurance which is my subject, we find that in the earliest stages 91 of civilization, there was no unemployment problem. Slaves did most of the work and their complaint was not lack of work, but too much work. In such nations, however, as the ancient Hebrews, where there was little slavery, but where sufficient in- dustrial development had occurred, so that some men could not alone do all their work, but found it necessary to hire others,, the two economic classes of employer and employe came into existence and maladjustment between the needs and wishes of the two classes inevitably arose. On the employer's side, this was lack of sufficient workers or of competent workers, and often occurred. On the employe's side the imperfect adaptation was lack of remunerativ employment, which attracted attention nine- teen hundred years ago, for it was mentioned by our Saviour in his parable about the laborers in the vineyard as follows: And about the eleventh hour he went out and found others standing idle and saith unto them: Why stand ye here all the day idle? They say unto him, Because no man hath hired us.^ It is an industrial phenomenon entirely independent of race or country. Over a thousand years ago, Wang Ngan Shih, a Chinese statesman, enunciated a set of fundamental principles, based on the experience of that nation, which he held should be observed by governments. One of these was: "A state should insure work for workmen," which shows that unemployment even at that early time, had become a problem in China. 2 In considering unemployment then, we are not dealing with a new problem, but the rapid changes in the methods of industry dtu-ing the past 150 years, sometimes called the "industrial revo- lution," have caused it to attract more attention from law makers and students of public affairs than formerly. This increast attention is also partly due to the steady growth of democracy thruout the world and to the invention and adoption of new and more humane and effectiv methods for dealing with misfortune and relieving or mitigating resulting human misery. Unemployment is a word which is its own definition, for any- 1 Matthew, 20: 6-7. * China Revolutionized, J. S. Thomson, p. 557. 92 one knowing the English language understands that it is the state of not being engaged in useful and remunerativ labor. Unem- ployment is of two kinds: voluntary, where the individual does not have the desire to work; and involuntary unemployment, where the individual is willing to work and able to work, but can- not get work. The first class may be called "won't works," the second class "can't find works." What proportion of the unemployed belong to the "won't works" and what to the "can't find works," is not shown by general statistics. In the winter of 19 13-14, however, a special study was made of two thousand unemployed men in the municipal lodging houses of New York City. From this it appeared that about 35 per cent, of those homeless men were unemployable. Some of these were phys- ically and mentally disabled, others habitual loafers, confirmed beggars or petty criminals. The remaining 65 per cent, were willing and able to work. The proportions of these two classes vary from time to time. In good times, such as prevail at pres- ent, the unemployed will be practically all "won't works," while in hard times, a great majority will be "can't find works." Any extended discussion of measures for dealing with voluntary unemployment do not come within the scope of this article. The physically disabled should be relieved by charity. The much more numerous class of vagrants and incorrigible loafers; the vicious and criminal should be firmly dealt with by being placed in farm colonies or other institutions where they can be and will be compelled to work, at least sufficiently, to produce the food and supply the other necessities of their useless existence. Our attitude should be very different toward those unfortunate workers who are suffering from involuntary unemployment; who are able and willing to work but cannot find work. Our first inquiry as to them should be to find, if possible, what are the causes of their involuntary unemployment. Unemployment arises from the incapacity of industry to ab- sorb the whole supply of labor at any given time. A brief study of the cause of this incapacity will convince everyone, that the waves of great prevalence of unemployment occurring at inter- vals of several years called "hard times," as well as the consider- 93 able amount of chronic involuntary unemployment, are in the last analysis due almost wholly to the imperfect adjustment of production to demand. The organization of industry is still crude, awkward and full of defects, so that irregularities con- tinually occur in the amount of work ofiFered. There is no in- herent necessity that this should be so. If production and dis- tribution were properly adjusted, there would always be a de- mand sufficient to consume all the time, all the products, that all the workers of the world could produce. You will, I believe, realize the truth of this in a moment without extended argu- ment, if you reflect how practically limitless are human wants and desires. I do not suppose there is any man or woman in this audience, much less in the general population, who is able to ob- tain all the commodities that he or she desires. Altho it is easy to see that every member of this audience is clothed in fine raiment and no doubt each fares sumptuously, and rides in auto- mobiles every day, nevertheless, I doubt not that each of you cherishes unfulfllled wishes for things someone else could make, and would be glad to make, and sell you. I know, you know, everybody knows, that even in our own fortimate land which is not afflicted by war, or pestilence, where the most fertile soil produces perennially in rich abundance, there are to-day thousands, yes millions, who can only get scanty and unpalatable food, who can only secure the poorest and coarsest clothing, who in sickness must go without physician's and nurse's care. There are many, many more who have a fair measure of these necessaries, yet live barren lives without books, or music or opportunity of recreation or travel and innumerable other things which make life pleasant. This infinit number of legitimate but unfulfilled wishes and needs, proves that it is only by reason of serious defects in our present industrial and social organiza- tion, that anyone willing to work to supply these needs, is unem- ployed. Subsidiary causes of involuntary unemployment are lack of knowledge of the worker where work is; lack of means whereby the worker can transfer himself cheaply and rapidly from one job to another; seasonal occupations; the temporary displace- 94 I ment of workers by new machinery; lack of adaptability to new work on account of old age or mental or physical weakness; lack of industrial training, either in youth or adult life ; over-specializa- tion which confines the chances of employment to small subdi- visions and particular operations of industry; and irregular buy- ing habits of consumers. All of these causes of unemployment are absolutely beyond the control of the individual worker and can only be regulated by coUectiv action. The effect of unemployment and the resulting lack of proper food, etc., upon workers does not require any extended descrip- tion or explanation, least of all to physiologists. The human organism, unfortunately, is not like a steam engine in which the fires can be extinguisht and then allowed to stand cold without expense until put to work again. The human mechanism re- quires continuous supplies of fuel in the form of food, as well as clothing, and other necessaries. If it once stops and grows cold, the most expert physician in the world cannot start it again. Unemployment inevitably causes suffering and deterioration, and is always followed by an increase in pauperism and crime, and so is a direct economic loss. In those cases where the worker has been able to accumulate some money in a savings bank, by investment in a home, or otherwise, as long as such resource holds out, neither he nor his family will endure physical suffer- ings. But there is a great number who have no such accumula- tions, and such as do have them, must exhaust them sooner or later, so that poverty and hunger are certain unless some means of prevention or relief can be found. Before proceeding to the consideration of the methods of dealing with unemployment, we should have some reliable information as to the amount of unemployment during the whole year, and at the particular seasons of the year. When we come to examine this branch of the subject, we find, however, that there are no such statistics covering the whole of the United States and but little for smaller areas. Even with all the facilities at the command of the United States Bureau of Labor Statistics, its Chief is obliged to say: 95 To the frequent question as to the amount of unemployment in this country the reply must be made that the statistics do not make possible any estimate of the number of unemployed persons in the United States at any time.^ Some statistics have been accumulated in New York and Massachusetts as to unemployment among the members of labor unions, but they cover only a part of the working population and show such discrepant results that no general inferences can be drawn from them. They have, however, some value as being for two typical in- dustrial states representing the best that has so far been obtained in the line of unemployment statistics in the United States cov- ering as much as a whole state, so that I present them for what they are worth. It will be observed that these tables show a wide difference between the results in these two adjoining states; I have not seen any reasons given for this and I am unable to suggest any myself. Number and Percentage of Members of Labor Unions Idle in the State of New York at End of March and September, 1897 to 19 ii. Idle at the end of March. Idle at the end of September. Number Percentage in all in all Years. unions. unions. 1897 43,654 30.6 1898 38,857 21.0 1899 31,751 18.3 1900 44,336 20.0 1901 42,244 18.5 1902 36,710 13.6 1903 41,941 12. I 1904 101 ,886 27 .6 1905 54,916 15. 1 1906 37,237 9-9 1907 77,269 19. 1 1908 138,131 35-7 1909 74,543 21. 1 1910 62,851 16. 1 1911 96,608 20.3 > Bulletin 109, U. S. Bureau of Labor, Percentage in repre- sentative unions. Percentage Percentage in repre- in all sentative unions. unions. 17-3 17 .6 27. 1 19.2 II. 6 18.3 37-5 23.0 22 .6 25.6 p. 6 (1912). Number in all unions. 23,230 22,485 9,590 31,460 18,617 18.377 33,063 36 , 605 17,903 21,573 42,658 80,576 36,968 63,106 50,390 6.3 9-4 12 .0 5-9 6.3 12.3 24.6 14-5 12.5 II .2 96 Number and Membership of Labor Organizations Reporting and Number of Members and Percentage of Membership Idle at End OF Quarters Specified, Massachusetts, 1908 to 19 it. Idle at end of quarter. Number Reporting ' k Quarter ending. unions. members. Members. Percentages. Mar. 31,1908 256 66,968 11,987 17.90 June 30,1908 493 72,815 10,490 14.41 Sept. 30,1908 651 83,969 8,918 10.62 Dec. 31,1908 770 102,941 14.345 13-94 Mar. 3i> 1909 777 105,059 11,997 11.42 June 30,1909 780 105,944 6,736 6.36 Sept. 30,1909 797 113,464 5.451 4-8o Dec. 31,1909 830 107,689 10,084 9.36 Mar. 31,1910 837 117,082 8,262 7.06 June 30,1910 841 121,849 8,518 6.99 Sept. 30,1910 845 118,781 6,624 5.58 Dec. 31,1910 862 122,621 12,517 10.21 Mar. 31,1911 889 122,002 12,738 10.44 June 30,1911 897 135,202 8,927 6.60 Sept. 30,1911 975 133,540 7,527 564 Dec. 30,1911 905 125,484 12,167 970 An attempt has been made to get some idea of the amount of unemployment by another method. Taking a selected list of manufacturers for the year 1909 according to the reports of the Census Bureau, a table was constructed which gives what percentages the emplo)anent for the month of least employment in them all, was of the amount of employment in the month of greatest employment. This list contains 261 industries and shows that on an average the amount of employment in the month of least employment was 88.6 per cent, of the amount of employment in the month of greatest employment; that is — 1 1 . 4 per cent, of unemployment in the worst month. The aver- age number employed diu'ing the year in the manufacturies concerned in the above list was 6,615,046, so that in them the total unemployed in the worst month was approximately the immense number of 754,000.^ A witness at a hearing before a Congressional Committee, who testified that she had been engaged in the study of the question of unemployment for eight years in Europe and the United States, * Testimony of Miss Juliet Stuart Poyntz, pp. 52, 60 and 61, Report of Hearings before Committee of Labor, House of Representatives, 64tb Congress, 1st Session, on H. J. Res. 159. 97 says, in relation to the relativ amount of unemployment in the United States compared with other countries : I would like also to say that the problem in America is more serious than in Europe. Not more than lo or 15 years ago it was the general belief that there was no problem of unemployment in America such as there was in Europe. As a matter of fact, it is a much greater problem here than in Europe. The percentages of trade-union unemployment in New York and Massachusetts indicate that American unemployment rises to heights that are unknown in Europe; that if unemployment is an evil in Europe it is a much vaster and more serious evil in America. It might be pointed out that speculation makes industrial changes much more rapid in this country and that transitions in our industries result in greater fluctuations. There are great fluctuations in all the industries affected by style, as, for instance, in the garment and boot and shoe industries, which are developt in this country to a much greater extent than in Europe. Unemployment is peculiarly our problem. If all the countries of Europe have been interested in this problem, America should be certainly. During the great crises which have swept over the countries of Europe within the last two decades the trade-union un- employment percentages have rarely risen above 10 per cent., whereas in the United States the general percentage of unemployment has risen above 20 and even 30 per cent.^ According to the census of 1900, the number of persons un- employed at some time during that year was 6,468,364, of whom 3>i77>735 lost from one to three months, and 2,554,923 from 4 to 6 months. 2 According to the census of 19 10 there were in round numbers, 6,000,000 persons who were unemployed at some time during the year, but concerning these figures, the Commissioner of the Btu-eau of Labor Statistics says : In regard to the amount of unemployment we know almost nothing. Those figures by the census are estimated, at best. They are taken in the month of April, and in that month the various people interviewed by the various agents of the Census Bureau are required to estimate if they were out of employment during the past year, and if so, how long. Now, I submit that that is extremely precarious data upon which to build any very elaborate superstructure, for those estimates are extremely inaccurate for they in- clude guesses at all unemployment from all causes — voluntary idleness for the purpose of taking a vacation, idleness due to sickness or other disability, 1 Testimony of Miss Juliet Stuart Poyntz, pp. 60 and 61, Report of Hearings before Committee of Labor, House of Representatives, 64th Congress, 1st Session, on H. J. Res. 159. * Testimony, Dr. B. A. Sekely, p. 15, Rep. of Hearings before Committee of Labor, House of Representatives, 64th Congress, 1st Session, on H. R. 5783. 98 idleness due to strikes or lockouts — in short, the census figures include every- thing that was in your mind, I think, when you put your question, Mr. Congressman. Nobody knows whether 6,000,000 people were out of employment part of the year 19 10, or whether 10,000,000 people were out of employment part of the year, and nobody knows anything about the industries and occupations affected, and nobody knows anything about the periods of idle- less of these men and the causes of idleness.^ More valuable information can be obtained from more limited investigations of unemployment. In the early part of 19 15, the United States Bureau of Labor Statistics made a complete census of 104 representativ city blocks located in various sec- tions of New York City, the less populated as well as the more congested section, and in addition of families living in 3703 indi- vidual tenement houses and residences also widely distributed. This showed that 16.2 per cent, of the wage earners in these fami- lies were unemployed, and on this basis it was estimated that the total number of unemployed in New York at that time was approximately 398,000. In January, 19 15, the Metropolitan Life Insurance Company made a census of all the families which held industrial policies in that Company in greater New York thru the agents who make the weekly collections. This showed that 18 per cent, of the wage earners in the families canvast (37,062) were unemployed. The same company also made a similar canvas of its policy holders in northeastern New Jersey adjacent to New York City, including Bayonne, Bloomfield, Newark, Hoboken, Irvington, Jersey City, Orange and Union Hill. In these cities it was found that 14.8 per cent, of the wage earners were unemployed. It is, of cotirse, certain that the con- ditions at present are quite different from those existing at that time. About aU that statistics establish is that at certain times there are, in the United States, immense numbers of unemployed workers, sometimes running up into millions. This much is absolutely certain and should be sufficient to convince us that unemployment causes immense undeserved suffering and also to impel us to earnestly seek remedies. The best way to deal 1 Testimony, Mr. Royal Meeker, p. 29, Report of Hearings before Committee of Labor, House of Representatives, 64th Congress, 1st Session, on H. R. 5783. 99 with unemployment like disease is by prevention. It is a hun- dred times better to prevent workers being thrown out of work when possible, or to at once furnish them another position, than merely attempt to relieve their destitution resulting from unem- ployment. Since, as we have seen, the fundamental causes of unemploy- ment are defects in our industrial and economic organization and the irregularities of labor demand resulting therefrom, the primary thing is to reorganize our industrial and economic sys- tems so that these irregularities will not occur. This is the great question of the present age, but unfortunately no agreement has been reacht about what should be done, or how it should be be- gun, altho numerous political parties have written platform planks about it and innumerable politicians, reformers, states- men, filanthropists, religious teachers and filosofers, have given it their earnest attention. I will, of course, not at- tempt to solve this prohlema problematorum (problem of prob- lem) for you this afternoon, but will leave it for those earnest souls bravely struggling with it. I wdll only venture to suggest that much has been done to regularize labor demand, by the volun- tary efforts of employers to so carry on their factories or other industrial enterprises, that their working people will be furnisht employment thruout the year. In those industries where the irregularities arise from the seasonal causes, as in agriculture, construction work, building trades, etc., something can be done by arranging industries so that when one stops another will take its place, and furnish employment to the workers. In the build- ing industries, for instance, it ought to be feasible to employ the workers during the winter season in sawing lumber, making structural iron work, brick under cover and other building ma- terial to be used by the same workmen in erecting buildings the coming summer. The problem of the agricultural laborer is of course more difficult, but if American agriculture was carried on as it should be, so that the products of the soil were manufac- tured on each farm into eggs, meat, canned goods, dairy and other finisht food products, work could be found for most of the work- ers thruout the whole of the year, and at the same time the re- lOO turns to the farmer would be increast, and impoverishment of the land by shipping away the grain and forage raised thereon prevented. These are merely random suggestions. It would re- quire many years of careful study and experimentation to work out a complete system but I beUeve it can be done and, in con- nection with agricultural co-operation, would do more for our farmers, and incidentally for all classes, than any other one thing conceivable. One of the indispensable prerequisites to such industrial regu- larization is the improvement and cheapening of all branches of our transportation system. This will aid both in the trans- portation of workers from place to place, and by the continuous, rapid and cheap transportation of the products of farming and other industries in small parcels direct to consumers, instead of irregularly by carloads and by trainloads, as at the present time, to one middleman after another. Another, and probably the most important, means of prevent- ing unemployment is the organization of a complete network of efficient free labor agencies covering the whole United States with complete records of all calls for workers everywhere, so that the willing worker can readily find the places where his services are in demand. There should also be some provision, by which a laborer traveling to find work could do so at very cheap rail- road fares, and find very low-priced and wholesome board and lodging while doing so. Such a system of labor exchanges has been developt in Germany where it has been of immense service. In the management of the German bureaus are included repre- sentatives of all classes concerned, and combined with them are frequently shelter, lunch rooms, waiting rooms, reading rooms, etc. There is spent in the United States, at the present time, in support of various labor agencies, exchanges, etc., public and private, an amount of money sufficient to support a nation-wide and efficient system, if it was properly organized under one man- agement with full correlation by immediate telefonic or tele- grafic exchange of information between all parts of the United States. I believe that this can only be efifectivly done by the lOI national government. The labor demand, like commercial de- mand, is no respector of state boundaries. In order to find work, laborers must pass freely from state to state and this they can only do when they have the information covering all of the states available at any labor exchange where they may happen to be, and while of course it is theoretically possible to exchange informa- tion between state employment agencies, practically, such a sys- tem could not accomplish the purpose with any approach to the efiiciency of a national system. Another method of lessening unemployment is the carrying on of such work as building canals, highways, harbor improve- ment, irrigation and drainage works, reforestation and many other kinds of public work dining slack times. This, of course, would involv planning ahead and thoro organization of all of these governmental activities, but if sufficient political and social foresight were used, great relief would be afforded in panics when millions of workers are suddenly thrown out of employment. Interesting suggestions concerning relief by public works, etc., are given by the recommendations made by the Unemploy- ment Advisory Board of New South Wales, calling for the crea- tion of: 1. A national intelligence department for men and women. 2. Labor depots, where the unemployed can be temporarily sheltered and employed. 3. Industrial farm settlements — an expansion of the labor depot, where the men are given work and technical instruction. 4. Assisted settlement blocks, where the men who graduate from the in- dustrial farm settlements are given farms of their own. 5. Compulsory labor farms for the vagrants. 6. Subsidies to mineral prospectors, advances to settlers, allotment of land to societies formed to settle cooperativly, treasury advances for the establishment of cooperativ industries in the assisted settlement blocks, and instructions in agriculture in the primary schools. Another method of dealing with unemployment is so-called "relief work." This is something done solely for the purpose of furnishing support to the unemployed. It has not been very successful and is usually considered as a disguised form of charity. I02 But in some of the industrial crises such as that of 1907, some- thing of the kind appeared to be necessary. ^ For deahng with such unemployment as remains after a faith- ful application of such preventiv measures as I have just de- scribed, instead of charity the most effectiv way is by insurance methods. I suppose there is not a person here who does not have some understanding of the theory of insurance so I will only need to say that insurance in general is a legitimate and well tested business method which by collecting contributions from each one of a large number of individuals liable to suffer loss from uncertain occurrences creates a fund, out of which the losses to such of those individuals to whom the contingency occurs will be paid, and in this way distributes thruout the whole num- ber insured the burden to the few unfortunates actually suffer- ing loss. The late Chief Justice Ricks, of the Supreme Court of Illinois, in the course of a decision involving the question of the interest of the public in it, gave the following eloquent characterization of the business of insurance which I cannot improve on: The business of insurance is the outgrowth of time and the demands and necessities of the public. It extends into and covers almost every branch of business and all the relations of life, and is applied to all the hazards of busi- ness in life where a basis of risk and compensation can be estimated. In all the stages of life, from the cradle to the grave, it asserts an interest and offers succor and aid. In the business enterprises, whether by land or sea; in the possessions of men, from a pane of glass to the mansion or the factory; in his undertakings involving every chance, misfortune, moral turpitude or the act of God, it demands admission and promises indemnity, reward or gain. It poses as the faithful and zealous trustee of his earnings and savings, and promises to the widow and orphan a guaranty against misery and want. It intercedes between principal and ag^nt, master and servant, contractor and owner, and insures against loss from almost any and every' cause. It is a public necessity that deals in its own credit for a cash consideration from the assured, and is stamped with public interest, and must yield obedience to necessary and proper regulations by the State in the exercise of its police power.2 ^ A very instructiv account of the practical and effectiv methods in use in Switzerland for dealing with the unemployment problem is contained in an article by Edith Sellers in Nineteenth Century 64: 763 reprinted in volume on Unemployment in "Debaters Hand- book Series." » North American Ins. Co. vs. Yates, 214 III. 272 (275). I03 Altho, there are, of course, difficulties, there is no inherent impossibility in making provision against the effects of unem- ployment by insurance methods. This is proven by the fact that a nation-wide unemployment insurance system is now in successful operation in England, with local unemployment in- surance systems in various other European countries, while even in the United States this function is to some extent fulfilled by some of the labor unions. Unemployment insurance may be carried on in two ways: the voluntary and the compulsory. The voluntary form is carried on by associations or organizations of workers in a par- ticular industry or trade, and usually is a part of the activities of an ordinary trade union which collects benefit funds to be paid to its members when out of employment. In some places in Europe these voluntary associations are subsidized or given aid by the state, the city or other political division. This subsidy is usually in the form of a certain percentage thereof added to the contribution made by the organization. This is usually known as the Ghent system because it was first used in the Belgian city of that name. The contribution by Ghent was 60 per cent, of the amount contributed by the Union. The city also main- tains a municipal labor exchange in the management of which the unions and the employers have equal representation. Any workman desiring to obtain the unemployment benefit must report at the Labor Exchange that he is unemployed and it en- deavors to find work for him. Not until the bureau has failed to obtain work for him can the workman obtain money from the unemployment insurance fund. This plan or some modifica- tion has been adopted in many of the cities of Belgium, twenty- five cities in Holland, twenty in France, ten in Germany, three in Italy and two in Switzerland. In favor of the Ghent or similar system, are the ease with which it can be administered thru existing agencies of labor unions, and the fact that all claims go thru the hands of union officers who are familiar with all the features of the labor market, in the trade in which the applicant works, which diminishes opportunities of fraud, and that it results in encouragement of I04 individual thrift and initiativ, because it only helps those who are willing to help themselves. On the other hand, it is urged by some that it is wholly improper for the government to subsidize labor unions as in the Ghent plan, because, according to their own statement, they are fighting organizations, so that subsidies out of public fund would amount to taxing employers to pay the expense of men who are opposing them, which would be absolutely unjust. Also that the cost of a system of unemployment insurance is very heavy, and if carried on in such a manner, as not to amount to subsidizing idlers and shirkers, would require practices and inquisitorial methods which would create immense dissatisfaction, and probably be im- possible under our form of government where the recipients are voters and have political power, which would be ceaselessly ex- erted in their own favor. Extreme individualists take exception to the compulsory features which are necessary to make a success of any branch of welfare insurance, but above all, are necessary in unemploy- ment insurance. It is absolutely useless to expect that any form of unemployment insurance will be taken advantage of or bene- fit a large part of the classes most needing it, unless it is made compulsory in character. Dr. S. S. Huebner, Professor of Insurance and Commerce in the University of Pennsylvania, and one of the leading authori- ties on insiu-ance in the United States at the present time, in a recent address states that insurance protection for wage earners cannot be left to voluntary action either by commercial companies or by the government. The present voluntary state life insurance plans of Massa- chusetts and Wisconsin, altho sound in principle and safe finan- cially and carried on at cost, have made practically no headway. The reasons for compulsory welfare insurance are the same as those for compulsory education, compulsory sanitary measures, compulsory food inspection and compulsory fire precautions, and are no more an unwarranted interference with the liberty of a citizen than are these and other compulsions to which every I05 good citizen willingly submits because they are for the benefit of the whole community, including himself. As the density of population and complexity of civilization increases, certain limitations of liberty of action become abso- lutely necessary under even the freest and most democratic form of government that can. be devised. Under even the most attractiv and secure plan of voluntary unemployment insurance, and also of other branches of welfare insurance, that could be devised, there would be a large proportion of thoughtless spend- thrifts who would fail to take advantage of it to make provision for themselves, or their families. There should be no reluctance for the state to apply compulsion to those so wanting in foresight and sense of parental responsibility as not to make provision for themselves and families, and such a course would not, I believe, offend the strong individualistic characteristics of the people of the United States when once the true purpose and immense advantages of welfare insurance are understood by them. Against these and possibly other disadvantages of unemploy- ment insurance there are many benefits which, I believe, under a properly planned and safeguarded system, far outweigh the dis- advantages. The first and greatest of these is, that it prevents undeserved suffering and destitution. There is nothing which should more strongly engage our sympathies than the spectacle of a man v/ho is able and honestly willing to work, to get the means to support himself and his family, but who is not able to find such work. There is no situation which causes more undeserved, helpless suffering. A system of unemployment insurance, even tho accompanied by difficulties which can prevent or even measur- ably mitigate this misery, is worthy of careful trial. Another benefit is that unemployment insurance by furnish- ing support, when none is otherwise available, will preserv the physical health and the moral character of the worker. Good physical health and efficiency can only be maintained by a regu- lar and adequate supply of food, clothing and proper shelter. Men and their families must have something to eat every day; they must have clothes to wear; they must have shelter and warmth, and if unable to gain these thru their own exertion, io6 some will be driven to crime; others will become the unwilling recipients of charity. Charity in the proper cases, and occa- sionally, is perhaps a blessing both to the giver and to the re- ceiver, but if long continued, as it would have to be to support all the unemployed under modern industrial conditions, would become an insupportable burden to givers, and as I have already maintained, a source of degradation and pauperization to the recipient. Human nature being what it is, it is unfortunately true that there is a certain proportion of men and women, who, when they find that charitable relief will be always forthcoming and become accustomed to receive the same, entirely lose the motiv to work and practically cease to work, depending on pub- lic or private charity. This discreditable side of human nature long ago attracted the attention of wise men. The author of the book of Bcclesiastes wrote : ,A11 the labor of a man is for his mouth. ^ And in Proverbs it is said: He that laboreth, laboreth for himself; for his mouth craveth it of him.^ The hunger motiv is the only one that will drive a great many men to work, and if this is eliminated by undiscriminating charity, such men will cease to work at all, and become able-bodied un- employables. Fortunately, as civilization and education advance, a constantly increasing proportion of mankind become amenable to other and higher motivs than hunger, but there is still, and will be for a long time, those who will, whenever possible, gain a living by begging or stealing, instead of working, even when abundant work is offered. For this class our scorn and contempt can hardly be too great, and all social plans should take into ac- count this class and include measures which will compel them to work to support their useless existence instead of allowing them to longer beg or steal, much less furnish them with a pension thru unemployment or other welfare insurance paid for by forced contributions from the labor of willing workers. The effect of unemployment insurance money received by the 1 Ecclesiastes, 6:7. * Proverbs, 16:26. I07 worker is entirely different from charitable relief. Because he has contributed directly or indirectly to create the fund from which he is paid, there is no loss of self-respect. Another benefit of unemployment insurance is that it will mitigate industrial crises by maintaining the consuming power of the worker. May I be permitted to say in passing, that I believe that the Federal reserv currency plan now in force has already proven and will prove in the future to be an exceedingly important factor in preventing or at least diminishing commer- cial crises, commonly called "hard times." Owing to their im- mensely greater numbers, the working classes consume by far the greater part of the products of all the industries, and when this consuming capacity is diminisht by the unemployment of any considerable part of the laboring classes, by an industrial crisis, such crisis is thereby aggravated. If only purchasing power for the necessaries of life, such as food and fuel, were maintained, it would go a long way to lessen all industrial crises, altho, of course, we all recognize that there are many other contributory factors which must be eliminated before their recurrence can be completely prevented. Unemployment insurance would also operate as a direct pre- ventiv of unemployment, because it would be a direct financial inducement to the employer to furnish regular work. In the English unemployment insurance system there is provision made for a markt reduction of the amount of contribution required from the employer if he furnishes regular employment to his work- men thruout the year and this reward should be a part of every unemployment insurance system. The preventiv effect of un- employment insurance will be comparable to that in favor of accident prevention, caused by workmen's compensation insur- ance. When we come to consider whether we should choose the volun- tary form, or the compulsory form, of unemployment insurance in the United States, we find that practically nothing has been done in unemployment insurance by voluntary methods, ex- cepting thru the labor unions. This is a very important and beneficial branch of their work, but it, of course, is impossible io8 for them to aid those outside their membership and this member- ship is only a small per cent, of all workers. So far as I know there is no hope in any quarter that, outside of labor unions, unemployment insurance would or could be made successful on the voluntary plan. The only alternativ is compulsory un- employment insurance. If this is adopted, it must be carried on by the state or United States, for two reasons. First, in order to avoid the excessiv and unreasonable expense of all insurance by commercial methods, and in the second place, because the only hope of making unemployment insurance a success is, as hereto- fore explained, by having it carried on as the integral part of a nation-wide system of labor exchanges or agencies.^ As the result of investigation into the subject of fire insurance which I began in 19 14, I have arrived at the conclusion as stated in my report on that subject, that on account of the excessiv expense incident to the present method of conducting the fire instuance business, and particularly owing to the existence of a nation-wide fire insurance combine, or trust, of the most op- pressiv kind, which controls practically all of the fire insurance business of the United States and enforces exorbitant rates every- where, the fire insurance business should be conducted by the different states or by the United States. The fire insurance combine is able to do this, because under modern commercial and industrial conditions where business is largely done on credit, fire insurance is compulsory; practically as much so as if re- quired by statute. This fact enables the trust to enforce its ex- actions. The same thing would happen if unemployment in- surance was made compulsory but conducted by commercial 1 As Chairman of the Social Insurance Committee of the National Convention of Insurance Commissioners I have been carrying on an investigation into the entire sub- ject of welfare and social insurance and I have in preparation an extensiv report on the subject. This has not yet been publisht but extensiv extracts from it have been printed as an appendix to my testimony given on April 6, 1916, before the Committee on Labor of the House of Representatives in relation to the joint resolution to create a commission to study social insurance and unemployment. (Hearing before the Committee on Labor, House of Representatives, Sixty-fourth Congress, First Session on H. J. Res. 159, April 6 and 11, 1916.) Until the printed supply of the report of the hearing is exhausted, copies of it can be obtained by those desiring a full and detailed discussion of the subject by applying to your Congressman. 109 interests, and the same reasons require that unemployment in- surance should be carried on by the state or United States as a part of the general system of welfare insurance. I believe there would be little hope of successful unemployment insurance un- less it was carried on by the United States. Of course, there will be strenuous objections from the financial and insurance inter- ests to this being done as well as to any other form of state in- surance, but these objections are entirely selfish in their origin and entitled to little consideration from those who have the wel- fare of the nation and its workers really at heart. The argument is the same as that used 1900 years ago by the idol makers against the great Apostle Paul in the riot which they stirred up when he preacht against idolatry in Ephesus. "Sirs," cried their leader, Demetrius, the silversmith, as the climax of his harangue, "ye know by this craft we have our wealth."! The danger to their source of easy wealth is at the bottom of all the outcry of the insurance interests against any form of state insiu-ance. A typical example of these miserably selfish appeals appears in a recent issue of one of the most widely circulated insurance periodicals in the form of an editorial on social insurance designed to arouse all insurance interests against it, in the course of which the writer says: Doubtless some agents may find employment as state inspectors and sleuths, but Othello's occupation will be gone for the great majority. For these reasons every insurance man in every branch is vitally concerned to oppose the "social" propaganda at every step. For his own safety he should consider himself in the advanced trenches whenever state insurance is proposed in any branch. The strongest lever exerted for any of the "social" branches is that it will "eliminate expense," Expense can only be eliminated in one way. That is by taking the work required to be done away from those now engaged in doing it, and throwing it compulsorily on every citizen.' In any plan of unemployment insiurance, particular attention should be given to prevention of fraud and imposition, and also to prevent the steady workers from being taxt to support the 1 Acts, 19:25. « Insurance Field (Life Edition), May 12, 1916, p. 3. no idle and thriftless. This can be effectually accomplisht by proper provisions and careful administration. I am certain that by careful study aided by experience, a plan of unemployment insurance can be workt out which will be just and beneficial to both employers and employes and of im- mense advantage to the community in general. This, together with other branches of welfare insurance, I believe, is the most important group of questions before the people of the United States to-day. It contains more promise of increasing their welfare and diminishing their misery than any other movement I know of. I am indeed pleased to learn from the interest which has been manifested in your discussions here to-day on these subjects, that your Academy is taking the lead in the movement for social justice by earnestly taking up the subject of welfare insurance, which I regard as the most important means of aiding in this great work. I am greatly honored in having been invited to address you concerning it and hope what I have been able to say, in the short time allotted to me, may cause you all to study and investigate it still farther. Your great profession has already done untold good to humanity by mitigating suffering and pre- venting disease, and it has the opportunity of further serving mankind by assisting in making welfare insurance a beneficent reality. THE RELATION OF MEDICAL BENEFITS OF HEALTH INSURANCE TO EXISTING HEALTH AGENCIES. By B. S. Warren, M.D., Washington, D. C, Surgeon, U. S. Public Health Service. Without an adequate medical service — clinical and pre- ventiv — health insurance will fail of its best results. By pro- viding a substantial part of the wages and medical treatment during sickness it will no doubt, as a relief measure, prove satis- factory to the welfare workers, the employers, and the employes, but without adequate provision for the prevention of disease it will not prove to be a public health measure. Each of the groups of people mentioned see, at close range, the damage done by disease and that the damage is greatest among the group of low paid workers who are least able to bear the burden. The welfare workers' field lies mainly among the group of low paid wage earners and, in their feeling of helplessness among so much suffering, the idea of health insurance has come like a ray of hope for the solution of problems that appeared well- nigh hopeless. The employer has found from experience of idle machines or from machines running at lessened output by inexperienced operators, that sickness is expensiv and whether he has sought to remedy this as a matter of economy or filanthropy he will find in health insurance a business-like method of meeting this situation. The employes may not be afraid of death, they may not be much concerned about accidents, ''but they dread the thought of illness," and will find that "the only way this matter can be handled properly so that the most necessitous will be provided for is thru universal compulsory state health insurance." ^ That group, who are interested in bringing about industrial peace, will doubtless find in health insurance, a common ground on which employer and employe can meet in agreement and thru 1 Royal Meeker, Commissioner of Labor Statistics, U. S. Department of Labor, Ad- dress before International Association of Industrial Accidents Boards and Commissions, Columbus, Ohio. The Survey, May 20, 1916, p. 205. 112 these agreements they have reason to beheve that peace in other fields will be promoted. In this way health insm-ance will have wonderful results as a relief measure, and will no doubt measure up to the expectations of those who advocate it on this account. But as stated above, it will fail of its best results if an adequate medical service — clin- ical and preventiv — is not provided. On the other hand, with proper provision for such a service, health insurance will be a public health measure farther reaching than any that has ever yet been enacted into law. It is on this account that it attracts the attention of health authorities. At present the fight for better health is one which is carried on at a great disadvantage. Health departments, national, state, and local, and volunteer health organizations are all suffering from the lack of men and money. Men trained in disease-prevention are too few, but if health agencies had regular and sufficient appropriations the men would soon be at hand. In this connection it is of importance to present some estimate, of the sum of money that the contributions to a complete health insurance system would amount to each year. There were ap- proximately 30,000,000 wage earners in the United States ac- cording to the census of 19 10. It has been tentatively stated that the contributions to the insurance funds would not have to exceed 50 cents per week per employe. According to these estimates the total sum contributed annually would be more than three-quarters of a billion dollars. It therefore becomes a problem as to the best method to cut down sickness and save a large proportion of this enormous sum. All health agencies realize that much sickness can and should be prevented. It will be to these preventiv agencies that the people contribut- ing these millions will sooner or later turn for relief. Experience with workmen's compensation laws has clearly demonstrated that the "safety first" movement is one of the best results of these laws. Just as the laws which fixt the price and responsibility for industrial accidents resulted in "safety first," just so surely will health insurance laws, which make similar pro- visions with respect to sickness, result in a movement for disease- 113 prevention. Furthermore, the demand for disease-prevention will probably be as much greater than the "safety first" move- ment as the loss from sickness is greater than that from accident. Why then provide a health insurance system without adequate machinery for disease-prevention? If one of the principle argu- ments for the measure is its effects in promoting health, surely then every effort should be made to bring into its operation the aid of the health agencies of the country. Up to the present time there is no experience in this or foreign countries which has been satisfactory as to the provision for proper co-ordination of the administration of the medical bene- fits with other health agencies. In Germany there was so much friction between health insurance administrativ bodies and the doctors that a "doctors* strike" resulted; this strike was only temporarily settled by a compromise known as the "Berlin Agreement." This agreement was made early in 19 14; the war began soon afterward and interrupted further action. In Great Britain the health insurance act provides for governmental administration of medical benefits and the free choice by insured persons of doctors registered on "the panels." This provision and the acceptance of disabiUty certificates signed by physicians of the insured persons, choice has, however, resulted in an improper drain upon the funds and it is freely admitted that doctors have been entirely too complaisant in signing certificates of disability. In the bills introduced into the several state legislatures in this country the German plan of administration of medical bene- fits has been followed and no provision has been made for corre- lating the system with health agencies. The public and those framing health insurance laws should realize the necessity of making proper provision for the adminis- tration of the medical benefits so that the best results may be ob- tained for the prevention as well as for the relief of diseases. They should profit by the mistakes made in the German and English acts. One reason for the mistakes made, is the lack of under- standing on the part of those framing the laws. They treat the whole matter as the doctor's problem, taking it for granted that all doctors of medicine are doctors of public health and have 114 made no provision for utilizing health agencies except possibly in the matter of the prevention of tuberculosis. To write into the law adequate provisions for the relief and prevention of sickness, the law makers should advise with doc- tors of public health and doctors of medicine as well as employers, employes, and welfare-workers. Surely some plan can be workt out by which adequate medical and surgical relief in home or hospital can be provided, one by which the doctors will receive every inducement to render his best services in the relief and pre- vention of sickness, and by which all health agencies can be brought into the system and use made of their specialists in disease-pre- vention. The following outline of a plan for bringing about proper co- ordination between health insurance systems and other health agencies was adopted by the Fourteenth Annual Conference of State and Territorial Health Officers with the United States Public Health Service, May 13-15, 1916: There must be a close connection of the administration of any health in- surance system with the health agencies of the country and with the medical profession. It is believed that this can be done along three lines: (i) By providing efficient staffs of medical officers in the federal and state health departments, to carry into effect the regulations issued by the central govern- ing boards or commissions; (2) by providing a fair and sufficient incentiv for the activ co-operation of the medical profession; and (3) by providing for a close co-operation of the health insurance system with state, municipal, and local health departments and boards. Corps of Full-time Medical Officers. — In view of the experience in both Europe and America, it would seem best to place the administration of the medical benefits directly under governmental agencies and to insert a pro- vision that no cash benefits be paid except on the certificate of medical officers of the national and state health departments acting as medical referes under the regulations of the central governing board or commission. Such medical officers should be selected according to civil service methods. Since these officers are the representatives of the health departments in the funds, their selection and appointment should also be based upon their knowledge of preventiv as well as of clinical medicine. After a probationary period of service satisfactory to the health administration they should be given per- manent appointment, subject to removal only for inefficiency or immoral conduct. One of their duties should be to examine each disabled beneficiary and keep themselves informed as to the progress of his recovery. It is need- "5 less to say that the referes should not be permitted to engage in private practice. Free Choice of Registered Physicians. — With such a check on the payment of cash benefits, the medical and siu-gical treatment provided for beneficiaries could safely be left to the physician of the patient's choice, and payment made on a capitation basis regardless of whether the patient was sick or well, after the manner of the English national insurance act. This method of selection and payment of physicians for the medical and surgical relief would offer every incentiv to them to keep their patients well and to endeavor to please by rendering their most efficient service. Hospitals and Dispensaries. — In addition to the provision for home treat- ment by the physician of the patient's choice, provision should be made for hospital and dispensary treatment and to this end hospital and dispensary imits should be establisht or contracted with, where the very best medical and surgical service would be available for all insured persons. Value of Such Plan in Disease-Prevention. — The greatest value of such a system of administration of the medical benefits would be in the splendid opportunity it would offer for preventing disease among the insured persons and their families, by the organized corps of medical officers, and the im- proved medical and surgical treatment. It would be thru the corps of full time medical officers of the health department acting as referes, that the health insurance system would be linkt up with other health agencies. It is not necessary to relate here the advantages which would arise from the! visits of such specially trained men into the homes of all sick persons. Nor is it necessary to tell how these officers, acting as health officers, could further lower the sick rate. The objection could not be raised that such a corps would be too expensiv. It would not require more than one such medical officer to approximately every 4,000 insured persons and at that rate they could more than save their salaries by relieving insurance funds from paying unjust claims. Furthermore, while an estimate cannot be made of the amount to be saved by their efforts in the way of lowering the sick rate, it is safe to say that it would amount to many times more than the sum of their salaries.^ With such a system funds would be provided and every existing health agency and newly created agencies could be utilized and fitted into its proper place and all work together without duplica- tion of effort. Above all there would be a financial incentiv given to each interested group to prevent sickness. The employer, who found that he was contributing more per 1 This description of plan for administration of medical benefits is taken from the re- port of the Standing Committee of the Conference of State and Territorial Health Oflficers with the United States Public Health Service. ii6 employe per year than his competitor, would doubtless inquire into the cause of the difference. The employe, who learned that his neighbor working in the same kind of trade was paying less dues than himself, would also be very likely to inquire into the cause of the difference. The doctor, who found his patients were sick so much that he was not able to attend as many insured persons as his brother doctor, would have a financial incentiv to look into the cause of the difference and remove it. The city or town, which found that a neighboring city or town was providing adequate hospital and dispensary treatment for its insured persons and not only obtaining more efficient diag- nosis and treatment but obtaining it at a less cost, would doubt- less establish similar institutions. The state, which found from the returns that its tax rate for sickness was in excess of a neighboring state, would have reasons for making this an issue in the next election. The United States Public Health Service, when the reports, for example, showed a markt difference in the sick rate of an iron and steel town in Pennsylvania as compared with such a town in Alabama, would be very likely to order the responsible officers to Washington to explain the differences. The final result would be that health would be placed on a competitiv basis in the political and business worlds. This too, after providing for the co-operation of all the agencies for the promotion of health so that all would work in harmony, and form one complete health machine. Above all there would be a financial incentiv to all interested groups to prevent disease. To do this they would be willing to spend money realizing that it would be a good investment. At present it may be generally recognized that to spend money to prevent disease is a good investment, but there is no administra- tion whereby the ones who make the investment can be sure of obtaining the profits when earned. Health insurance will pro- vide this and what is more to the point, it will provide the money, there will be over three-quarters of a billion dollars each year for the relief and prevention of sickness. This will eliminate 117 the question of obtaining appropriations, which now takes up much of the time of all health organizations. At present contri- butions and appropriations for health work are so uncertain and irregular that definit plans for the work cannot be made and carried out with anything like the degree of efficiency and success as obtains in other lines of business. With sufficient funds and the machinery at hand thru which the health agencies can work effectively and continuously with the insurance agencies, there will develop a system of research into the cause of sickness as has never been seen before. The records of disease will be so complete that not only the immediate diagnosis will be known but also the working and living conditions which may be operating as remote causes of sickness. All will be brought under the microscopic observation of the trained men from the health department — not for a single day but for each day in the year. It is in this particular relation that a health insurance system if not properly correlated with health agencies will fail of its greatest benefits, whereas if properly correlated it will prove to be a public health measure of extraordinary value in improv- ing the health and efficiency of the 30,000,000 wage earners in the United States. DISCUSSION. Dr. Robert B. Harkness, Houghton, Michigan (read by Dr. Grayson) : To cover the subject of workmen's compensation, a recital of the argu- ments for and against should properly be presented ; it would seem unnec- essary at this date to be obliged to present the case at length ; fathered some 35 years ago by powerful statesmen largely interested for political reasons, a realization of its tremendous value was gradually forced upon people gen- erally, and in the following years it has become a part of the laws of some forty nations, or parts of nations, including about two-thirds of the states of the United States. Its history would seem to establish its value. During this time social insurance against sickness which became an activ issue about the same time as workmen's insurance, has made slower progress and has not always been a complete success. Its value cannot be doubted; statistics presented by capable and unprejudiced persons are conclusive and the arguments advanced in its favor apparently unanswerable. Statis- ii8 tics and argument should not be necessary to convince the man who comes in contact with sickness among working people that some form of relief is necessary and if a given form of sickness insurance does not seem to be per- fectly suited to our conditions, nevertheless those at present suggested have a minimum of flaws and should be supported. There can be no doubt that people want some form of insurance against sickness — the rush to join lodges that promise medical attendance in almost any form is evidence of this ; this type of insurance is not available to the per- son most in need of it — that is, the man whose wages are barely equal to his necessary expenditures and who prefers to trust to luck rather than submit himself and family to the necessary hardship which the payment of monthly dues to such a society would necessitate. ^'The matter of medical attention as furnished by lodges has received con- sideration by the medical societies; many of them are on record as opposed to it and with some reason. One must realize, however, that this is a phase of social insurance, represents the trend of the times, and should be controlled rather than violently opposed; this type of practise properly conducted has much to recommend it in spite of its limitations. Social insurance against accident and sickness has as an important aim the decrease of sickness and accidents by impressing upon the employer the saving to him brought about by this decrease; by the method of carrying out the workmen's compensation in this country this aim is largely defeated; the employer insures himself with a liability company, pays his premiums, and thereafter is not compelled to give much heed to accidents if he does not care to do so. It is becoming customary to have a thorough physical examination of men applying for work with careful concerns; men not physically perfect even though fit for the job applied for are usually rejected. Until recently a one- eyed man had extreme difficulty in getting work because there had been no authoritativ answer in this State to the question of the liability in his case if he should lose the remaining eye ; that is, should compensation be upon the basis of the loss of a single eye or on total loss of sight? The definition of "disability" in drafts of health insurance acts before various legislatures is given as "inability to pursue the usual gainful occupa- tion;" under this definition the man who has received an injury and is so far recovered as to work at something else but not at his original job may remain technically disabled. A case of this sort under the compensation law has come to my knowledge recently; a man who had a broken leg has so far re- covered as to be free from pain and while incapable of working at his old job which requires standing all day, is capable of working at an equally gainful job; he prefers to do nothing, or work about his house, and draw compensa- *' tion. The definition of "disability" might well be "inability to pursue the usual or equally gainful occupation." The important question of malingering should receive a great deal of con- 119 sideration; there can be no doubt that the amounts paid under workmen's compensation acts would be startlingly less if this unpleasant factor could be eliminated. Any safeguard which may be erected against malingering is protecting a cident and sickness insurance against what is probably the greatest menace to its successful operation. Dr. John L. Heffron, Syracuse: I am not competent to discuss the papers. I wish, however, to express my gratitude to those who have taken part in the program for coming here and presenting papers which, it seems to me, combined, would make about the best text-book on welfare insurance that it would be possible to secm-e. I think we have been strongly imprest with the fact that insurance is a science and that to be intelligent on the subject of insurance against these various forms of disability we must put ourselves into a studious frame of mind and inform ourselves in regard to the principle of insurance and the various methods of administration of insiurance which have been carried out effec- tively here and in foreign nations. The number of problems represented by these papers is very, very great. The question of administration of insurance is one of the very greatest im- portance. The splendid paper of Dr. Warren, in which a way out has been suggested, is of very great value. It is in contrast with statements which I have lately heard in regard to the administration of insurance against sick- ness and which were to the effect that, if such insurance should be adopted in the various states, the administration of the insurance ought to be turned over to experts in insurance. I suppose it is correct, that expert administra- tion is essential to success, but that need not mean that social insurance should be turned over to insiurance companies. One of the difficulties in the State of New York has been the division of the burden of the insurance between the employer, the employe and the state. I suppose Dr. Andrews knows of experiments being tried in this connection in various large indus- trial concerns, I happened to be in Akron this winter at the Goodrich manufactory where they employ 16,000 people and have 1600 employes in the offices. The head of that business told me that last November they inaugmrated at their own expense a complete system for the care of the health of their employes and that up to the time I was there the benefits which had accrued to the company had not only met the expenses of this care but had exceeded it by a considerable sum. They did not feel, therefore, the neces- sity of putting any of the burden upon the employe or the state. As a result of such a condition of affairs it is the town's comment that a man cannot get a place in the Goodrich concern unless somebody dies. I think in all probability that concern is not the only one carrying out that experiment on their own hook. I am particularly grateful for this discussion and for this splendid series I20 of papers upon this subject, and I wish in this connection to express my gratitude to Surgeon-General Blue for very willingly consenting to have Dr. Warren come here and present this valuable paper. Dr. J. E. Tuckerman, Cleveland: These papers are evidence of a very healthful state of mind. The medical profession, at least, so far as the rank and file are concerned, has been rather backward in realizing that certain types of insurance were inevitable. Some of us in Ohio five years ago endeavored to get our associates to realize that workmen's compensation was coming. We could not get them to see it, and consequently the profession is suffering the penalty of this negligence. That penalty is, of course, that while we have a fairly good law, we find that no matter how admirable a law may be, its administration may be such that the best results are not obtained. It was a mistake to assume that physicians generally were going to be paid their small fees, and a cutting down of bills has caused much hard feeling. So generally is this so in the larger cities that specialists are refusing to cooperate in consultation on certain cases of industrial accident, particularly of the eyes. Altho the law as written does in large measure protect the employer against the suits after- ward, it in no way gives any protection to the physician who may be sub- jected to suit for alleged malpractice. Personally, I have felt that industrial insurance should be a direct charge against the industry. I am not so sure that sickness insurance should also be a charge against the industry; probably a man should pay from his earn- ings a small portion, not necessarily one-half, for the purpose of getting his activ cooperation. I am interested to know whether Dr. Andrews has discovered any ten- dency on the part of the industrial insurance companies to oppose the plan suggested by him, inasmuch as his statement shows that it would take away from them and give to the state a considerable amount of business which the companies now have. These papers would have been incomplete without the paper which we heard last. It is the first time I have heard given any comprehensiv scheme whereby the activ cooperation of the practicing physician could be obtained in forwarding the aim of health measures such as we have in mind. I judge the idea is to have the physician paid according to the number of individuals treated and not according to the case or nature of the particular service. I can see no way to get away from that final solution. The important thing is for physicians to recognize that the problem must be met and to meet it in the spirit of cooperation rather than of opposition. One of the other papers brought up a point which interested me not a little. Mr. Potts mentioned that there were certain underlying elements other than 121 the mere question of health insurance which had to do with the question of unemployment. Certainly there is no greater loss to a community than the loss of a man's labor. Machinery can be restored, but a day's labor gone is absolutely lost to the community. I was much interested to note that Mr. Potts advocated something that was indicated a number of years ago, which shows that the world does move. A certain gentleman from Ohio, heading what was known as "Coxey's Army," marcht to Washington for no other purpose . whatever than to induce the United States Government to take notice of the fact that it would be a good thing in times of industrial depres- sion to employ the unemployed upon public works of permanent charac- ter. I do not care to take up the time of this body upon the question of taxa- tion, but there must be a changed attitude on the part of and a study by physicians, and other professional men of the question of taxation. None of these plans can be put into operation without a proper solution of the prob- lem of taxation. Such funds as the state shall contribute must be so raised as not to penalize the individual or firm engaged in activ production. It is a curious system which makes it possible that a man who builds a building and employs labor should be immediately penalized for having made a pub- lic improvement and having rendered a public service by increasing the op- portunity for employment. Dr. George A. Hare, Fresno, Cal. : I do not think that the American Academy of Medicine or any other or- ganization has ever listened to a more intelligent discussion of the broad aspects of insurance than we have had presented to-day. To me the sub- ject has been an intensely interesting one. Upon the western coast this question is claiming a great deal of attention, and the discussion this after- noon has been exceedingly direct and edifying. Dr. Van Sickle, closing: There are four great bodies in the United States concerned in this social study: (i) The State, in which we might include the United States Govern- ment; (2) Capital; (3) Labor; (4) The medical profession. These various papers touch vitally one of these four organizations. They have brought out things which we as a small body should not keep to ourselves; the literature should be given the widest publicity. I feel that in Dr. Andrews' statement we have something which the profession at large must appreciate, that the health insurance shall not only take in the employer, employe and insurance carrier, but that there shall be in these conferences a representativ of the medical profession, so that these four bodies shall be represented. Dr. Andrews' suggestion of social insurance against sickness would cer- tainly reliev the state and local municipaUties of a large amount of expense from pauperism. If social insurance is to operate upon the scheme of the 122 smallest cost to the greatest number we must have cooperation. Dr. An- drews brought to our minds the fact that there is a continuous demand for cooperation of medical men which can be brought about only by action of all the bodies. We have a lot of men who are like workmen in regard to the labor union, medical men who do not belong to these bodies. These are the men whom we must get together for discussion of the subject. This audience, while small, has an opportunity to do good missionary work in this field. Dr. Andrews, closing: I have noted three or four points which I shall mention without going into the matter at length. It is very significant, I think, that Dr. Van Sickle, coming from Pennsylvania, has made out strongly the point that the adminis- trativ commissions should be given greater discretion in granting additional medical aid. This is especially true in Pennsylvania under workmen's com- pensation. No other state is limited so severely, to $25 and two weeks for medical aid. That allowance, of course, is so utterly inadequate that all friends of workmen's compensation regret seeing Pennsylvania pass such a bill. Medical aid ought, I believe, to be "reasonable." The administra- tiv commission ought to have the power to say that all the medical aid neces- sary — and necessary is reasonable — should be given, and not a two weeks' or $25 maximum. As Dr. Van Sickle has said, the smallness of the medical fee under social insurance is counterbalanced by the fact that payment is certain when the plan is properly workt out. In the third edition of the tentativ health in- surance bill of the Association for Labor Legislation the medical experts who are cooperating with us in drafting the measiure discuss this question of remunerating physicians. These medical experts have not reacht definit conclusions, but offer for discussion foiu* possible methods, including a com- promise, which has workt well elsewhere, between the capitation and the visita- tion systems. Under this plan a total sum, calculated on a per capita basis, is distributed among physicians in accordance with the services rendered by each. This plan seems to combine the advantages of both systems men- tioned, and to counteract some of their obvious disadvantages. As Dr. Alexander Lambert, chairman of the social insurance committee of the Amer- ican Medical Association, points out, the plan presents a known charge on the insurance funds, makes it possible for physicians to check those few of their colleagues who might make unnecessary visits, and may prove a financial stimulus to preventiv medicine, since the fewer visits the entire body of physicians is called upon to make the more they will be paid for each visit. Dr. Warren, who has been doing excellent work in public health matters, approaches the problem of medical control under health insurance from the standpoint, as he frankly states, of a public health officer. There are, how- ever, other groups, outside of the public health officers, who take a different view of the manner in which health insurance should be administered. Many 123 physicians are not yet willing to put the whole matter into the hands of the health officers, and as one speaker has said, to do so might in some places lead to an undesirable association with politics. In the opinion of many prominent medical men, the work of examining claimants, issuing certificates of disability, and supervising medical care generally, is best performed by medical officers employed by the insurance carriers themselves. A very interesting statement was made by another speaker about an es- tablishment fund in a concern in Akron, Ohio. Investigators have records of a large number of such enterprises. We must realize, however, that these funds establisht by the employer here and there all over the country are not going to reach the worst part of the problem. Only the most prosperous employers are likely to feel that they can assume this service. Then, too, there is the disadvantage of the physical examination instituted by the em- ployer, which has become a very vital issue in this country. Under work- men's compensation, for instance, many employers hire a physician to make physical examinations of applicants for work. The employer thus has in his hands information which enables him arbitrarily to hire and to fire. Many times, for example, it may be said that there is something the matter with a workman's heart, whereas it may be that the man in charge is more ac- tivly interested in preventing union organization in the plant than in safe- guarding the physical condition of the applicant. In health insurance, on the contrary, with employer and employe paying equal amounts, the situa- tion no longer exists under which the employer's hired physician has all the say and the employe no say. The employe has an equal voice, and that to my mind is the only answer to the objection to physical examinations. In conclusion, it seems clear from the discussion this afternoon that we are on the way toward greater cooperation among all of the different interests in this matter and are working out a practical plan for compulsory health insurance. I believe that is the thing we should emphasize now. Let us get together, present our ideas, and draft a bill which next year we can all get behind and be proud of. Mr. Potts, closing: I do not feel that I can add to anything that has been said. I am fully in accord with the spirit of the meeting; the cooperation suggested is that which brings success to all undertaking. I appreciate your calling me again, but I feel I can say nothing fiurther. Thank you. Dr. Warren, closing: I fear I did not make myself exactly clear about the Health Department from what Dr. Andrews said. I did not propose to put any great part of the administration of the medical benefits under the health departments. I would provide for federating all of the local funds with a federated direc- torate composed of equal number of employers and employes in certain dis- 124 tricts, such as he has outlined in his plan, and let them as a federated body administer the medical benefits instead of the local fund. In other w6rds, we would have a wholesale medical benefit with less overhead expense than would obtain by permitting each local fund to operate independently. The only way in which I would link up the health department would be by de- tailing to those federated bodies, medical officers of health departments to act as medical referes and relieve the practicing physician of the responsi- bility of signing the disability certificate. A plan somewhat similar to this is followed by the Public Health Service and the Immigration Service in which our medical officer issues the certificate of disability. Such certificate is re- ferred to the administrativ board which passes on the question of admitting or of deporting the immigrant. That plan suggested to my mind the prac- ticability of its being used to solve this problem. The medical officer, there- fore, from the health department would have little to say in the administra- tion of funds, but would advise upon disability and issue the certificate. The insured persons would have the right of appeal to the federated body and to the Commissions. The doctors of the public health department could also act as advisors to the federated body in the matter of disease-pre- vention. I did not mean that the health department should take over the administration. As to the statement of Dr. Andrews that in medical mat- ters "pus and politics" went hand in hand, I will say that with proper efficiency tests prior to appointment and as often thereafter as may be necessary to maintain the medical corps at the highest level of effectivness, I believe we can avoid the defects he points out. I feel certain that this plan of appoint- ment in an important executiv department of the state is calculated to ob- tain better medical referes than the method proposed in the model bill in which it is proposed that the local carriers each employ a doctor, in which local politics is more liable to bring all of the evils he dreads in the health department. His method would also lose all of the advantages of a mobile corps formation. Furthermore, doctors employed by the carriers could not act as referes, because they would be the employes of one of the parties at interest and liable to some bias on that account. THE NEW YORK STATE SANITARY CODE, HOW ENACTED— ITS SCOPE AND LEGAL STATUS. By Hermann M. Biggs, M.D., State Commissioner of Health, Albany, N. Y. The International Congress on Tuberculosis, which was held in Washington in the autumn of 1908, gave a new impetus to the campain for the prevention of tuberculosis. Prior to that time a large amount of important pioneer work had been carried on in the City of New York under the direction of its Department of Health. In 1887 that department issued its first printed circu- lar on the cause and prevention of tuberculosis for distribution among families and in homes where there were persons affected with the disease. In 1894 a resolution was past which required the reporting of cases of tuberculosis from institutions and in 1897 this was extended to require the reporting of all cases. These requirements were made by amendments to the Sanitary Code of the City of New York. With the new knowledge and new enthusiasm given by the International Congress increast activity was stimulated in the tuberculosis problem, not only in New York City, but also thru- out the State of New York. An important factor in the campain then inaugurated was the New York State Charities Aid Associa- tion, which, in co-operation with the New York State Depart- ment of Health, prepared a number of exhibits on tuberculosis and held a large number of public meetings in numerous localities thruout the State. As a result of this campain many local com- mittees were organized and the interest and support of many prominent officials and citizens obtained. This educational activity created an increast interest in all fases of public health work. It was soon realized that in the prevention of tuberculosis many sanitary factors must be con- sidered. Many persons became interested and sought to eradicate other associated causes of the disease by improving the care of the delicate child, by improving the milk supply to prevent in- 126 fection from cattle, by better housing, and by generally improving conditions in the factory and home. During this campain the fact was first fully realized by the officials of the State Health Department and by members of various citizens' committees thruout the State, that the health boards (numbering more than 1200) of every city, village and town had the power to enact their own sanitary regulations, but that such regulations in many places had never been enacted, or if enacted at all only existed in theory on the minutes of the Common Council or the local Board of Health, and were actually never enforced nor utilized. In some of the more progressiv cities comprehensiv sanitary codes had been establisht and were regularly enforct. As a re- sult of this situation in many municipalities the health officer acted as he saw fit, and the sanitary administration really depended upon his personal intelligence and efficiency. An effort was, therefore, made in the early part of 19 13 to se- cure the appointment by the Governor of a Commission for the study and revision of the public health law of the State. Such a commission was appointed by Governor Sulzer, of which I^ had the honor to be Chairman. Others serving on this Commis- sion were the Hon. John A. Kingsbury, now Commissioner of Charities of the City of New York ; the Hon. Homer Folks, former Commissioner of Charities of the City of New York, now Secre- tary of the State Charities Aid Association; Dr. John C. Otis, of Poughkeepsie ; the Hon. Ansley Wilcox, of Bufifalo, and Miss Adelaide Nutting, of Teachers College, Columbia University. In the investigations made and hearings held by the Commission during the year of 19 13 one of the most striking features was the fact already alluded to; namely, that there was no uniformity in the sanitary regulations then in force thruout the State. In drafting a sweeping revision of the Public Health Law it was recommended that there be establisht a Public Health Council of seven members, one of whom should be the Commissioner of Health, the other six members, appointed by the Governor, each to serv for a period of six years. The Legislature accepted this recommendation and in the revision of the Public Health » Dr. Biggs'. 127 Law, now known as Chapter 559 of the Laws of 19 13, then adopted, empowered the Governor to appoint such a PubHc Health Council and gave it power to enact sanitary regulations having all the force and effect of law thruout the State outside of New York City. It was expressly stipulated that the Council should have no ap- pointiv or administrativ powers. The political controversies which developt dtu-ing and after the legislativ session of 19 13 postponed for a considerable time the appointment of a Commissioner of Health, altho the Council was appointed and held its first meeting in October, 19 13. Still little work was done on the Sanitary Code until January, 19 14. The Public Health Council then began its work in earnest and after several months promulgated the first two chapters of the Sanitary Code, relating to the communicable diseases. These regulations for the control of communicable diseases deal chiefly with the method of reporting, the period of isolation and various other procedures necessary to prevent the spread of infection and to control the infected individuals. From time to time additions have been made to the Code, a chapter was added providing for the grading of the milk supplies of all the municipalities of the State; a chapter regulating the practice of midwifery by midwives; a chapter regulating the establishment and sanitation of labor camps; a chapter providing the procedure for the investigation and abatement of nuisances, and a miscellaneous chapter regulating the sanitary conditions of barber shops, chiropodists, and prohibiting the use of the common towel or common drinking cup in public places. The Council has now under consideration the enactment of regulations for the control of water supplies and a number of other important prob- lems. The importance of a uniform Sanitary Code which applies to every part of New York State except the City of New York cannot be overestimated. It enables the local health officer to have regulations enforct with the backing and support of a State Law, the violation of which may be either a misdemeanor, or in some cases a civil action may be instituted for a violation thru the office of the Attorney-General of the State. 128 In the various localities of the State, especially in the rural dis- tricts, it was not previously possible to compel the enforcement of sanitary regulations owing to the close relationships which exist between the health officer, who was perforce a practicing physician, and who had to enforce sanitary regulations upon patients who might themselves be high in authority in the administration of the city, town or village in which he resided. The health officer can now say, "I have no other course to pursue. The State Sanitary Code requires it," and he can also state that if it is not enforct the State will compel him to enforce it or send a repre- sentativ to see that it is enforct. This gives great moral sup- port to the local health officer and enables him to accomplish far more than he could under the old system. There are many objections to and criticisms of the Sanitary Code. Complaint has been made by laymen and legislators that the regulations were too stringent and that their enactment by an appointed body was unconstitutional and was the sole preroga- tiv of the Legislature. In the development of our modern sys- tems of government often it is not possible for the Legislature to go into the necessary detail as to the methods of procedure and it has become customary for the Legislature to grant power to various boards and commissions to enact regulations. This is true in the State of New York in the Department of Agriculture, Public Service Commission, Industrial Board of the Labor De- partment and in many other departments of the government. An attempt was made during the legislativ session of 19 15 to de- clare the Sanitary Code null and void until its provisions should be subsequently approved by the Legislature. This attempt was defeated. In considering the amendments adopted by the Legislature in i9i3> giving the Public Health Council power to enact sanitary regulations, this matter of legislativ authority was given careful consideration and it was believed that ample precedent existed for this purpose. In 1886 the Legislature of the State of New York created a Metropolitan Board of Health for the sanitary control of the City of New York (then situated entirely within the County of New 129 York) and the counties of Kings, Richmond and Westchester, and the towns of Newtown, Flushing and Jamaica in the County of Queens. When this Board was created it was given power to enact sanitary regulations for the control of the public health in the entire Metropolitan District. One of the first regulations enacted by that Board prohibited the driving and slaughtering of cattle within certain limits in the City of New York. Protest was immediately made against the legality of this regulation and an action was brought in the courts to prohibit the Metropolitan Board from carrying into effect its own regulations. This matter was finally brought to the Supreme Court of the State, which upheld the regulations of the Metropolitan Board of Health. It would, therefore, seem that this was an ample precedent for the Legislature to give boards of health or a public health council authority to enact regulations for the entire State or any part thereof. In considering this feature of the law it should be remembered that primarily the State was organized and granted power by the various towns and cities, and that the municipalities had the power to enact sanitary regulations for many decades prior to the or- ganization of the State government, and it has been assumed by some that the State cannot take away or supersede this power. The courts have, as just pointed out, held differently and altho no test case has been brought under the present Sanitary Code, the Public Health Council and executiv officers of the State De- partment of Health are fully convinced that the regulations en- acted are constitutional and legal. About a year ago the Board of Health of the City of New York enacted a regulation forbidding any street car corporation in the City of New York to admit to its cars more persons that 50 per cent, in excess of the seating capacity. The railroad com- panies immediately appealed to the courts and the matter is now in abeyance. The railroad companies also caused a bill to be introduced in the Legislature for the purpose of taking away the power of any local board of health in New York State to enact any regulations controlling the number of persons to be admitted in street cars and this bill past both houses of the Legislature, ISO but as the enactment of legislation of this kind was taking away the power and prerogativ of a board of health, Governor Whitman very properly vetoed this measure. This account shows briefly the trend of sanitary legislation. However, boards of health and public health councils similar to the Public Health Council of the State of New York should consider carefully each and every regulation and have good and sufficient sanitary reasons for the enactment of any such regulation. For, if such boards or council exceed their authority or enact regulations which may cause imdue hardship upon an individual or corporation without the protection of public opinion, the power to enact these regulations may be taken away at any session of the Legislature. Progress in the enactment of new sanitary regulations should be made deliberately but steadily and only along lines which will be definitely productiv of the greatest good in the diminution in the amoimt of sickness and death. If those in authority in pub- lic health work have always this end in view they will not fail to steadily serv the people and to conserv the public health, and will in the end assuredly receiv the support of their respectiv com- munities and also of the legislativ bodies. INTERSTATE SANITARY RELATIONS. By Assistant Surgeon General W. C. Rucker, M.D., M.S., Gr.P.H., United States Public Health Service. Washington, D. C. The increase in population and ease of travel in the United States has vastly changed the sanitary relations existing between the states since the formation of our government. Originally a sparsely populated fringe of colonies bordering the Atlantic Coast, having no railroads and few highways, and depending for the most part upon slow sailing craft, we have become a nation which extends from ocean to ocean, the component parts of which are in intimate relation with one another by swiftly moving trains and rapid steamships. The original isolation of the states has ceased to be and the integration of our national life has become such that insanitary conditions in one part of the republic must inevitably exert an untoward effect upon almost the entire body politic. As the country has become more thickly populated there has occurred a pollution of the interstate streams which en- dangers the water supplies of other states. The invention of refrigerator cars and the introduction of intensiv methods of farming, particularly of truck gardening, has made it possible for infection to be rapidly carried in a viable state for long dis- tances, and modem transportation has made equally possible the rapid carriage of infected persons from state to state. It is thus seen that the interstate sanitary relations of the United States are exceedingly complex, touching every stratum of life and bearing upon the health of every American inhabitant. The United States has created a first line of defense against disease from abroad. This has taken the form of the maritime and overland foreign quarantine, and may be called our coast fortification against disease. So long as we continue to main- tain our foreign quarantine on an efficient scientific basis we have relatively little to fear from the importation of disease from other countries. As witness of the efficiency of the system may be cited the fact that no case of yellow fever has occurred in the United States since 1905; that despite the fact that cholera was 132 widespread in epidemic form in many parts of Europe in 1910 it gained no foothold in the United States, and that whenever plague has appeared in an American seaport it has been speedily- stamped out before it has had an opportunity for further spread As a matter of fact it may be stated that so far as the major pesti- lences are concerned they have practically ceased to exist so far as the interior of our country is concerned, and that we are now free to devote ourselves to the conquest of those commoner and more familiar diseases which in their end result are a far greater menace to our national health. At the present time measles exerts a far more harmful influence on national health than does bubonic plague, and while there is always a certain danger of the importation of typhus fever by lousy persons who evade quarantine, still our ability to control this disease is such that we have little to fear from it. The great problem which concerns us is the con- trol of disease by the states and the prevention of their interstate spread by the Federal Government. The constitutional right of the general government to control disease rests entirely upon the commerce clause. The police powers of states being reserved to the states, the sanitary policy of our government looks to the individual states to control disease within their respective borders and to the general government to prevent the passage of disease over the borders of an infected state into another state. The line of demarcation between the sanitary duties of the states and those of the general government is not and . cannot be sharply drawn. If the commerce clause may be invoked to prevent the interstate movement of manu- factured articles produced by child labor within the borders of a sovereign state, it is seen that it would be equally proper for the general government to prevent the interstate movement of food- stuffs manufactured under insanitary conditions within the borders of a sovereign state. The complexity of this problem is such that unless due care is observed there will be an enormous overlapping and reduplica- tion in the sanitary work of the United States, and if the general government was to go to the extreme of its power in the control of commerce between the states there would be relatively little 133 need for state departments of health. Carried still further this argument would abolish municipal and county health authorities and place the entire operation of health matters upon the shoulders of the F'ederal Government. This would be a reductio ad absurdam entirely out of harmony with the principles upon which our nation is founded. It would, therefore, follow that in the sanitary re- lations between the states there must be a unity of purpose on the part of the counties, districts and cities of every state with the state officials and that all the states must perform their func- tions with uniformity and with due regard to the union of the states. This principle was gradually evolved and it was not until 1893 that it assumed a definite form. The sanitary history of our government shows a constant movement to this end. In the early days of the republic the states were very jealous of their own rights and fearful lest the general government should in any way interfere with the discharge of state functions. This was soon seen to be impractical in the administration of quarantine and a definite attempt was made in the third Congress to relinquish this portion of the police power to the Federal Government. This failed and until 1878 all quarantine measures adopted by the nation as a whole were in aid of state health authorities. Then followed the period in which states operated maritime quarantines according to a minimum standard which was set by the national health authorities. In 1893 the Government not only assumed the right to set the minimum standard of maritime quarantine but to take charge of state quarantines and to operate them once they were transferred to the authorities at Washington. More than this, the act of February 15, 1893, definitely recognized the Government's duty not only in excluding disease from abroad but in preventing its spread from state to state. Under this authority of law the interstate quarantine regula- tions have been promulgated. For the present these concern themselves with the regulation of common carriers for the pro- tection of the health of passengers, for the safeguarding of persons living along the right of way and the handling of the communicable diseases so as to check so far as possible their interstate spread. 134 These regulations indirectly exert a tremendously beneficial effect upon national health. For example, common carriers carrying passengers in interstate traffic may not furnish to passen- gers drinking water below a certain standard. The sources of these water supplies are certified semi-annually and oftener under certain circumstances. As a result many cities have improved their water supplies rather than have them discontinued for use on trains by Federal order. The abolition of the common drink- ing cup and the common roller towel by these regulations also exerts a very salutory educational effect upon the public mind. Eventually the interstate quarantine regulations will take into account the interstate shipment of milk and other foods but as yet the Government's health machinery is not large enough to attack this phase of the problem. In the interstate sanitary re- lations the work which may be carried on in this way is limitless and there are many things remaining which the national health service can and should do. In the doing of these things, however, the policy should be that of upbuilding and strengthening the ^tate departments of health to the greatest possible degree. They should be encouraged and if necessary aided in the perform- ance of their functions but the general government should assume none of the duties which properly belong to them and their sani- tary rights should be scrupulously observed. So far as purely intrastate matters are concerned the governing principle should be that of sanitary home rule while in interstate relations and the protection of all the states against the diseases of the outside world the Federal forces should be supreme. It is not, however, practical for the states to control every situa- tion or to grapple with every problem which arises within their borders. Economy demands that the overhead expert machinery be maintained by the states at a standard suiHicient for ordinary needs and that in time of great stress that the general government be called upon for aid. The states maintain a militia for the preservation of peace within their jurisdiction but in time of pub- lic danger the army is requisitioned lest harm be done to other states. Similarly in time of grave epidemic the states very properly ^all upon the Public Health Service for its experts to speedily 135 eradicate the disease before it can spread to other states. This is an economy and makes for efficiency in the protection of national health. In the matter of research the Federal Government can and should render equal aid. To maintain forty-eight corps of field and laboratory workers would be a needless expense when one set of Federal experts could perform the duty. What is done for one state in this way profits all the states and a single worker can make similar investigations of conditions within each of the states one after another. In the broader field of research the Federal Government very properly makes studies of diseases which are widespread and which, therefore, affect the health of many states. The results of this work are available to all the states. The col- lection of morbidity and mortality statistics primarily rests upon the states but their assemblage into form which fits them for use is the duty of the general government. In a similar way the publication of the results of scientific studies and the work of popularizing hygiene and sanitation are functions which economy, efficiency and expediency dictate should devolve on the federal health body. For example, the Stereopticon Loan Library of the Public Health Service is able to render excellent aid to health lecturers throughout the nation, while the Health News reaches 8500 newspapers and millions of readers. To sum up, there are certain clearly defined functions which must be discharged by state and local health authorities. Equally there are definite duties devolving upon the Federal Govern- ment. Between these two there is a zone in which either may do the w^ork, either separately or in co-operation. To accomplish this properly there must be a harmony and unison of purpose to the end that the health of the nation may prosper. DISCUSSION. Dr. WiUiam H. Price, Detroit: Emfasizing one or two points in the most excellent and timely papers, I believe that any enactment concerning a sanitary code would be better left in the hands of a small legislativ body. It is my experience that the enact- ment of instruments passing thru a large legislativ body is not always most satisfactory in its results. In Detroit we are fortunate enuf to have our 136 health authority vested in a small board. Public health work has become more complicated and technical with the progress of modern civilization. It includes not only the knowledge of the medical man, but that of the engineer, the chemist, the bacteriologist, and the worker in many other specialties. Even after a code of regulations has been compiled it is of use only as it is applied in a definit way, and to accomplish this it is necessary to have the support of the community, the support not only of the good citizen but of the average citizen, that the regulations may be operativ upon the minority who, from opposition, indifference, or an exaggerated sense of personal lib- erty, is not willing to be guided by the judgment of the majority. As Emerson has said, a law can have only so much force as it has in the character of many men. Dr. Edward Jackson, Denver: I was much interested in the paper of Dr. Biggs concerning the possibility of obtaining an efficient state sanitary code. State laws have given sufficient authority to local boards and commissions but the possibilities of state legis- lation have generally been supposed to be confined to the state legislature. This view has been a serious obstacle in obtaining efficient state health regula- tions. This difficulty has been felt by those administering the health ordi- nances in Denver, with reference to the milk supply. Denver has had an ex- cellent health department for twenty years, and good regulations with ref- erence to the milk supply but in all that time there has been an obstacle in the control of the portion of the milk supply coming from outside of the City. The lack of state requirements for the inspection of the dairies, cattle, etc., has interfered with the efficiency of the Denver regulations. As I understand Dr. Biggs' paper, the work of the legislativ state commission rests, like our interstate commerce regulations, on a comparatively small number of persons. If such a law, giving legislativ authority within certain definit lines with regard to health matters, operates well and is sustained by the courts of New York, it must have an important influence in other states. Health move- ments are held back by conflict of authority between states and local authori- ties, and between state and national authority, and every suggestion we ob- tain for the overcoming of these obstacles is of very great value. The increas- ing intercourse between communities raises this issue all the time. We have plenty of authority given to many local boards, but it is not worth half as much as it would be were it made statewide; and the problem is all the time passing beyond state lines. We must depend upon a small commission for efficient health regulations. It is impossible thru any state legislature to get a thoroly wise and effectiv sanitary code. Dr. B. S. Warren, Washington: The speaker just preceding me stated that the interstate regulations rested upon a very small peg. I don't think he realized the authority of the Acts of 1890 and 1893. These give the national health authority power to make 137 regulations. The authority to enforce reasonable regulations has been upheld by the United States courts in the California plague quarantine de- cision. So far as ascertaining where the disease may be, the Act of 191 2 gave the United States Public Health Service authority to investigate the diseases of man without regard to state lines. The broad powers given to the United States Public Health Service by virtue of these three acts would appear to give ample authority for all reasonable regulations promulgated by the Service. The fact that the Act of 1893 did not have a penalty clause for violation of the Act does not weaken the law, as it is easily enforcible by the Department of Justice thru the United States courts. Dr. Otto R. Kichel, Albany: It occurs to me that several important facts may interest you in connec- tion with the New York State Sanitary Code and its enforcement, namely, the statutory requirement that the Public Health Council, which enacts the Code, shall consist of six members, three of whom shall be physicians "and shall have had training or experience in sanitary science, and one shall be a sani- tary engineer." The law also makes the Commissioner of Health a member of the Council. Therefore, of the seven members, five must have had train- ing or experience in sanitary science. The law empowers the Council to pre- scribe the qualifications of local health officers, directors and sanitary super- visors of the state department, and of public health nurses, — and such quali- fications have been prescribed. Effort is being made to raise the standards and personnel of the local health officers upon whom depends very largely the routine enforcement of the Code. In the future candidates for appointment must be not less than twenty-eight nor more than sixty years of age, and shall have had certain special training or experience in public health work. To facilitate this the New York University and the University of Syracuse have prepared courses in public health for health officers. In order to meet the prescribed quali- fications many health officers have enrolled for such instruction. The 20, more or less, sanitary supervisors, who maintain general super- vision over the work of the many hundreds of local health officers, were ap- pointed two years ago from a competitiv civil service list. All of the men appointed had either special training or experience in sanitary work, and many of them had accomplished some definit constructiv public health work. The supervisor represents the State Health Commissioner in the field, and each covers a district which includes several counties, about 300,000 popula- tion, and about 60 local health officers. He acts as an advisory expert and superintendent, and is the essential link between the central state department and the local board. The advent of the sanitary supervisor has been wel- comed by local authorities and already his services have become indispensable to them. The work in New York State is progressing rapidly and there is a notice- able improvement in the standards and efficiency of the local health officers. 138 In all the larger municipalities there should soon be available for these posi- tions men who have had special training or experience in sanitary science. The result will be constantly better enforcement of the sanitary code and other Tiealth regulations and a corresponding improvement in the public health itself. Dr. George A. Hare, Fresno, Cal. : It is interesting to note that the Academy is developing a clearing house for practical ideas in health legislation which seems difficult for legislators to obtain in many of our states. The thought I gathered from Dr. Biggs' paper is that the Public Health Council of New York has legislativ and exec- utiv power over all the territory of New York and takes precedence of all local health authorities, with the exception of New York City. I should like to inquire why New York City does not come under the same jurisdiction? Dr. Kichel: New York City not only has an old, highly organized, and very efficient health department, but its population is much larger than that of the rest of the State. It was therefore deemed entirely unnecessary and imprac- ticable to include Greater New York in the general state health supervision. Dr. Jackson: Would not the exception, made in regard to New York City not being under the jurisdiction of the Public Health Council, form a precedent for other states? Dr. J. L. Heffron, Syracuse: I think the situation is that the Health Department of the City of New York had been so highly organized and had done such splendid work that Dr. Biggs took the law in force in New York City as a model for the State law. As I understand it, the Council is not only a legislativ but an admin- istrativ body. Dr. Eichel: In certain details the Code enacted necessarily corresponded with the New York City Code, but the New York City Code was not adopted as the State code. It is of interest to note that a number of municipalities throughout the State have adopted the State Code almost in its entirety as their local regulations, with various additions to meet local conditions. Dr. Hare: I have observed that if you cannot get what you want, it is well to want what you can get. New York has set an exceptionally good example in her Public Health Council work as outlined in this paper by Dr. Rucker. I think we shall watch with more than ordinary interest the working out of this plan. 139 Dr. Rucker, closing: The vast regulatory powers which the Interstate Commission has all hang upon the Commerce Clause of the Constitution. Section 3 of the Act of February 15, 1893, provides that immediately after the passage of the Act that the Surgeon-General shall examine into all of the regulations of the states for the purpose of finding out whether such regulations are adequate for the prevention of the introduction of disease from abroad and the prevention of disease passing from one state or territory to another and that he shall aid the local and state authorities in the enforcement of these regulations. Should these regulations be found to be inadequate the Secretary of the Treasury shall promulgate regulations for the prevention of infectious and communicable disease from abroad and from one state or territory to another. If the state and local authorities are not willing to enforce such regulations the President shall take measures for their enforcement. There are also penalties of fine and imprisonment for infraction of any regulations made under any of these regulations. There are relatively few regulations, — only 32. The policy has been to pass only regulations which are reasonable — they have to be reason- able from the standpoints of sanitation and common sense to have the force of law. That is the secret of a good public health law. No public health law is worth the paper it is written on unless the people really want to obey it and really want to see it enforced. As a result there has been very little difficulty in getting the Interstate Quarantine Regulations obeyed. As time goes on these regulations will be enlarged but only as rapidly as they are assimilated. The Board which has charge of the preparation of these regu- lations for the Surgeon-General's signature and Secretary of the Treasury's signature goes on the policy that it will have nothing "dead" in the regula- tions. In sanitary work you get what you get when you get it, and you don't get ideals; you just get what you can get, and you are mighty thankful to get that. The psychology of Americans is such that if you try to bully them into doing a thing they will turn right around and go the other way as fast as they can, but if you explain a matter and show them they are getting a square deal you can get what you are going after. We have had too much sanitary regulation in this country. We have stuff on our statute books that is worse than useless, and which would never hold in court. Such regulation hurts the cause of public health. The general public in this coun- try is nobody's fool, and people can tell when you are trying to fool them. If, on the other hand, they know you are telling them simply what ought to be done and are asking for their help, then health regulations will be shown to be worth while. THE DRINK PROBLEM AND LEGISLATION. By John Koren, A.B., Boston, Mass. The differences of opinion about the drink problem appear to be irreconcilable. Many men and more women invest their peculiar doctrine of what should be done to prevent the consump- tion of intoxicants with a religious significance. They have elevated to a dogma the assumption that every use of liquor, not to mention its manufacture and sale, is sinful. In their eyes men cannot be white sheep, that is morally solvent persons, unless they seek dry pastures for themselves and others. It is their creed that drink is the chief source of human ailments, — mental and physical diseases, poverty and crime. These concep- tions bound their ideas of public policies seemingly to the exclu- sion of all others. Opposed to this condition of mind — I cannot call it a reasoning opinion — stand those who hold that the liquor question does not present a purely moral issue but, in its public aspects, one of social expediency; and I submit that this view is compatible with as deep a realization of the ills that result from the abuse of drink and with as abundant a desire to counteract it as actuate the extreme reformers. I said that the two points of view appear irreconcilable. At bottom the reason for this is that the radical among our present- day temperance reformers will not concede that one may be earnestly solicitous about the drink evil while denying the effi- cacy of their legal specific, and brand those who differ with them at least as unconscious advocates of wrong, if they do not impute to them base motives. I refer to this regretfully, not because the indiscriminate hurling of anathemas hurts much, but because the condition of mind back of it presents one of the greatest obstacles to progressive temperance reform. To make this statement is to express the belief that the drink evil cannot be cured by sumptuary legislation. My reason for this conviction can be stated simply, and I trust without the acrimony of one who desires to provoke controversy. 141 The theory of prohibition rests upon a false psychology. It assumes that private habits and modes of life are amenable to legislative control in matters that do not involve a distinction between absolute right and wrong but merely what is socially desirable. The theory overlooks the fundamental question Why do men drink? ignoring the fact that the world-wide use of intoxicants denotes a demand — we can condemn it as much as we please — which will seek its usual satisfaction unless we suc- ceed in stilling it through some substitute or direct it into safer channels. The prohibition theory further assumes that the only thing needful to make it effective is its approval by a bare ma- jority of voters, whether obtained by persuasion or by downright coercion. The almost platitudinous maxims that a strong minority opposition undermines sumptuary laws, and that no legislation can accomplish its task unless it is re-enforced by a strong public opinion, are brushed away as if they had lost their meaning. The prohibition theory assumes that the verdict given in its favor is unalterable, and therefore men seek to write it into the organic law of the country. How unstable the majori- ties are in their attitude toward liquor legislation, history has abundantly recorded. Finally, the main reliance of prohibition in order to become effective is not popular conviction but force — • police force — and thereby hangs the long and painful story of its failures. The prohibition attitude involves a curious contradiction: The liquor question is proclaimed to be a moral issue and in the same breath right of option is insisted upon. But do we ever submit other questions which mankind agree relate to an in- herent wrong for a decision at the polls? By the very appeal to a plebiscite it is confessed that the issue is one of social expe- diency and not one of abstract morals. The vicissitudes that mark the attempt to enforce prohibition I shall pass over except to say that we can take but scant com- fort in the successes with which we are regaled. Or is the legal disappearance of that embodiment of the drink evil, the saloon, an especial cause for rejoicing so long as it is not synonomous with a cessation of the abuse of drink? Let me point out but a 142 single disquieting fact: while there is boast that never before in the history of this country so large territory has been laid dry, the revenue returns according to reports indicate an increase of about ten million gallons in spirits withdrawn for consumption during the current fiscal year and the sixty million gallons de- crease in the production of beer does not offset it, but is from the temperance point of view merely a matter for regret. Furthermore, I beg you to remember that unenforced prohi- bition has its attendant evils which may far outweigh an apparent gain in sobriety. The habitual and open violation of the law at which so-called good men connive breeds contempt for law in general, sows corruption, and corrodes the public conscience. It is a saddening spectacle of public morality when in a prohibi- tion locality all political activities pivot upon the question whether the constitutional and statutory law relating to drink shall be up- held. It will be answered that the entire fabric of arguments will tumble about my ears on the advent of prohibition of the national variety. To which the only answer is: the assumption rests upon the same false psychology; the same blind reliance upon the validity of artificial majorities; the same doctrine that morality is gained by coercion; the same appeal to brute force as a means for making a man sober. Why this confusion of thought and of relative values? The nation appears to make preparedness its slogan. Apparently it occurs to but a few that one essential is to be prepared in mind, and I solemnly assert that one unmis- takeable indication of our intellectual unpreparedness is the fatuous manner in which we are content to seek a solution of the liquor problem. This blunt utterance of what to me seems to be incontrovertible truths wiU in some quarters earn for me added reputation as an enemy of temperance reform. But does the condemnation of theoretical vagaries and their failures when translated into prac- tice involve any criticism whatsoever of the essence of temperance reform? I should be the last to deny that the vast activities to stem the traffic in liquor have been without lasting wholesome re- sults. One can indulge in the most wholesome denunciation of 143 the excesses of the trade, its lust for socially dangerous power, its greed of money which makes it batten upon other men's mis- fortune; one can roundly denounce the iniquities of the saloon and advocate its banishment in many ways; one can preach the virtues of sobriety, and yet insist earnestly and truthfully, that our theories of liquor legislation, whether they relate merely to the control of the traffic or to its abolition, each in its own way spells rnore or less evident failure. No one will venture to dispute that rational social legislation must be based upon truthful concepts of the problem it deals with, and that we must legislate stupidly and in vain if we let our vision be obscured by false and exaggerated notions. The motive in liquor legislation does not divide us; it is to prevent intemperance. Surely there is no need of enlarging upon the evils that flow from the abuse of drink — they are too palpable and saddening. Science has powerfully come to the support of temperance effort by re-enforcing what already common sense teaches about the dangers of alcoholic indulgence. But science has not yet demon- strated that every use of intoxicants is necessarily injurious and until that time, if it comes, or until the great mass of individuals is permeated by the conviction that their personal use is harmful and wrong, legislation which would far outstrip public opinion merely writes its own doom. Does not, therefore, wisdom lie in legislation designed to pre- vent abuse and gradually to diminish consumption rather than to attempt the impossible — to stop all use? The promise of a heyday of virtue and prosperity and the absence of the great human ailments under sumptuary legislation is but pleasant moonshine without warmth and without substance. Drink has, indeed, the gravest consequences to answer for, but total abstinence is not a primary virtue, and in the nature of things does not suffice to abolish disease, poverty, vice and crime. Therefore do not let us premise our laws on the untenable. Our constant abortive efforts in legislation arise in large part from the fact that we either attempt this or are content with legislative measures which ignore common-sense principles of progressive control. Having thus given the briefest possible accoimt of my point 144 of view, let me try to summarize some constructive efforts that hav^ not yet been attempted but which are elsewhere accepted as stepping stones toward an increasingly effective repression of the drink evil. Our laws commit the unpardonable blunder of treating all intoxicating liquors alike from the point of view of taxation. We make them bear the heaviest possible burden without asking whether this method is in the interest of temperance. It does not require demonstration, least of all before the present assem- bly, that the real scourge of the drink evil is to be found in the abuse of distilled liquors. Yet we do not discriminate by aid of differential taxation in favor of the least alcoholic and therefore least injurious beverages. Indeed, legislation goes to the absurd extreme, in some instances, for forbidding within so-called dry- territory the use of any liquor bearing the terrifying name of malt, whether it be intoxicating or not! By the same token, where the sale of beers is legalized no distinction is made between the heaviest and intoxicating kinds and those that by scientists as well as by prohibitionists in more enlightened countries, are regarded and treated in law as non-intoxicating, that is, generally speaking, all beers under 2V4 per cent, alcohol. H^re, then, is a fruitful field for reform which should have for its object nothing less than the virtual extinction of the manufactture and sale of spirits, and the substitution of fermented kinds, favoring the least intoxicating. Perhaps in time we shall be ready to take another step in advance. Otu" present-day license systems virtually put a premium on the distilled liquors by subjecting them to the same regulations and the same burdens as the fermented kinds which do infinitely less harm. Indeed, we legislate in license matters as if the en- tire object were to obtain as great returns as the traffic will bear without questioning if we thereby counteract abuses and pre- vent intemperance. Time will not permit me to discuss the merits and demerits of present systems of issuing and controlling liquor licenses. For the most part, they set a poor example of effectiveness. For the same reason I cannot dwell on the hundred and one ( 145 « restrictive devices whose ostensible purpose it is to lessen abuse in some way. A few of them are obviously beneficial, many are futile, and some purely irritating. Let us rather turn to a possible substitution for licensing systems which, under proper modifications and safeguards of the law, can surely be adapted to American needs on a large scale. I refer to the so-called Company System of Scandinavian origin. Its essence is that instead of granting privileges to sell intoxicants to private individuals, they may be given for a whole community which declares itself in favor of license to a private company which engages in the traffic without prospect of other benefits than a modest return on the capital invested and thus is shorn of the incentive to push the sale of liquor for private profit. The system at once divorces the sale of liquor from any affiliation with politics, excludes private interests, and sets itself the one object of restricting consumption and divesting it, so far as possi- ble, from harm, by a number of devices which lie easily to hand, such as limiting the hours of sale, the quantity that can be pur- chased, and blacklisting habitual inebriates. Only one objec- tion can be raised to experimentation with this system, which in the course of many years of trial has abundantly proved its worth, — the one coming from the extreme temperance wing which be- lieves that any sale of intoxicants, no matter under what auspices and how unproductive of actual intemperance, is inherently wrong and therefore cannot be permitted. Let me not be misundestood at this point. I believe that the local community should exercise the privilege of determining for itself whether or not it will tolerate the traffic in intoxicants. Local option is a principle which has come to stay. But I see its shortcomings when, for instance, the attempt is made to lay an urban community dry against its will by the aid of the rural vote, or when a handful of voters on petition can at an opportune time force a vote favorable to their side. In short, we boast of the invention of the principle of local option but fall pitifully short in its application and tolerate its perversion not in the in- terests primarily of temperance but in the interests of statewide prohibition. 146 It is right that the local community should outlaw the saloon if it seems expedient to do so. The country at large shows little tolerance with the saloon as an institution. And there is common consent that it no longer has a place in the village or in the coun- tryside. For this let us be thankful. But where a community shows no inclination to abide by the verdict that there shall be no more saloons or where their exclusion simply means that the illegal traffic with all horrors flourishes, then such a community should be given the chance by means of the Company System to provide a substitute which safeguards the sale of intoxicants so far as human ingenuity and conscientious endeavor will permit. In the present state of public feeling and thinking about the liquor problem, in view of the composition of the populations, I solemnly believe that in urban communities of any magnitude, particularly where they are isolated from the larger centers, evil and not good will come from an attempt to gain abstinence from drink through coercion. But this does not mean that the medium through which drink is dispensed should be permitted to remain the same, much less the excesses which we legislate against and deplore. Some will deny vehemently that the sug- gestions I have offered would progressively promote temperance. The difference between us lies in this, — I would take some ac- count, if you please, of the frailties of human nature, I would ap- proach gradually the goal that all desire and mean to work for, believing to see clearly and without a shadow of doubt that human progress does not come in obedience to a legislative mandate but by persuasion and education, and is merely aided by laws which rest upon the firm foundation of public conviction about what is expedient and right. He must be blind indeed who does not see that in obedience to the very things I have mentioned there has been steady advance toward sobriety and cleaner living. To deny this is to condemn the most patent forces in human life. What further progress shall be made depends in no small measure on wise laws, but let us not commit the fatal mistake of assuming that sobriety and other virtues that should adorn our civilization will spring into life by the mere fiat of legislation. 147 Dr. William R. White, Providence: Mr. Chairman: I have been intensely interested in the paper to which we have just listened. I wish the reader would give us a little more in detail the working application of what I think he termed the Company System of control originated in Scandinavia, whether it embraces the wholesale and retail distribution of intoxicants and what are the actual results of its opera- tion. I must say that I am in sympathy with his argument against the sumptuary attempt at controlling the use of all intoxicants. I live in a city where both license and prohibition have been tried. I remember well what rejoicing existed in the community among the advocates of prohibition when that law was enacted. This enactment resulted largely from the in- coming of strangers who talkt most forcibly in favor of prohibition. The law remained in force for two years and then an overwhelming vote restored the license law. I do not wish to speak on the merits of the two; I am not competent to discuss them adequately, but I know that our community was very much dissatisfied with the working out of the so-called statutory pro- hibition. It resulted, as it has many times, in the back door and basement sale of abominably poor liquors. It did not stop intoxication; it did not stop crime; it did not stop inebriety among our working classes. It led to a condition that was entirely unsatisfactory. I am very much interested in the constructiv argument of the speaker. Mrs. Florence Kelley, New York City: I spend my summers in Maine, a State which has given a longer trial to prohibition than Rhode Island has done. Every one here remembers no doubt that a few years ago the State of Maine, after trying state-wide pro- hibition for fifty years, submitted to a referendum the question whether prohibition should be continued as a part of the Constitution. By a very- small majority Maine retained state-wide prohibition. Three grave diffi- culties were mentioned in the campain: That it could always be shown that there was a great deal of drunkenness in Maine, This was beHeved by the people of Maine to be the result of other states sending into Maine, in defiance of the laws of Maine, large quantities of alcoholic drinks of all kinds, particularly heavily laden distilled liquors. These were brought in under the Federal provision covering unbroken packages. Another difficulty was the immigration of people accustomed to drinking distilled liquors with heavy proportions of alcohol, who availed themselves of the Federal law. The third difficulty was that those people within the State of Maine who suffer most from the abuse of liquor and have the least enjoyment in drinking — the women of Maine — have no share in deciding whether there shall be local enforcement of the State law. In discussing the results of sumptuary legislation it is well to keep in mind the limited power of any state to establish it, under the present Federal legislation and judicial decisions, and the lack of voting power of the people 148 who suffer most from the evils of drunkemiess. It seems fairer to consider as a basis of discussion a state in which prohibition has been tried out half a century and in which, with all its limitations, it is thought worthy of con- tinuance, rather than to dismiss as a failure a state prohibition law which has been tested for two years, and then generalize from that failure. Dr. Tom A. Williams, Washington, D. C: I cannot speak upon this matter from any experience with legislation, nor can I speak of personal knowledge of any prohibition state; but the remarks of the last two speakers make me wish to come forward and say something about certain prohibition states which I happen to know about very well second-hand, that is to say, from statements made to me by professional colleagues practicing in those states who had good opportunity to observ the situation, because they were men of practical minds and of the better type. I am referring to men whom I see in medical consultations in those states. The States particularly referred to are West Virginia and North Carolina. In Virginia only recently prohibition has been enacted and it would not be fair to say anything about the state of opinion there. Physi- cians to whom I have spoken living in West Virginia nearly all believe that the prohibition law in that State has greatly lessened crime, has increast the prosperity of their communities and has met with scarcely any dissatisfac- tion. Apparently the law has been as successfully carried out as one could expect where the drawbacks spoken of by the last speaker exist to some extent. It must be remembered, however, that these States are inhabited by people who in very large proportion ( I refer to the negroes) are not re- garded as worthy of the full possession of political rights and that the pro- hibition measure is lookt upon as one of protection for them. I was very much interested to read in the paper the other day Mr. Gar- field's remark in reply to the attempt to introduce into the Progressive Party's platform the prohibition provision. He said that he thought the matter was one rather of education than of prohibition. That might be interpreted to mean education to tolerate prohibition, just as one is educated to tolerate certain discipline in civil life, which is unpleasant perhaps to us when we are young men, which we accept on account of its value. Theoreti- cally, of course, in a democratic country, the position of the prohibitionists is entirely untenable. It assumes a certain interference with liberty to do as one pleases about his own particular habits. Practically speaking, I have come to think that perhaps it is a wise expediency until we can attain to educational standards of information regarding our bodies and our minds which will make us all see that alcohol is a rather unnecessary and often a very unwise indulgence. We have to remember, however, that even in a democracy and when that democracy is educated, as I hope it will be, there are certain individuals who on account of their own particular weakness, often psychological, have particular temptations to the kind of stimulation which is produced by alcohol. Until we take more care to provide for the 149 special — education, I should call it, but it means more than the ordinary education of such individuals — ^we shall always have many people who have a strong craving for some kind of what has been called stimulant, tho alcohol is probably not a stimulant. The problem will never be solved until we take account of those individuals who are the exception, yet quite numerous and often of high usefulness to the community. Dr. L. Duncan Bulkley, New York City: I think the statement of Mr. Koren that the medical profession is not united upon the harmfulness of alcohol should not go unchallenged. Ten or fifteen years ago in London Sir Victor Horsley, in speaking upon alcohol, exhibited a diagram showing the steadily lessened quantities of alcohol used in the hospitals in the last ten years. He also had taken from the books the amount of money spent on milk each year in the same ten years, and the amounts were practically reversed. The results showed that alcohol had been excluded from medical use, which is certainly the experience and view of the best physicians now. Dr. F. F. Lawrence, Columbus: Does this report give any figiures to show how much of the alcohol was given to the patients and how much was consumed by the staff? Dr. Bulkley, New York City: I am positiv that were some such diagram made from our New York hospitals that the result found in the London hospitals would be duplicated in almost every instance. Mr. Koren: My statement was that the medical profession was not entirely agreed that alcohol under all conditions and under all circumstances was injurious. That has nothing to do with its consumption in hospitals. Dr. Bulkley: I think the profession is practically agreed upon eliminating alcohol from the practice of medicine. I merely felt that the statement of Mr. Koren ishould not go unchallenged in a medical body, when it is so well known that alcohol is so much less used than formerly. Dr. Lawrence: I want to call attention to one thing only, the constructiv side of legislation, not only concerning alcohol, but regarding the question of health insurance, for instance. Such insurance is coming just as surely as that the sun rises in the East, and it behooves the medical profession and particularly the American Academy of Medicine, to get busy and very busy in a constructiv work, and see that health insurance is made impossible in every state for the users of alcohol to excess, and that physicians who use alcohol at all cannot be examiners for health insurance. That is a constructiv proposition for consideration. I50 Dr. Edward Jackson, Denver: It may be that, in the matter of temperance as in the matter of sanitary codes, "We get what we get when we get it." While the theory of sumptuary legislation may be very defectiv, there is a practical psychology underlying the movements toward what is called prohibitory legislation. In prohibition legislation there are going on many slightly different kinds of legislativ ex- periments, and a close examination of all these experiments may teach some important facts. In Colorado there was added a prohibition amendment to the State Constitution, which went into effect the first of January of this year. It was a movement that seemed to me at the time of doubtful wisdom, tho I was not prepared to oppose it and I watcht the operation with a good deal of interest. In the first place, the law is prohibitory only in a certain sense; under existing conditions outside of the State any one in Colorado who has sufficient foresight and self-control can get all the liquor he wants to use. There are certain restrictions on the shipment of liquor into the State. It has to be consigned to the person who is to be the consumer and it has to be labeled. Certain records have to be kept of the consignment but no one in Colorado is prevented from getting all that he needs of any kind he chooses, under certain restrictions. The enactment has stopt the manufacture of malt liquors and of all distilled liquors within the State. It has stopt ab- solutely the saloon, as the saloon was known previously and as the saloon is known in most parts of the country, and apparently it is going to be per- manently effectual in that direction. It has not stopt the use of beverages that contain less than 2 per cent, of alcohol. At least two of the breweries in Denver have gone into the manufacture of "Near-beer," and other pro- prietary beverages that contain alcohol in less than 2 per cent. These beverages are largely used by the former drinkers of beer. This prohibitory legislation has caused the consumption of beverages with a very low alcohol percentage instead of beverages with a much higher alcoholic percentage. There is no doubt that in Denver, which is perhaps the largest city in the country which has adopted prohibitory legislation, having 250,000 inhabi- tants, it has caused very much less drunkenness, altho the majority of voters in Denver, including the women, were against the prohibitory amendment. There was a majority of between 8,000 and 10,000 against the amendment in Denver and only 10,000 for it in the whole State. Only within a week I noticed in the daily papers the serious proposition is coming up before the councils of the city to provide a substitute for the supply of broken stone that had come from the "rock pile" to which the drunks were sent. Since the first of January no men have been sentenced to breaking stone for drunken- ness and the supply of broken stone has run out. The effect of this legislation is undoubtedly different from that of other prohibitory legislation in other states. This legislation is largely experimental and is worth looking at in the scientific spirit, endeavoring to recognize the resemblances and differences of effect in different localities and under slightly different enactments. 151 Dr. A. J. Read, Battle Creek, Mich.: I feel that a paper of this type ought to call forth considerable discussion from the Academy of Medicine. I do not think that we could accept in toto all the ideas advanced by the author of the paper and I do not believe that he would expect us to. The paper has presented to us a constructiv idea in legislation and controlling the drink problem, which is worthy of some study and consideration, I beheve, the constructiv idea, as I understand it, being a substitute for the present prohibitory measures more or less in vogue thruout the country in a sort of restrictiv legislation controlling the sale of intoxicants and as a substitute for so-called sumptuary legislation. Mr. Koren (to Dr. Read) : If you understand my constructiv idea clearly — it is a direct step — when public conviction is ready for it — toward any sort of prohibition. Dr. Read (continuing): The constructiv program, it seems to me, does call for more or less false premise as presented by the paper. The author of the paper, as I under- stand it, takes for granted that the present prohibition movements more or less prevalent in the country have been executed more from a moral basis than from a scientific basis. I would feel like challenging that on the basis of fact as I understand the question. I do not think that the legislation which the intelligent men of this country have enacted prohibiting the sale of intoxicants has been on a moral basis. I will admit that there are moral problems involved, and that they have been felt very often in the agitation of the subject, but I do not think the legislation has been purely on a moral basis. The question of personal liberty is involved; but I do not know of such a single law that does not curtail personal liberty. I need only mention Emma Goldman and other speakers of that type. My understanding of my right to life, liberty and the pursuit of happiness is that whenever the habits or acts of another interfere with that right, it is time that legislation should control them. Here in Detroit a short time ago a company of joy-riders at one o'clock at night ran into a street car, smashing into it in terrible shape — suppose you had been in the automobile. We have come to a day when the lives of men hang in the balance of other men's actions, and for that reason I believe it is perfectly proper that men should be prevented by legislation from using intoxicants. I do not believe that prohibition as it has been enacted thruout the United States does materially interfere with the personal liberty of any man or set of men as long as they honestly want to carry on honest, straightforward business tending to the general uplift. So it seems to me that there is a bit of sofistry in this paper and I should like to have the whole subject well studied before its acceptance by a body of scientific men. The President, Dr. George A. Hare, Fresno, Cal. : I wish to thank the reader of the paper for presenting this subject. Whether 152 or not we endorse the thought of the author, the paper has led to a considera- tion of a problem which is being discust pro and con and which will be settled finally by intelligent legislation just as inevitably as the question of suffrage will be settled by granting it to women, just as inevitably as health insurance and industrial accident insurance will be granted by the public, just as in- evitably as orphan children will be reared in homes rather than in institutions because these measures will promote the broader interests of human welfare. Mr. Koren: I do not rise to have the last word in support of my views. My first ex- perience in the study of this subject dates back about twenty years, and I have endeavored to ascertain the truth about alcohol not only in the United States but in other parts of the world. My experience is that upon no subject can one be so easily misunderstood because of preconceived notions. One or two corrections I should like to make: Dr. Reed must not understand that I mean that all prohibition legislation has been enacted because of the world-wide or state-wide conviction of a moral kind. I am speaking of the ultra state of mind behind prohibition, and without the push of a moral issue many states would not have accepted prohibition. I have already referred to the apparent misconception of what I said about the attitude of physicians. I merely meant that the medical world, so far as I have been able to read — and I think I have gone over all the literature — does not yet accept the teaching that every use of alcoholic drink is per se injurious. If that were once establisht, the public would come to believe it, and we should then make much more rapid progress with our legislation against drinking. My quarrel with the situation is not that we do not need legisla- tion, but that legislation tends to outstrip public opinion so far that there is not a sufficiently strong force behind the law and that being the case the law defeats its own end. My position is that we should approach the whole problem in another way and more gradually. Therefore I referred to the Company System which might be used as a temporary expedient for the education of people to a state of mind which would prepare for a possible prohibition. That has been done elsewhere. In Norway the Company System brought about a reduction in the use of distilled spirits of about one-half twenty-five years ago. That has not been accomplisht anywhere else so far as I know under any other regulations, whether prohibition, or license legislation. In Norway up to the present time no sale of spirits is allowed except in quantities of 250 gallons, except thru these privately organized companies and they receive only a modest return on the earnings. In many communities no distilled spirits are sold. People must be pre- pared if at all for state wide prohibition by some such expedient. All I de- sire for our country is that we at least be given a chance to try out progressive legislation. With the personal liberty argument I have no patience. I want to be protected against the drunkard, but I want to see whether we cannot by some law educate men to become sober. A recent addition to the 153 Norway Company System is the Individual System of Licensing. A man must present a certificate with some one guaranteeing that he will not abuse the privilege of buying spirits. Dr. O. H. Lau, Detroit: Did I understand Mr. Koren to say that it has not been determined that the drinking of alcohol in any quantity has been injurious? Mr. Koren (replying to Dr. Lau) : The over use of alcohol is in itself injurious. There is a moderate use of alcohol that is not harmful to a normal individual. LEGISLATIVE PROTECTION OF THE PEOPLE FROM THE EVILS OF PATENT MEDICINES AND MEDICAL FAKERS. By F. F. Lawrbncb, M.D., D.Sc, LL.D., F.A.C.S., Columbus, Ohio. Mr, President, Ladies and Gentlemen, Members of the Academy: There are two distinct propositions to be discussed, altho they are so closely allied as to make it impossible to discuss the one without discussing the other also. The first proposition is "Legislative Protection of the People from the Evils of Patent Medicines." The second is "Legislative Protection of the People against Medical Fakers." In order that we can understand or measure the value of laws, we must remember that legislation is either constructiv or correctiv. In which class does legislation for the protection of the public against patent medicines and medical fakers belong? If it is to be classed as constructiv, then its value is to be measured by the amount it contributes to the education of the public to the inherent evil of patent medicines and medical fakers. If it is to be classed as correctiv, then its efficiency is to be measured by the curtailment of the sale of nostrums and of the activities of medical fakers. I venture the assertion that these curtail- ments have been a negligible quantity. If these statements be true, there must be a WHY. Is it possible to find the why, and, if found, to apply it to the solution of the problem ? Let us analyze the situation and study it under the following heads : First. One important evil of patent medicines is the habit- froming drugs contained in them. These have not been eliminated by the Harrison Law, but merely decreased. Second. The other most important evils of patent medicines and medical fakerism are exactly identical. They are as follows: a. Improper or ignorant treatment frequently produces danger- ous effects. b. They lead to neglect of proper treatment in many cases in which only surgery can accomplish any good, until it is too late even for surgery, hence causing unnecessary sacrifice of life. 155 c. They produce mental and physical wrecks, by suggesting diseases of which the individual previously knew nothing, and with which he was never afiiicted. d. They create a distrust of doctors and scientific preventive medicine, thus breeding various "antis" — as anti-vaccinationists,. and anti-vivisectionists. Third. The inseparable interests of patent medicines and medical fakers are: a. The credulity of the public. h. The plausibility of the advertisement. c. The financial profit. d. The political influence of a large bank account. e. The ability to play the church and other religious or philan- thropic organizations. /. The ease with which a comfortable income is assured, leading men of some ability, but weak courage, into the patent medicine business or the practice of the faker. g. The difficulty of the honest and poor doctor contending against these combined forces. h. No honest potential remedy. Fourth. What are the needs of the public and its desire for protection? Does the public desire legal protection? If not, why not? Fifth. Past endeavors at legislative protection against patent medicines have been partially but not completely successful. Why? Sixth. A faker is a false pretender, no matter where found. Many such are harbored within the profession. Seventh. Unethical advertising methods of some doctors lead the public to classify them, and thru them the entire profession, with advertising quacks. Eighth. Carelessness among doctors tends to drag the profession down to the level of the patent medicine pedler and the faker. Ninth. The profession itself is responsible for the hold patent medicines and fakers have on the people. Tenth. It is necessary that we cleanse the profession before we can hope to control those outside. 156 Eleventh. Law unenforced is impotent, and practical, common sence methods only will lead to national laws strictly enforced. Twelfth. There are other and better ways to effectively attack the evils of patent medicines and fakers. Most of the above mentioned evils of patent medicines and fakers are self-evident to any medically experienced audience; but one or two points might be expanded upon. One of the greatest, if not the greatest, of the evils of patent medicines, lies in the suggestion of ills of which the reader of the advertisement never before knew. In other words, the patent medicine advertiser, by shrewdly wording his advertisement, leads the reader to believe he has some ill for which the particular patent is a panacea. This particular feature of the patent medicine business is as potent a factor for ill as Christian Science, altho directly the opposite in its action, because Christian Science may, and often does lead one, afflicted with a serious disease, to believe he is not ill, while the patent medicine advertisement leads many perfectly normal men and women to believe they are afflicted with a disease which only the particular "patent" will cure. In some of the advertisements, notably the Lydia Pinkham's ghost, the errors and short-comings of the medical profession are * 'played up" to the highest point of efficiency. Other patent medicines are excelled in this art only by the proprietary medicine men, who thru their "detail representatives" secure the co-opera- tion of doctors and buy space in medical journals to exploit their preparations in a manner similar to the "ready to wear" clothing merchant. Do the people want legislative protection, and, if not, why not? It is quite probable that the "strenuous life" and high cost of living may bear some relationship to the attitude of the public toward medical legislation. It is a fact well known that the public is too busy with its own affairs to give much of either time or thought to the motive back of an advertisement. In other words, the psychological effect of a patent medicine advertisement is produced upon the public mind by its more or less positive sug- gestion of cure or relief from physical ills at a nominal expense to the individual, without exciting any effort upon the part of 157 the individual to look for or analyze the motive. That is, the reader does not feel inclined to weigh the fact that the advertiser has something to sell, and that the prime motive of the advertiser is to create a demand for his product by the subtle suggestion of something which will be of benefit to the patient at less cost and with more positive results than he could get from an educated and honest physician. He simply swallows the bait (like the cat- fish), bait, hook and a good part of the line. It is the past master's art of suggestion, inasmuch as it first suggests a condition or disease and then suggests a remedy, following this with the ever potent suggestion of economy. These suggestions are so skill- fully blended as to make them each helpful of the other. It might be pertinent to ask in what way has any legislation in the past been directed to the lessening or overcoming of the influence of these suggestions. In the Federal Pure Food legis- lation something has been accomplished. For example: a syrup made from corn cobs, or other material, cannot be sold under a label of "maple syrup;" but, has it diminished the sale of "Maple- ine," or other imitations of maple syrup? Not at all! It is pre- sumed that the individual has a right to use, as food, anything, not violently harmful, that he may like, so long as he knows what it is. Yet this is probably one of the strongest pieces of Federal legislation against pretention. Of course, the Anti- Narcotic Law must be given first place in practical legislative effort. But has the legislation against the sale of habit-forming nostrums materially lessened the sale of such as "Bull's Cough Syrup," 'Xydia Pinkham's Vegetable Compound," "Peruna," "S. S. S.," or any one of a host of others? Apparently not to any appreciable extent. I recently visited a number of otu* local druggists, and asked them what, and how much patent medicines they were now selling, as compared to the past. Without exception, they answered that they sold about as much patent medicines as they ever did. Two stated that they were selling more. All mentioned the nostrums I have named above as being the leaders in sales. If this condition exists among the druggists in one city, is it not quite probable that the same condition is more or less universal? 158 (A lack of time, since accepting your Secretary's invitation, pre- vented me making an extensive inquiry from druggists in many cities.) The foregoing would seem to lead to the conclusion that, as far as the patent medicine evil is concerned, legislation cannot be effective unless it be directed toward the psychic suggestion of the form of the advertisement in such manner as to positively control the publication and distribution of testimonials. Considering the reason why legislation in the past has not diminished the sale of patent medicines, it is pertinent to note the opinions of several druggists. One who is both a wholesale and retail dealer says, "The testi- monials distributed by circular and published in newspapers keep up the sale of patent medicines." Another says, "Patent medi- cines will be sold just as long as the patent medicine men can hire those who have a modicum of medical education added to a keen business insight, to direct their advertising department." Another prominent North High Street druggist says, "Patent medicines will be sold as long as newspapers advertise them and people will send them testimonials." These are three of over twenty-five statements of like character by druggists. This, then, is a concrete statement of the fact — legislation which does not reach the cause can never cure the effect. Can legis- lation be enacted which will strike at the root of this matter? I doubt that legislation can be enacted which would prove consti- tutional at the present time. It may be that after a few more years of education, the public and our courts may be so developed as to see the need of sustaining such a measure, when passed by a legislative body, or even to aid in securing such a measure. The more you or I face this problem squarely, the more will we be convinced that the real remedy lies in our own hands, but it means endless, honest work. This work is so closely connected with our second proposition that I will discuss that now, — "THS PROTECTION OF THE PUBI.IC FROM MEDICAI. FAKERS." What is a medical faker? Is the term to be limited to him who has NO medical training and pretends the same, or is it to include 159 all who really fake, even tho they have M.D., A.M., or other addenda to their names? Is the great surgeon who permits his name to appear in a magazine section of the New York Times as ''never having had a failure'' any less a faker than the street vender with his wig and monkey? I hear a hearty NO! Is the ignorant pretender more culpable than the educated faker? There is a scripture which seems quite applicable here. "For without the law sin was dead, but the law came and sin revived." This is to say that the man who knows no scientific law must be less culpable than the one who knows some or much scientific law! Is it a fake for a man to claim, either thru medical journals or lay papers, to have "treated a case hitherto unknown, or to have performed an operation which was the first of its kind ever performed" — when the truth of the matter is the pages of our medical journals and text books show such cases to have been known, treated and operated upon years before? You and I know that advertisement is as necessary to the doctor as it is to the merchant. The only quibble is as to the form, and the truthfulness. As to the form — the doctor of olden times believed that "By their fruits ye shall know them," and relied upon the advertise- ment from mouth to ear. This method of advertisement was slow. It did not, and never has yet, produced a very large following. The first step in getting away from this was the establishing of medical colleges for the sole purpose of advertising its promoters, and we had many kinds, as we still have many cults for the same purpose, cults taking the place of former cheap schools. It was and it is yet said to be very unprofessional to advertise in lay newspapers and pay for the space the same as the commercial man pays. But there is one strange thing, in that it seems to be professional if we can "work" the newspapers for a magazine sec- tion advertisement under the guise of news and not pay for it. You, who know the business side of the newspaper world, know very well that the business manager of a Metropolitan newspaper is not a philanthropist, and, knowing that, you also know equally well that all these advertisements have been paid for either di- i6o rectly or indirectly, and you also know that it is the acme of hypocrisy for anyone to assume an air of injured innocence in case of flambuoyant magazine section advertisements. It is a very difi&cult and probably thankless task to attempt the correction of this thing. I am, however, thoroly convinced that if we are to succeed in securing such legislation as can be enforced to control patent medicine evils and to abolish medical fakers, we must in sincerity and force, first abolish this iniquitous system of "working the newspapers for free advertisement of prominent men." How can you, reasonably, expect the public to believe that a patent medicine cannot be made to fit its needs if a doctor is ever ready to dish out an envelope filled with "ready to serve pills or tablets" or prescribes a fluid preparation which is poured out by the druggist from a bottle bearing a label as grotesque as any on the patent medicine bottle? Or in a surgical case, how can you reasonably expect the lay- man to think there is any virtue in asepsis or antisepsis, if he go into a doctor's office with a wound and the doctor unwraps a roll of cotton from a paper wrapper, without washing his hands, picks up an instrument from a dust covered stand, and proceeds to infect the wound? And yet such things are common among the profession. If, then, the public does not see the importance of, nor desire legislative protection against patent medicines and fakes, whose is the fault? We play into the hands of the patent medicine men and the fakers by these unscientific and careless methods. At the same time we have utterly failed to take note of the fact that the patent medicine men exert an influence over the public mind thru their advertisements, in which they com- bine all the arts of suggestive therapy. Christian Science, vito- therapy and financial economy. There can be no question about the sacrifice of life or of the wreckage of health which is constantly the result of patent medi- cines and medical fakers, but the responsibility for the hold they have on the public rests upon the shoulders of the medical pro- fession to a considerable extent, because — i6i First. We have not taken the people into our confidence enough to educate them to their needs. Second. As a profession, we have not publicly taken any action toward condemning members of the profession for the acts above referred to. Third. There has been no positive action taken by our medical societies looking to the curtailment of these activities. Fourth. The American College of Surgeons was organized with the avowed purpose of controlling some of the evils, chief of which was fee splitting, and in its inception some of those who had been most active practicers of these evils were made charter members. They kept other men out by objections and have tried by malicious letters, and otherwise, to injure members or Fellows who have never been known to split fees or commit any other professional wrong. The general public soon finds these things out, recognizes the Phariseeism, and is quick to resent an espionage by such men. The fee splitter will continue to split fees, and the faker wdll continue to advertise his wares with the approval of the public until we, as a profession, cease to commend or recommend in any way whatsoever, men who flagrantly violate every sense of professional ethics and refinement. We cannot reasonably ask or secure enforcable laws to restrict the faker in his operations unless we actively, positively and effectually control the adver- tising activities of the prominent men in our profession. In other words, the profession must come wath clean hands, if it expects to demand of the public support in controlling fakers. The neces- sity may be ever so great, but the people cannot, and will not, see any line of demarcation between professional humbuggery and the humbuggery of the faker, and we must be honest enough to own that there is only a slight moral difference, and that is in favor of the faker , because he is not as well educated or trained as the professional man, and consequently, cannot be expected to see the real scientific and moral refinements with as clear vision as the educated doctor should. Then if we have fakers and advertisers inside the profession and do not attempt to discipline them professionally, what right have l62 we to seek legislative restriction for those outside, whose educa- tion is not equal to, and whose appreciation of the responsibilities must, therefore, be less than those medically trained? It is an absolutely fair proposition. How canst thou say to thy brother, Brother, let me pull out the mote that is in thine eye, when thou thyself beholdest not the beam that is in thine own eye? Thou hypocrite! cast out first the beam out of thine own eye, and then shalt thou see clearly to pull out the mote that is in thy brother's eye. Can we, as a profession, consistently ask legislators to enact laws to control the other fellow's short-comings, which are no worse than our own, so long as we have done, and are doing, nothing in our medical organizations to eradicate professional buncombe? Is it not time that we be honest with ourselves? Is it not high time that we see to it that our profession is far above reproach ere we spend so much effort to reform the other fellow? I believe that you will agree with me that it is of prime import that we first cleanse our own stables ere we undertake the task of cleansing the Augean stables of the fakers and patent medicine men of the filth and accumulation of years, due to our own neglect. Hercules was able to command the waters of the two rivers, Alpheus and Peneus, to cleanse the Augean stables, and we must be able to command the waters of courage, conscience, character and common sense, if we are to clean and purify the public mind of the filth, foibles and falsity which have accumulated thru years of activity on the part of patent medicines and fakers, and culpable neglect upon the part of the profession. These are unpleasant truths, I know, but that they are truths, I challenge any man to controvert. Then the first legislation, to be of effect against medical fakers, must be such legislation in our medical organizations, strictly enforced, as will prevent faking by any member of the profession. National and state laws have been enacted to correct some of the evils we are discussing, but most of them are not enforceable because the evidence cannot be obtained. These laws do no good, but, on the contrary, do much to minimize the influence of the medical profession by the failure in enforcement. One law thoroly i63 enforced is of more value than one hundred which are openly defied. To epitomize a few suggestions : First. It is not more legislation that is needed, but better, truer and more complete education. Second. The education of the public in the patent medicine heresy is only to be accomplished by and thru the medical pro- fession, and in order to accomplish practical results, each member of the profession must be an active committee of one to instruct his clientele and Third. The printed matter which goes to the public must not be limited to the newspaper advertisements of patent medi- cines and fakers and the circulars of testimonials sent out by them, but the profession should establish and publish a common sense journal for the people, to contain articles by honest men, telling them, in plain words, the truth, and without assuming anything fantastic. Fourth. How are you going to frame a law which will reach the patent medicine evil? It can only be done by direct attack upon the form of advertisement. This attack may be delivered in both of two ways. a. By sectuing co-operation of advertising agencies, newspapers, magazines, etc., to restrict the form and character of advertise- ments to statements of truth only. h. By Federal and state legislation to control the form and character of all advertisements. The question then is, can such a law be constitutional? STANDARDS APPLICABLE TO CHILD LABOR. By Hblbn L. Sumner, Ph.D., Assistant Chief, U. S. Children's Bureau, Washington, D. C. In these days of anxiety over war the need of considering thoughtfully how to bring up the younger generation sound, healthful, and unstunted in growth has become apparent even to the layman who has no interest in social problems. It is well known that thousands of applicants for enlistment in the United States Army are refused because unable to pass the physical test. Yet this country is deplorably behind European coun- tries in gathering data as to the physical condition of children. ^ It is well known that every growing body is peculiarly liable to injury from overstrain and is peculiarly sensitive to all sorts of industrial hazards. Yet so far as I have been able to discover, the only investigation of the effects of child labor on the growth of the body ever made in this country is the series of measurements of working and school children now being made by Dr. Helen T. Woolley, of Cincinnati.^ Four years ago Dr. Teleky, of Austria, at the meeting of the International Congress of Hygiene and Demography at Washington, urged that those having an oppor- tunity for such study should report as to the physical effects of industrial labor on children.^ Yet we still have little besides d priore reasoning on which to base a judgment as to the effects of occupations on growing human bodies. In considering physical and probably all other standards ap- 1 The first systematic series of measurements of children in this country appears to have been that made by Dr. Bowditch, of Harvard, forty years ago. Bowditch, H. P.: "The Growth of Children." Boston, 1877. (In Massachusetts State Board of Health, 8th annual report, pp. 275-323.) » For preliminary report of this investigation see Woolley, Helen T., and Fischer, Charlotte R: "Mental and Physical Measurements of Working Children." Psychological Review, Monograph, December, 1914, V. 18, No. 1. » Teleky, Ludwig: "Altersprobleme gewerblicher Hygiene." (In 15th International Congress of Hygiene and Demography, Wash., 1912, Transactions, V. 3, Pt. 2: "Hygiene of Occupations, "pp. 957-974.) i65 plicable to child labor, all minors should be classified as children. The age of attaining majority, coming as it does near the period when growth is completed, is a fairly close approximation to the physiological end of childhood. Legally, moreover, a minor is under the guardianship of the state, which has an unquestioned right to abridge his freedom of contract or to impose upon him any regulation deemed to be in his interest. On the one hand, the minor is peculiarly subject to regulations calculated to es- tablish standards for his protection because of his legal status as a ward of the state, and, on the other hand, he is peculiarly in need of the establishment of such standards because of his weak- ness and because his organism is carrying a double burden, that of self-renewal and that of growth. The problem is only in part to be solved by prohibiting child labor. Under modern industrial conditions the young, immature body and mind must inevitably be injured by the strain of keep- ing pace with a machine, by carrying heavy weights, or by work- ing under abnormal conditions of temperature, humidity, dust, or fumes. An age standard for entrance into industry has there- fore been established. In this country the minimum age for em- ployment in industrial occupations is generally fourteen and in many states children under sixteen may not be employed in processes which are believed to involve unusual risk. These ages, it is highly probable, will be raised by two years each within the next decade, particularly if investigations of the physical effects of child labor demonstrate the need for such changes. But during an unforeseeable future the vast majority of young people will enter some gainful occupation before their physical growth is entirely completed, and the standards to be applied to the work of these young people constitute a vitally important part of the problem of child labor. Two kinds of standards must be considered, those applying to entrance into industry and those applying to conditions and character of work after entrance into industry. Of the standards appHcable to entrance into industry the principal ones actually in use relate to age, to education, and to physical condition. i66 Age is a fairly well-defined standard, yet Dr. Rotch and others^ have pointed out the marked difference between the chronologic and the physiologic age of children and have urged that the stage of physiologic development be taken into account in con- nection with the years of life. The desirability of doing this is brought home to anyone who visits an office where working papers are issued to children from fourteen to sixteen years of age and sees strapping young boys and girls — strong perhaps only in appearance — side by side with small, undeveloped chil- dren. In several states, if a child cannot produce documentary evidence of his age, he is given a physical examination to deter- mine whether he is probably over fourteen. But as in such cases the aim is to secure an approximation to chronologic age, no method similar to that advocated by Dr. Rotch, of taking a radio- graph of the bones, is used. Indeed, the development of the teeth seems to be more often relied upon than any other single factor in giving a physician's certificate of age. Educational standards for entrance into industry differ widely but only rarely is any provision made for the various mental states. Yet children applying for working papers grade from the exceptionally bright down to mental defectives. Out of fifty unselected children who had gone to work at fourteen, after hav- ing completed the fifth grade, and who were tested by the Yerkes point scale at eighteen years of age. Dr. WooUey found that 13, or about one-fourth, belonged in the class of mental defec- tives, while 15, or more than another fourth, were border-line cases.2 Fourteen years is generally regarded as the average age for completion of the eighth grade, and many people are sur- * Rotch, Thomas M.: "Chronologic and Anatomic Age in Early Life," Journal of the American Medical Association, 1908, 51, 1197-1203. "The Labor and Work of Children Should Be Adapted to the Individual Child." (In 15th International Congress of Hygiene and Demography, Wash., 1912, Transactions, 8, Pt. 2: "Hygiene of Occupa- tions," pp. 975-984.) Crampton, C. Ward: "Physiological Age; a Fundamental Principle." American Physical Education Review, IS, 141-154, 214-227, 268-283, 345-358 (1908). "The Significance of Physiological Age in Education." (In 15th International Con- gress of Hygiene and Demography, Wash., 1912, Transactions, 3, Pt. 1: "Hygiene of Infancy and Childhood," pp. 224-236.) * Woolley, Helen Thompson: "A New Scale of Mental and Physical Measurements for Adolescents and Some of Its Uses," Journal of Educational Psychology, November. 1915. i67 prised to find that among fourteen-year-old children applying for working papers completion of the eighth grade is the exception rather than the rule. If children were required to have completed the eighth grade before going to work, few, if any, mental defec- tives could secure working papers before they were sixteen. Under a law recently enacted in New York State, ^ no child un- der fifteen can work without a certificate of graduation from the eighth grade, and this is regarded as practically raising the min- imum age to fifteen years. In a state like Massachusetts, which requires completion of only the fourth grade, many mental de- fectives must enter industry on exactly the same basis as normal children. Yet these mental defectives are undoubtedly subject to greater risk in industry than are normal children. A dozen or more states^ require every child to be examined by a physician and to be declared either "in sound health" or "physically able to perform the work which he intends to do," or both, before working papers will be issued. Sometimes this physical examination is supposed to be repeated each time the child changes his position, and in Maryland each time he changes his occupation. In states requiring re-examination on change of position, the examination is supposed to have refer- ence to the particular occupation and the child is therefore re- quired to bring a promise of employment signed by the prospec- tive employer and stating the occupation in which he is to be engaged. But studies of the administration of child labor laws made by the Children's Bureau have shown that physicians giving the physical examination rarely if ever have enough knowl- edge of occupations to say that a particular child should not en- gage in one occupation, but may safely engage in another. Some physicians have told us that they would n4t give a child with heart trouble a certificate to run errands, but these same physi- cians, through ignorance of the duties involved, might give such a child a certificate to work in an occupation which would involve cany^ng heavy weights up and down stairs. In England the certifying siu-geons themselves study at first hand the occupa- 1 New York Laws of 1916, Chap. 465. effective Feb. 6. 1917. * Sumner, Helen L., and Merritt, Ella A.: "Child Labor Legislation in the United States." (U. S. Children's Bureau, Publication 10. Industrial Series No. 1.) i68 tions for which they give certificates. But in this country we pay our physician only for making the physical examinations and make no provision for scientific study of occupations, either by the examining physician or by anyone else. When such studies are made it is to the credit of the individual physician and not of our system. In states requiring intelligent discrimination between occupations, serious need exists for the establishment, through careful study of the different kinds and degrees of strain involved, of an occupational standard or measuring rod by which a physician can determine what occupations each individual child can engage in without the probability of injury. When the law, on the other hand, requires that the child shall be in "sound health" certifying physicians are in great need of a standard of measurement for "sound health." New York, for example, has such a law and in some cities, notably Rochester, children are required to have their teeth put in order before they can go to work, whereas in other cities little or no attention is paid to the condition of the teeth. ^ When the law adds that the child must be of normal development for his age, physicians need to know what is normal development for children of differ- ent ages. Recently a pamphlet has been published containing a statistical study of the heights and weights of applicants for working papers in New York City,^ with a view to establishing standards of height and weight at different ages from fourteen to sixteen for the use of certifying physicians. But European studies have demonstrated that children of the working classes are shorter and lighter than children of the upper classes.^ Are we to be satisfied in this country with a standard of "normal development" based on a group of children who are probably underdeveloped ? Another standard which ought to be applied before entrance into industry relates to the choice of occupations. In many » Sumner, Helen L., and Hanks, Ethel E.: "Employment Certificate System in New York." (U. S. Children's Bureau, Publication 17. Inaustrial Series, No. 2. Pt. 2, p. 48.) » Frankel, Lee K., and Dublin, Louis I.: "Heights and Weights of New York City Children 14 to 16 Years of Age; A Study of the Measurements of Boys and Girls Granted Employment Certificates." Metropolitan Life Insurance Company, N. Y., 1916. » Loriga, Giovanni: "Lavoro dei fanciuUi e cresceuza del corpo." (Italy. Ministero di agriculture, industria e commercio. UflScio del Lavoro, 1910.) i6g cities in Germany the school physician gives advice to children leaving school for work as to the kind of occupations for which they are by nature fitted. Such advice, in the light of Mrs. Woolley's experiments, ought to take into consideration both physical and mental status. Vocational education of children should also have regard to these two factors. For this reason, if for no other, all school children should be examined periodically to determine their state of physical and mental growth, and the results of such examinations should be placed before vocational counsellors and before physicians who are required to certify to the children's fitness for work. Advice as to choice of occupa- tions, however, can be given only by persons who are thoroughly acquainted, often as a result of personal observation, with the requirements of the various vocations. At present the most poorly defined standard for entrance into industry is the physical. The same thing is true of standards applicable to character and conditions of work after entrance into industry. A priori we know that a child is peculiarly suscepti- ble to all industrial hazards, including injury from overstrain. We know that some occupations involve overexercise of one set of muscles and underexercise of all others; that in some there is too much sitting and in others too much standing; that in some children are obliged to carry weights far beyond their strength and that in others, particularly agricultural labor, they are fre- quently deprived of sufficient sleep. Austrian sickness insurance records show that frequency of invalidity is extremely high among youthful laborers.^ It is noticeable, moreover, that the invalidity rate is not the greatest at the age of fotuteen, immediately upon entry into industry, but becomes alarming diuring the second year of working life when the injurious results of the occupation have had time to show themselves. The experience of German invalidity funds confirms this result. ^ Accidents are also known to be abnormally frequent among yoimg workers. And the Federal Bureau of Labor^ has shown that in the city of Fall River, Mass., the death rate from tuberculosis among boys 1 Teleky, Ludwig, op. cit. * Report on Condition af Women and Child Wage-Earners, Vol. 14, "Causes of Death among Cotton Mill Operatives." p. 75. 170 15 to 19 years of age employed in cotton mills was nearly double that of boys not so employed, and that similar rates for girls of the same ages show even a greater difference. The evils of child labor, however, cannot be measiwed primarily by the incidence of the ordinary occupational injuries and dis- eases to which both adults and children, in varying degrees, are liable. Records of occupational injuries and diseases are being collected at the Massachusetts General Hospital and also, I understand, at some of the hospitals in Philadelphia, and these records may in time give us statistics showing the relative lia- bility of children and of adults to such ill results of labor. But except for Dr. WooUey's measurements of height and weight nothing, so far as I know, is being done in this country to throw the light of science upon the effects of occupations upon the growth of the body — the real primary test of child labor. Some years ago a pamphlet on this subject, written by Pro- fessor Loriga, of the University of Rome, was published by the Italian Labor Bureau. ^ In this pamphlet Professor Loriga gath- ered together the results of all the scientific studies of the effects of child labor on the growth of the body which up to that time had been made in any country. Professor Loriga's conclusions are: first, that the period when vitality is needed for the growth of the body, and not merely for its maintenance, ends only between the twentieth and twenty- fifth years; second, that in every comparison of height, weight, and lung capacity of children of wealthy and of poor parents, great differences in favor of the wealthy classes are shown; third, that similar measurements of working and non-working children show great differences in favor of the non-working children; and, fourth, that comparisons of the height and weight of con- scripts from different occupations demonstrate conclusively that after the normal age for growth has passed it is impossible ever to repair the damage done by conditions which have retarded or caused uneven development. He admits that heredity plays an important part, but maintains that heredity merely fixes an average around which there is ample room for individual varia- » Op. cit. 171 tions. The more favorably situated tend to attain the maximum while the ill-nourished and hard-worked tend to fall to the min- imum possible to their heredity. The most important period of growi:h, he says, the period during which "the organic needs are most exacting in their demands upon the energy of the young," is the period of adolescence, extending from the twelfth to the eighteenth year — the very period "during which children are permitted to begin manual labor and are often exposed im- mediately to its most serious hardships." The author calls atten- tion to the great importance to health and strength of every deviation from the normal in the form of the skeleton and main- tains that malformations and arrested development are fre- quently caused by too early labor. Though Professor Loriga fiuiiher maintains that not all conse- quences of early labor are visible and measurable, he advocates periodic medical examinations of all children at work to deter- mine whether their state of health and of growth appear to justify their further employment and to discover, in so far as possible, the injurious influences of occupations before the resulting in- juries become of pathological importance. "In other words," he says, "the medical visit should establish in what degree the bodily development of working children progresses under the influence of labor." Perhaps the most important consequences of early labor which are not capable of immediate and direct measurement are those resulting from fatigue. It may never be possible, in fact, to es- tablish any definite standard of physical and mental labor for either adults or children until scientific measures for fatigue and reaction from fatigue have been established. "Young per- sons," says Dr. Hayhurst, of Ohio, "particularly those under eighteen years of age, are permanently and more seriously dam- aged by the poisons and toxins of fatigue than are those of ma- turity, because the functions of growth and development are seriously interfered with and reserve forces are so dissipated that, from the weakened constitution, liability to consumption and heart disease is great." ^ 1 Hayhurst, E. R.: "Occupational Diseases and Industrial Hygiene.*? Chicago Tuber- culosis Institute Bulletin, Nov. 15, 1915. 172 The war and its accompanying need for maximum production of munitions has attracted considerable attention in England to the subject of fatigue and its relation to output. Last year a report was issued of the preliminary results of some experiments conducted for the Home Office by Dr. Kent, of the University of Bristol/ with a view to discovering "a test for recognizing the presence and a gauge for estimating the degree of fatigue as met with under factory conditions." The results of these ex- periments indicate that in the power of recovery from fatigue is to be found an index of the general condition of an individual which may be of great use, but the most promising direct tests of fatigue were found to be the simple measurements of acuity of sight and hearing. Dr. Kent considers these tests of great im- portance because of their simplicity in application and their con- sistency in results, and because they indicate distinctly fatigue of only moderate severity. Recently, however, a pamphlet on "Industrial Fatigue and its Causes^" has been issued by the British Health of Munition Workers Committee which defines fatigue as "the sum of the re- sults of activity which show themselves in diminished capacity for doing work," and which concludes that the true sign of fatigue is diminished output. But it may be questioned whether, in considering the effects of fatigue on children and their develop- ment, diminished output would be an adequate test even in an occupation where output could be definitely measured, and in an occupation involving the use of automatic machinery fatigue might cause a serious accident long before any diminished output would be evident. The effects of fatigue in children are probably not to be measured within any definite period, but only within the lifetime of the individual. According to Dr. Treves, of Turin, speaking at the International Congress of Hygiene and Demog- raphy, in 1907,^ the crux of the whole question lies, not in greater or less productiveness, but in the cost to the worker of different * Kent, Albert F. S.: "Interim Report on an Investigation of Industrial Fatigue by Physiological Methods." (Gt. Brit. Home Dept.), London, 1915. 2 Gt. Brit. Ministry of Munitions: Health of Munition Workers Committee, "in- dustrial Fatigue and Its Causes." London, 1916. (Memorandum 7.) » Treves, Zaccaria: "Fatigue as a Result of Occupation." (In 14th International Congress of Hygiene and Demography, Berlin, 1907, V. 2, Sec. 4.) 173 units of production. Says Dr. Treves, "If the physical cost of the long hours and overstrain which characterize unintelligent industrial organization were directly and proportionately evi- dent, both in the sensation of fatigue and in the output of the industry, individual and collective, the problem of fatigue, as a result of industrial labor, would, in my opinion, have been solved long ago, instead of being obscured by the illusory profits of long hours and insufficient wages." Any standard of work for growing children should obviously protect them, not only from the ordinary occupational hazards, but also from labor calculated to retard their physical develop- ment or to cause abnormalities in their bodily growth. Short hours — perhaps half-time employment and half-time schooling — and adequate provision for the safety and sanitation of working places where children are employed are, of course, essential. The age limit for especially hazardous or unhealthful occupations should be as high as experience may prove desirable even if all minors are excluded. Young persons should probably not be employed at all in occupations where poisonous substances are handled or given off for, as Dr. Teleky^ points out, on the one hand the young organism is peculiarly sensitive to poisons, and on the other hand the care and strict personal prophylaxis necessary cannot be expected of children. The age limit for each differ- ent occupation should be set so high that on reaching it every normal child may be expected to work without injury in that particular occupation. But every child — every minor — at work should be examined periodically to determine whether he is being injured or his growth is being interfered with by what he is doing. This may seem a high standard, but it is a necessary standard for the efficiency of the race, either in war or in peace. In conclusion, I should like to urge upon the medical profession, not only the political and social importance of the establishment of standards which will make possible the intelligent enforcement of already existing child labor laws, but also the need for such scientific investigations of the effects of different occupations on the body during its formative period as will furnish an authorita- 1 Op. cit. 174 tive basis for further legislation. As Professor Loriga states: "Only an individual who has had a sane and normal development can acquire, when grown, fulness and equilibrium of all his facul- ties and be able to perform his work with the greatest possible physical strength and mental efficiency. In order, therefore, to conserve and increase the most valuable capital of society — the force and health of mankind — it is our imperative duty to adopt such measures as will prevent the impoverishment of child life." .Yet only by exact observations and measurements can it be conclusively demonstrated whether or not in this country, as in Europe, early labor endangers the physical development of children and causes young people to grow up stunted or malformed who under other conditions would be healthy, vigorous and well built. DISCUSSION. Dr. Charles Bernstein, Rome, N. Y. : The Royal Commission in England found that as a result of the mother working during gestation the children were much smaller and of less weight than those of mothers living under different conditions. In the matter of child labor I often wonder what is going to happen to the child from i6 t^ 1 8 years of age if he is to be prevented from working, and whether as a result of bad habits formed thru lack of occupation his condition will not be much worse than if he were working. Mrs. Florence Kelley, New York City: For many years I have been engaged, as a member of the National Child Labor Committee, in striving to get standards establisht with regard to child labor. It seems a deplorable misfortune, therefore, when the official critic of a paper rich in facts and ideas, and written with care ahd caution, sleeps thru the reading and then imputes to it that which is not in it. There is no suggestion in Dr. Sumner's paper of prohibiting work for young people be- tween 1 6 and i8. No advocate of restricting child labor in this country proposes anything so absurd as that. We have unfortunately no medical study of the effect of work upon the children. That is a need very greatly felt by the organizations woich are seeking legislation. Dr. J. L. Heffron, Syracuse: I should like to ask Dr. Sumner whether the contention which I have heard is correct that the increasing stature of the young women and young men of to-day is due to the fact that the boys and girls of the middle and upper classes are overfed and underworked diu-ing the period of development? 175 In establishing a standard of development I do not think that height alone is to be considered; it is the proportion of the height to other dimensions of the body that is to be considered. The children in this country of the better classes are relatively larger than the children of the same classes of other countries. Dr. Sumner, closing: I think that Mrs. Kelley answered the point regarding children working between the ages of i6 and i8. I do not mean that they should not be work- ing, but that they should not do work which would stunt their physical de- velopment. WOMEN AS WAGE-EARNERS. By Mrs. FlorbncB Kellby, General Secretary, National Consumers' League, New York City. In two fields the National Consumers* League has long been activ, in the effort to shorten, by laws and court decisions, the working hours of women wage-earners, and in modifying by minimum wage legislation the pay that they get. Recently a new problem has arisen, that of compulsory sick- ness insurance as it affects women. The importance of laws shortening women's working day grows by leaps and bounds with the growth of their numbers and the speed and strain involved in their work. Recently the number of wage-earning married women seems to have been suddenly increast. Altho all statistics on this sub- ject more recent than the United States Census of 1880 are mere guesswork, those of us who have long been living in the industrial pit know that married women are more numerous in certain industries and certain nationalities. One markt exception is the Russian Jewish colonies where the mothers stay at home with the children. Incidentally the local health figures seem every- where to show an exceptionally low infant mortality rate among Russian Jewish families. Among other nationalities, the Italians, Bohemians and Poles, for instance, there is notoriously rapid growth of married women in laundries, canneries, cigar and tobacco factories and in the needle trades. In many of these places women have to make great physical exertion. These facts enhance the importance of the decision of the Supreme Court of the United States sustaining as valid the California eight-hours law for women employed in all occupations except domestic service, nursing the sick as graduate nurses, and horticulture, viticultmre, and agriculture. Four states now have the eight-hours day for women, upheld by this decision: Arizona, California, Colorado, and Wash- ington. 177 Five other states have establisht by law a period of rest at night for women: Massachusetts, New York, Pennsylvania, Indiana and Nebraska. Connecticut provides that women shall not work in factories after lo p.m., but does not prescribe when they may begin in the morning. Since the war began and contracts poured in, therefore, the following schedule has been in force in a great munitions works in New Haven : The day shift begins at 7 a.m. and ends at 6 p.m., with an hour off at noon. The evening shift works from 6 p.m. to 10 p.m. In compliance with the law it then stops. Two hours are spent in a dance hall, eating late supper and dancing. At one minute past midnight it is the next day, and work is resumed and continues until 6 a.m., the evening shift thus completing its legal working period of ten hours interrupted from 10 p. m. to midnight. Tuberculosis nurses and charity workers in New Haven re- port much illness among mothers who work at night and take care of their homes and children by day. All efforts to amend the Connecticut law to correspond with the California decision, or even with the less advanced statutes of the eastern neighbors of Connecticut where night work is limited, have failed. The Consumers* League defends statutes shortening the work- ing hours of women, when they are attackt as unconstitutional. In numerous elaborate briefs it has placed before the United States Supreme Court the facts relating to fatigue and disease. It is a singular circumstance that we are only now beginning to get from the American medical profession any substantial contribu- tions of facts available for these briefs. Of equal importance with overwork in relation to disease is underpay. Mr. Brandeis, now Justice Brandeis of the Supreme Court of the United States, giving his services as counsel for the Consumers' League, therefore, defended before the Supreme Court of the United States on December 17, 19 14, the Oregon minimum wage law, being invited by Attorney-General Brown, of Oregon. The Oregon Industrial Welfare Commission had prescribed $8.64 as the minimum weekly wage of an adult 178 woman employed in a paper box factory in the City of Portland. No decision has been reacht, and a rehearing has been ordered after the election. If the Com! holds the Oregon law unconstitutional, the Con- sumers' League will be confronted by the heartbreaking task of amending the Constitution and changing the powers of the Court, for a democratic industrial Republic cannot persist in which grow- ing masses of wage-earners are unable to live in health and frugal decency by their daily work. I regret very much not to have heard the discussion upon in- dustrial insurance. In the Eastern States it is proposed to re- quire compulsory contributions from women workers to the in- surance fund. This is a form of new taxation. It is of serious importance where thousands of women are living at, or below, the bare level of vital efficiency, and are to be compelled to pay a part of an insufficient wage for medical treatment of ailments due to hunger. Before making compulsory deductions, a living wage should first be assiured. We urge, therefore, that insurance be made non-contributory from employes who get less than $9 . oo a week wages. We contend, also, that a mandatory provision should require the presence of women upon all boards, commissions and com- mittees created to administer funds to which women contribute. Finally, we protest against cash bonus payments for the bene- fit of men who send their child-bearing wives into industry. There is at present no ascertainable answer to the question, "Whose child-bearing wife works for wages, and why does she work?" The existence of such provision in some foreign countries does not absolve Americans from the duty of thoro enquiry into the American facts. To legislate without enquiry is to make a leap in the dark. HOUSING REFORM THROUGH LEGISLATION. By Mr. Lawrence VeilleR, New York, Secretary, National Housing Association. I suppose there is no statement we hear expressed so often these days as that there is too much legislation. Legislation is nothing more nor less than public sentiment crystallized in writing. To say that there is too much public sentiment is rather absurd. My topic is "Housing Reform through Legislation." The housing problem some of us are just beginning to be conscious of. It is a problem bound up with civilization. It is created by man and therefore can be cured by man. I would not suggest that the cure of bad housing conditions rests solely in legislation, but probably more can be accomplished through legislation than through any other form of endeavor. Bad housing is due to a variety of causes. As modern practi- tioners we must, of course, treat causes and not symptoms, and when we come to treat the causes of bad housing conditions the most effective remedy will be found to be through the medium of legislation. To illustrate, we find people in all cities living in cellars, underground rooms without sunlight or ventilation. What method is there for stopping people living in such rooms? Education has not proved effective. Suppose we find, as was found in New York some years ago, 350,000 windowless rooms. Could we get windows into those dark caves by telling the people they ought not to live in them, or by saying to the landlords that they ought not to rent them ? We have never yet been able to get results by that process. The only effective weapon is the club of legislation, the strong arm of the law. The methods we are employing in housing reform are the same as the methods that are employed in the matter of securing a proper milk supply. No one would think of controlling that vitally important ques- tion by building a model dairy. Instead they would pass laws to prohibit the sale of bad milk. The same principle applies to housing which is as much a commodity as anything else. We have found that the largest returns in results come through i8o wise legislation effectively enforced. There is an unfortunate tendency among Americans to think that with a law once passed we have solved or cured a condition. At the best the passing of a law may be said to represent the aspirations of the people. A poor law well enforced is better than a good law badly enforced. No one admires the work of the health officers of the country more than I do, but health work in the United States is still in its infancy. Many of the health officers do not even know the conditions in their own cities. In a recent eJBFort to find the num- ber of privy vaults, etc., I felt I could get the information from the health officers of different municipalities. I found, how- ever, there was no list of such officers in existence anywhere. In all our cities we see the same bad housing conditions; it is only a matter of degree. The methods of remedying the evils come down primarily to legislative effort. We get 99 per cent, of result through legislative effort compared with i per cent, through other forms of effort. I do not mean to say that there are not other efforts that are most profitable. We should do everything that will yield results — if the single tax or suffrage will get us results, let us by all means use them — let us do every- thing that will give results, but experience shows in the long run that we get the greatest degree of results through laws. Some of the worst housing conditions can be overcome only by education, especially education of the people who live in the houses. No one needs education perhaps more than the average landlord, and the architect as well. Many a woman breaks her back bend- ing over a low sink because no one has sense enough to make it higher. The matter of the right kind of houses rather than the building of tenements is worthy of much study. In some places tenements are the only things possible; in other places the small house is perfectly feasible. The detached house allowing the entrance of fresh air should be built rather than the house in rows, where this is possible. Such houses perhaps are not feasi- ble for the man who gets from nine to fifteen dollars a week, but this touches upon other aspects of the housing problem. Legis- lation still remains the way in which we shall get the larger re- turns, the 99 per cent, of results instead of the i per cent. Every i8i community having slums must start with the fundamental law that houses unfit for human beings shall not be allowed to exist. When, through legislation, a city is rid of its worst conditions, its people then may well turn to other interesting and profitable forms of endeavor. DISCUSSION. Dr. John B. Andrews, New York City: I feel that we may all take off our hats to Mrs. Kelley, a woman who has been a pioneer in social work and who has always had the courage of her convictions. I have nothing to say with reference to the hours or wages mentioned in Mrs. Kelley's paper, but will use the two or three minutes which I have to refer to a few points concerning the health insurance aspect which she toucht upon, familiarly known as maternity insurance. Mrs. Kelley recognizes the existence of the problem; she recognizes that married women are already in industry to a very large number and that that number is increasing somewhat rapidly. We, of course, know that there are thousands of women in this country dying each year in childbirth and many more thousands of little children dying for the lack of care at the time of birth and shortly thereafter. We also know that the governments of four states in this country have already recognized this problem by prohibiting by law the industrial employment of women during a few weeks before and after childbirth. At the very time when a woman needs assistance the most, we at present say she shall not earn her usual income, and in this respect we are different from all other countries who do thru social insurance look after these problems; we provide nothing for her as a matter of right during that time — no medical, obstetric or nursing care, yet the maternity benefits are universally included in all European health insurance laws. Because of a single objection bills introduced for health insurance in three states in 1916 omitted the feature of maternity benefit, except for the insured woman herself. The bills were criticized more for that one omission than for any other single thing. The criticism came, so far as I know, never from "avaricious husbands" who would force their wives into the factories that they might profit, but almost without exception from women, and from un- married women, some of them very prominent suffragists, some of them very prominent socialists. Just see how easy it is to safeguard against the alleged dangers of maternity benefit. At no time has it been suggested that the insured woman should not be in the fund for a period of at least six months before she is entitled to draw any benefits. It is easy for people to come up with definit concrete proposals to increase that period. It is also easy to say that we shall place a maximum limit upon the cash benefit which can be paid. When you re- call that it is absolutely necessary that a woman refrain from her gainful employment before and after delivery and recall that the premiums must I82 be paid in and know that the maximum benefit depends upon that, you reduce the opportunities to the "avaricious husband." As to the unfairness of requiring young unmarried women to pay into the fund, I beHeve that most young unmarried women will be mothers later, and if we recognize the principle of insurance here as we recognize it else- where we shall realize that these young people going into the insurance plan will reap their benefits later. I already pay a tax, by the way, for schools in the City of New York. I have no children in school, but I have a little boy nearly a year old, and I don't object to paying my share for the school system. Neither do I believe that the most of us object to paying for the care of the women and children — the babies — at the time the care is most needed. It seems to me this question of maternity insurance is one upon which we should be able to get together and that we can provide for ma- ternity benefits in America as they are provided for in European countries and without any serious difiQculty. The President, Dr. George A. Hare, Fresno, Cal.: I wish to thank Mr. Andrews for discussing in the very clear manner one of those questions to which we have all given too little thought — the care of mothers and children. Mrs. Kelley: I shall not speak upon minimum wage legislation. Social insurance legis- lation is bound to come. I am in favor of it in principle and shall be in prac- tice as soon as the laws are so drawn as not to favor the sordid husbands at the expense of family life. For five and twenty years I have lived at the bottom of the industrial pit, and I know the sordid husbands who sit in the tenement basements gambling while their wives work in factories. They may do this because they have been workt out in their early manhood, I should like to give them the benefit of the doubt. But it is a clear duty to protest against all bills which provide for gifts to sordid husbands out of the earnings of single women, many of whom receive wages below the living level. All such legislation should moreover provide for representation of women upon the bodies administering insurance. Dr. Hare: I should like to ask Mrs. Kelley whether she is opposed to the legislation which provides that a woman before and after confinement may not work for a definit time and that for this time there shall be an insurance? If so, has she any method of solution of the difficult questions involved in the ob- jection she has raised. Mrs. Kelley (replying to Dr. Hare) : The first thing we need in this country is to ascertain whose wife works for wages. We do not know how many wage-earning child-bearing wives there are, or what their husbands are doing. MEDICINE AND THE INDUSTRIES. By George M. Price, M.D., New York, Director, Joint Board of Sanitary Control. Medicine is a complex science. Its subject is the human living body. Its object is to treat the iUs which the body is heir to. Its purpose is to cure and also to prevent disease. Its ideal is to preserv the health and to prolong the life of man. Man is a social being — a unit of a big social organism. His bodily ills are often caused by his physical environment. The spread of disease is favored by close social contact. His health and length of life are profoundly influenced by the economic, social, intellectual and moral progress of society. Medicine is therefore also a social science. In its study of the etiology of disease it must take into consideration all the many and various factors influencing human health and length of life. In the study of means of healing it must take cognizance of all the facts which bear upon the predisposition of the body to disease, the increase of its power of resistance and the curativ effects of the environmental and social conditions. In the pursuit of its ideal to prolong the span of life, medical men must become the priests of prophylaxis, the teachers and preachers of indi- vidual, municipal, public and social hygiene. Ours is an industrial age — an industrial form of society. The economic industrial factor — ^the method of industrial production — is the foundation upon which the whole superstructure of intellec- tual, moral and social development rests and is based. The in- dustrial population is the predominating part of society. The queens and the drones are but a small minority of the human bee-hive. Hence the interdependence of disease, health and life with industry, industrial conditions and industrial population. Hence the close interrelation between medicine and the industries. 1 84 I. Modem industrial society is scarcely one hundred and fifty years old. It has succeeded the ancient and medieval forms of society based upon slavery and the feudal systems. From the dawn of human history and the very beginning of the science of medicine, the influence of work upon man was recognized by physicians. Hippocrates knew that "there are many handicrafts and arts which cause those who exercise them certain pains and plagues" and speaks of the specific diseases of miners and burden carriers, of gardeners, riders, etc. Plato considered philosophy unfit for those "whose bodies are not only deformed by their arts and handicrafts, but whose souls are also in like manner confused and crushed by their lj£e of labor." The Romans well knew the effects of labor upon man. Mart al speaks of the "blear-eyed smith" and "lame tailors." Galien observed the diseases of certain workers. But thruout ancient times all work was peformed by slaves whose health and ^ives were of little consideration, and medical men thot little and cared less about occupational diseases and the cure of ills due to industry. Nor was the condition of the industrial population much better during the middle ages, or the relation of medicine to in- dustry more humane. The methods of production changed but the slave remained a serf. Religious intolerance and general ignorance weighed heavily upon the industrial population and the condition of workers was cared for but little by the medical man of that time. Not before the sixteenth or seventeenth century did physicians begin to give expression to the knowledge of occupational dis- eases and to a desire of ameliorating the condition of the workers. There must have been considerable data on industrial hygiene during the fifteenth and sixteenth centuries in order to enable the father of industrial hygiene, Ramazzini, to produce his epoch- making work on the "Diseases of Artisans" — a work based upon i85 rich clinical experience and a deep knowledge and insight into industrial activity and conditions. For a century and a half after the publication of Ramazzini's great work, very little was done in the field of industrial hygiene, altho here and there may be found the names of physicians who gave some attention to the subject. SuflSce it to mention but a few who have done pioneer service in this field — such as Richard Mead (Short Discourse Concerning Pestilential Contagion, etc.), John Pringle (Diseases of the Army), James Lind (On Means of Preserving the Health of Seamen), Gilbert Blane (Observations on the Diseases of Seamen), C. Turner Thackrach (The Effects of Various Trades, Professions, etc.). But it is only since the middle of the nineteenth century when industrial hygiene has become a real science, thru the efforts of Hirt, Bhlenberg, Albrecht, Arlidge, Layet, Levy and the more modem representatives, whose names are familiar to everyone now. II. Three elements are essential for industrial production: Raw materials, machinery and human workers. The greatest progress of the industrial age has been made in the invention and discovery of means of production, in the application of natural forces to industry and in the utilization of the natural resources for indus- trial uses. This has been attained and made possible by the prog- ress of industrial engineering and by application of this science to industrial pursuits. Altho the human element is so essential to industry, no such progress has been made in the development of human resoturces, in the care of the workers, in the study of the effects of arts and crafts upon the industrial population, of the prevention of occu- pational diseases and of the promotion of the health of the indus- trial element of the population. Industry was considered as presenting an engineering problem alone. The great medical problem of industry was entirely neglected and the science of human engineering was left far behind that of technical engineering. It is only but lately that the importance of the human element in industry has been recognized, that the relation of medicine to i86 industry has become much closer and the physician has been called upon to take his place in industrial evolution and produc- tion. As yet industrial hygiene is in its infancy and the participation of medicine in industry but at the very beginning. No doubt, however, exists in the minds of all who have knowledge of the sub- ject that great changes are about to be wrought in industrial methods, and the paramount importance of the human element, at last being fully recognized, medicine will become the hand- maid of industry and the physician an important part of industrial production. The time is not far distant when every industrial plant in the country will engage the full-time service of one or more medical men and that our captains of industry will no more think of run- ning their plants without a medical supervisor, than they do now without a technical foreman. As to the functions of the industrial physician, these are bound to develop and take in all the fases of indtXstrial production and the care of the health and hygiene of the workers. The functions of the industrial physician will be to supervise (i) materials of production; (2) the plant; (3) the processes; (4) the conditions of work; (5) the selection of workers; (6) the medical care of the workers while in the plant; (7) medical care of the work- ers and their families outside of their work; and (8) educational activities in conjunction with the medical work. The supervision of the materials of production is necessary for the prevention of occupational diseases by infection and the carrying of infectious germs in some of the materials, also in a knowledge of the toxic nature of certain materials of production and their effects upon workers and their health, and possible substitution by inocuous materials. The supervision of the plant is needed for the proper installa- tion of all safety devices and to insure and improv the ventila- tion, heating and sanitation of the industrial establishment. The supervision by the physician of the industrial processes must be a part of his duties in order to prevent dangers from 187 gases, fumes and other injurious processes adversely affecting the health of the workers. The supervision of the conditions under which work is carried on becomes necessary in order to regulate the temperature, humidity and other conditions under which the work is being carried on, all of which profoundly affect the employes of a plant. A preliminary medical examination in the selection of workers for a plant is imperativ in order to prevent physically unfit work- ers to take up tasks for which they are not fit. The proper care after accidents, first aid, periodic examinations and dispensary clinics within the shops are needed to preserv the health of the workers, to prevent disease and to keep them in a sound condition. The care of the health of the workers and their families outside of the industrial plant in which they work is a necessary adjunct to the work within the plant, because it avails little to take care of the health and lives of workers during the eight or ten hours they are within the industrial plant, while totally neglecting the same during the sixteen or fourteen hours that they are outside of their shop. Finally, educational activities by industrial physicians are factors in the improvement of the health of the workers and consist in teaching personal and industrial hygiene and inculcating the proper habits of health and life among the industrial popula- tion and their families. III. It is thus apparent that the relation of medicine to industries is very important and is bound to become more important as in- dustry calls in the physician and makes him an integral part of its organization. It is time therefore for the medical profession to prepare for the coming events and to educate its members in the new specialty of industrial hygiene. It is about time for our colleges and medical institutions to create and open new depart- ments where occupational diseases and industrial hygiene should be taught and expounded, and where students may take under- and post-graduate courses fitting them for the important tasks before them. In a time when the whole country is being agitated and aroused for mihtary preparedness and increase in our supply of means and devices for human destruction, the medical profession, ever on the side of charity and humanity, should be in the fore in the cause of medical industrial preparedness and of progress in the welfare and health of the industrial population. THE PHYSICALLY DEFECTIV. By Edward O. Otis, M.D., Boston. Whether any of us are mentally perfect is a question, for as Tuke, the great authority on mental diseases, remarks, it is to be assumed that the deity is sane but whether anybody else is, is a debatable question. At all events, most of us have some kind of a mental bias. Morally, we confess that we are all "miser- able sinners;" physically, we are no less imperfect. "There is always somewhere a weakest spot." However, that "weakest spot" does not, with the majority of men, incapacitate them for a man's career in the world. It is only some markt and glaring physical deviation from what we call the normal that places one in the category of the physically defectiv, and this class is what we have to consider. Mind and will always triumph over matter, and when the will-power is intelligently directed and grimly determined, it will make a defectiv body do its bidding. Illustrations of this are innumerable, and all of us can doubtless recall examples in our own experience of success attained in spite of physical handi- caps. Henry Fawcett became blind thru an accident at the be- ginning of his career, yet later he became professor of political economy at Cambridge University, a writer upon the subject, a member of Parliament and Postmaster-General of England. Huber, the blind naturalist, contributed to entomologic science some new observations upon the habits of the bees. It was Mil- ton's blindness which gave us that matchless poem, so sad and yet so triumphant: When I consider how my light is spent Ere half my days, in this dark, world and wide. And that one talent which is death to hide Lodged with me useless. The remarkable development of Helen Kellar is familiar to us all. One of our own United States Senators is blind, and an eminent member of our own profession, who has added most to medical literature, has suffered from the same misfortune since youth. Even our friend Silas Wregg, with the handicap of his wooden leg, made the most of his opportunity and won temporary distinction as an educator of the credulous Mr. Boffin. The men and women, however, who have achieved markt dis- tinction in spite of acquired or congenital physical defects are the exception. Besides the will to succeed and an exceptional mind, they usually enjoyed unusual opportunities for education. Not so with the great mass of the physically defectiv. Like the rest of us, they are of mediocre mental inheritancte, and a large ma- jority are without means of education, or opportunity of develop- ment unless some assistance is rendered them. Such are the blind, the deaf and dumb, the crippled and deformed, and those suffering from various other physical handicaps. It is indeed bewildering, as well as depressing, to consider the vast numbers of this kind which the present war is producing at wholesale. Granted that the physically defectiv are of sound mind, there is much to be hoped for in their care and education, as experience has shown; the "lame man may not leap as an hart, or the eyes of the blind be opened, or the ears of the deaf be unstopped, or the tongue of the dumb sing," but many, perhaps the most, can be expected to become self-supporting or more; they can be trained to employ the faculties that remain to the best advan- tage and thus discount their handicaps. The legitimate duty of the state is to provide for the welfare of its people — all its people; and each state must decide in what way and how far it will and can do this. Two fundamental ob- jects, however, are obviously the duty of every well-ordered state: First, to protect its citizens from palpable injurious in- fluences, such, for example, as contagious diseases, impure food and drink, unwholesome conditions in factory and workshop, exploitation of child labor, etc.; hence the free distribution of diphtheria antitoxin, compulsory vaccination, milk and food in- spection, the notification of contagious diseases, hospitals for consumptives, etc. Second, to afford its citizens an opportunity for development, a chance to realize that "freedom, equality, and pursuit of happiness" which is declared to be the birthright 191 of us all in this country; hence the public schools and libraries, and other public educativ measures. Furthermore, the public has, to a greater or less degree, taken upon itself the duty of caring for many of its unfortunates in mind or body, both for their own good and also to prevent them from being a source of injury to others, or from becoming dependents; hence the public hospitals and insane asylums, institutions for the feeble-minded, comsunptiv sanatoria, reformatories for the criminal class, schools or institutions for the crippled and deformed, the blind and the deaf and dumb. It is of the three latter classes of physical infirmities that I wish especially to speak, namely: (a) the crippled and deformed; (b) the blind; (c) and the deaf and dumb, for they constitute the major part of those whom we include under the physically defectiv and for whom legislation has done much, particularly for the blind and the deaf and dumb. For the crippled and de- formed the states do not appear to have made equal or adequate provision, altho this class probably largely outnumbers the other two classes. "It may be stated in general," says the Secretary of the State Board of Charities of Massachusetts, "that the pub- lic care of crippled and deformed children who are not necessarily public dependents, is the rare exception rather than the rule in social development." We still see, all too frequently, the maimed or crippled man selling lead pencils or shoestrings on the street corner, who, with an industrial education, might be setting type or cane-seating chairs and earning a steady and not a half -begging precarious income. How much more inspiring is it to undertake the education of a crippled child with a sound mind than to expend the same amount upon a feeble-minded one who can never be anything but a burden upon the community ! How many crippled children and adults there are in the United States no one knows, for, unfortunately, no census of them has ever been taken. Dr. Orr, of the Nebraska Orthopoedic Hospital, estimates the number as 259,000. Prof. Lange, quoted by Miss Reeves,^ stated in 19 10 that the number of crippled children under fifteen years of age in 1 "Care and Education of Crippled Children in the United States," by Edith Reeves, Russell Sage Foundation, N. Y., Survey Associates, etc., 1914. 192 Germany was 98,263. One hardly dares to imagine what the number of crippled and maimed adults now is in that unhappy country which is so rapidly producing them. If the number of crippled children in this country, says Miss Reeves, bore the same proportion of the general population as in Germany, there would be about 133,000 crippled children under fourteen years of age, and at present only 4,901 are cared for in the 37 existing institu- tions for them, public and private. It is evident, then, that a not inconsiderable number of such children, indeed the greater number, are growing up illiterate and without training owing to their inability to attend the com- mon schools. It would appear to be a duty as well as an economic measure for the state to afford these defectives a common school and industrial education and thus render them self-supporting members of society instead of a burden upon it. There are only five institutions for crippled and deformed children maintained entirely by state appropriations: one each in Massachusetts, New York, Nebraska and two in Minnesota. Some of the other similar institutions receive public aid but are controlled and ad- ministered by private boards. The "Massachusetts Hospital School" is the largest and most elaborate of its kind in America and has a capacity for 250 children from five to fifteen years of age who are "mentally competent to attend the public schools." It was establisht in 1907 by a state appropriation of $300,000 and the annual maintenance expense at the present time is $80,000. Besides indicated surgical treatment, the children are given a common school and industrial training. As stated in the act establishing the school, "the purpose (of which) shall be the education and care of the crippled and deformed children of the Commonwealth." Industrial training is given in household arts, sewing, and handicrafts, such as basketry, printing, tailor- ing, cobbling, carpentry, etc. "The results achieved," says Miss Reeves, "thru vocational training evolved from the daily life of a large institution are most strikingly seen here and at the Widener Memorial School." This latter, the Widener School, is a residential institution and is probably the most perfect one 193 of its kind in the world, both in the perfection of its plant and in its large endowment of four million dollars. The New York Hospital for Ruptured and Crippled is a similar institution of the highest development and efficiency, at which graded school work and vocational training are afforded for the deformed children, the City Board of Education paying a cer- tain sum per year for each pupil. Besides those mentioned above, there are some thirty other institutions of a more or less analogous character, principally establisht and supported by private charity. Some are called hospitals, some asylum homes, some convalescent hospitals or homes, and others schools; in most of them there is more or less educational work and vocational training. The greatest need. Miss Reeves found in her investigation, was for children in rural communities, and the only institutions that were adequately meeting this need were the state institutions of Massachusetts, New York, Minnesota and Nebraska. Besides the residential institutions for the crippled and de- formed children, there are day schools, either private or public; in some of the larger cities as in Chicago, New York, Cleveland and Detroit, special departments or classes are provided in the public schools for such children. The Boston Industrial School for Crippled and Deformed Children is a notable example of a highly develop t day school for such defectivs. In this institu- tion, which consists of one large building for general use, and I refer to it especially as it is in my own city and I am familiar with its work, there is a primary and a grammar school depart- ment similar to those of the public schools; and manual training adapted to those grades, including paper-folding, clay modeling, basket making, Sloyd, cane-seating, cobbling, needlework, cook- ing, typesetting, and printing. Most of the pupils are conveyed to the school and returned to their homes daily, and all receive a substantial dinner at noon. There are also trade classes for those over fifteen years of age, and as soon as they become pro- ficient these workers receive pay. Connected with this school is a modem outdoor school-room for those suffering from deformi- ties of a tuberculous origin. Adjustable desks and special seats 194 are provided, cots for rest periods and special gymnastic training are given. A nurse is constantly in attendance who also visits the children at their homes. There is also medical, surgical and dental supervision and care. It is evident that state legislation needs to do far more for this hopeful class of young defectives than yet has been done, for as has been noted above only about 5,000 are at present cared for. Apparently the crippled and deformed do not seem to make quite the appeal to one's sympathies as do the blind or the deaf and dumb. For the class of indigent adults who are physically defectiv for such diseases as rheumatism, paralysis, cardiac disease, syphilis and other incapacitating conditions, the state almshouses or work houses are the common public provision, and all states provide such accommodations, some better, some w^orse. Private charity also supplements the state provisions by various homes and hospi- tals, such, for example, as the Robert Brigham Hospital for In- curables in Boston with an endowment of several million dollars. The loss of one of the senses, like that of sight or hearing, seems such an incomparably greater misfortune than to be crippled or deformed, that one's sympathy and pity are more strongly aroused towards this unfortunate class. To be forever shut out from the sight of all the objects of beauty and interest in the world, or never to hear the sound of a friend's voice or the Largo of a Handel is indeed an appealing misfortune, and hence it is that the public early exprest its sympathy in a practical form and began to make provision for the education and training of the blind and the deaf of school age, so that at the present time every state either has its own institutions for the education of those bereft of one or the other of these two senses, or else, as in the case of the smaller or sparsely populated states, makes arrangements for their edu- cation at public expense in neighboring states. As the census report of 19 10 upon "Benevolent Institutions" says: "There is probably no one class of persons for whose educa- tion and training such complete provision is made as for the blind and deaf." At the twelfth census, an investigation con- ducted by Dr. Alexander Graham Bell showed that there was a 195 minimum of 64,763 blind persons in the United States, and of these somewhat over half were totally blind and 8,000 were under twenty years of age. According to the report of the Commis- sioner of Education for 1908 there were forty state schools for the education of the blind with 4,340 pupils, and the census of 1910 shows 4,720 in such institutions. The education of these children is not regarded as a charity but as a part of the educa- tional system, carried on at public expense. In 1879 Congress appropriated $250,000 as a perpetual fund for the purchase of books and apparatus for the different state schools. Normal schools for the blind are also maintained in some states. The first school for the blind establisht in this country was a private enterprise, that of the Perkins Institute in Boston, founded in 1829, and rendered famous by its two great directors, Dr. Samuel Howe and Dr. Anagnos, and by the remarkable work of the former in the education of Laura Bridgman, who was deaf, dumb and blind. With infinit patience and devotion Dr. Howe succeeded in unlocking the mind of this poor deaf mute until she became mentally alert and developt into a well-educated woman. Soon after the founding of the Perkins Institute, those at New York and Philadelphia were establisht in 1831 and 1833, respectively, and then as the duty of the public towards these defectivs began to be recognized came the state institutions, which now exist in nearly every state. The education given is at first similar to that of the ordinary common school, accompanied by manual training and gymnas- tics. Special training is also afforded in some handicraft, or for some professional or business occupation, according to the talent and ability of the pupil. Music and piano-forte tuning have been found peculiarly adapted to the blind, and some have at- tained eminence in the latter, as, for example, John Stanley, who was an organist at the age of eleven. The aim in the educa- tion of the blind is, first, to establish hope, the hope that in spite of their grievous handicap they can attain a man's standing in the world, for hope stimulates endeavor; second, to give them a general common education; and third, a practical or technical education so that they may become self-supporting. It speaks 196 well for the altruistic spirit as well as for the economic sagacity of this country that it is so fully and liberally accomplishing this self-imposed task. Culture and humanity are not necessarily close companions, as is vividly illustrated by the example of one of the belligerents in the present war. We still seek philosophy from Plato and culture from ancient Roman literature, but it was a custom both of the Greeks and Romans to throw their deaf into the river and destroy their defectivs — a rather merciless eugenic method of ensuring a sturdy race. The deaf were re- garded as being in the same class as idiots. St. Augustine de- clared that the deaf could have no faith since "faith comes by hearing only." A century ago, even, the deaf were practically outside the human thought and activities, and for a long time were regarded as an exceptional class, like the peculiar silent folk Rip Van Winkle encountered in the mountain hollow. Various legal enactments were made indicating this attitude towards them, such as exemption from poll and other taxes; forbidding them from making wills, unless their intention was declared in writing; the appointment of guardians for them, etc. As time went on, however, and civilization advanced, it was found that these peo- ple of silence were mentally sound and by education could be de- velopt into rational beings. At the beginning of the last century schools for the deaf began to be founded on the Continent and in England, and in 18 16 Gallaudet establisht the first school for the deaf in America at Hartford, called the Connecticut Asylum. At the present day liberal state provision is made for the education of the deaf and the deaf and dumb, and after they have received their education they are regarded as are any other members of society and are considered able to look after themselves. As wage earners they compare well with the average of the rest of the population. According to the Census of 19 10 there were 43,812 deaf persons in the United States, 90 per cent, of whom became deaf before the twentieth year and nearly three-fourths under five years of age. From three-fifths to two-third are caused by accident or disease, mostly from the latter, of which scarlet fever and menin- gitis are the most frequent causativ factors. 197 In every state except New Hampshire, Nevada and Wyoming, there are pubHc institutions for the education of the deaf, and these three excepted states, on account of their small population, make provision at public expense for their deaf in other state schools. Some states have more than one such school. It can be said that every deaf child in the United States under twenty- one years of age is now given the opportunity of an education and afforded maintenance in a state institution. In a few of the Eastern states the institutions are in private hands but receive state assistance and are subject to public supervision. In ten states there are dual schools for the deaf and blind. W. H. Addison, of the Mosely Commission of England, who visited this country in 1907, testifies that "the care and instruc- tion of the deaf seems everywhere to be regarded as one of the first duties of the state and in the equipment of her schools for the deaf America far surpasses Great Britain." At the close of the year 19 10 there were 10,543 inmates of deaf and dumb institutions, of which 5,712 were able to speak and 4,831 were dumb. Of the whole number, 7,054 were children and of these 4,172 were able to speak. The two methods of teaching the deaf, as we know, are the sign and the oral methods, or a combination of the two. This educa- tion is not cheap, for it costs the state eight times as much to edu- cate its deaf children as its hearing ones in the regular public schools, and four times as much in the day schools. Besides the state institutional schools in which about five-sixths of the deaf children are educated, there are day schools which are a part of the public school system. These exist principally in the large cities, as in New York, Chicago, Boston, and elsewhere. One of the first schools of this kind was the Horace Mann School, establisht in Boston in 1861. There are now in all sixty-five such schools. It has been found, however, that better results are obtained in the institutional or boarding schools, where the children reside continuously, than in the day schools. In addition to all the states are doing for the deaf. Congress estabHsht at Washington, in 1857, a college for the deaf and dumb, 198 now united with the Gallaudet College and called the Columbia Institution. This is wholly supported by Congress. A few of the aged and infirm deaf are found in the almshouses, but the total number is a little over one per cent., thus showing that the great majority of the deaf form a self-supporting part of the community and engage in almost all the various occupa- tions and many of the professions. Ancillary to the problem of the deaf and blind is the medical examination of school children, by means of which these distress- ing defects in sight and hearing may in some cases at least be prevented, for by the early detection of infantile and infectious diseases, which are a prolific cause of deafness and blindness, and by timely treatment, such ultimate evils may be avoided. In Massachusetts, the law requires the examination of the eyes and ears of the school children in all cities and towns of the state, the State Board of Education furnishing the test. Another great class which may, I think, be included under the physically defectivs are the tuberculous, altho, of course, this incapacity is not always permanent, and the aim in the wide pub- lic provision made for them is not only treatment and care but prevention. Quite every state has establisht one or more sana- toria for such sufferers and maintains them at public expense. The public appropriation for this purpose last year (19 15) was 5^14,500,000, and of this sum four states. New York, Pennsylvania, Illinois and Massachusetts, contributed over eight million dol- lars. Besides the sanatoria special tuberculous dispensaries are maintained by some states, as in Pennsylvania. In Massa- chusetts all cities of 10,000 inhabitants are required by law to establish and maintain such dispensaries. Municipalities in many instances maintain similar institutions under their boards of health, and likewise open-air schools or school-rooms for the children with evidence of latent tuberculosis. Besides sanatoria for supposedly curable cases of tuberculosis, consumptiv hospitals for the incurables have also been establisht in some states, generally thru local instrumentality, but with public supervision and state aid in maintenance. In Massa- chusetts the law requires all cities to establish such hospitals, 199 and also towns when requested to do so by the State Board of Health. Municipalities have also taxt themselves to provide consumptiv hospitals for their indigent incurables. Chicago, by the mill tax upon all taxable property of the city, has erected a great institution which will provide for nearly a thousand patients. Boston has expended over a million dollars upon its Consumptiv Hospital, and is constantly enlarging it. So of other cities. It is now proposed that by an act of Congress a special division of tuberculosis should be establisht in the United States Public Health Service, with an adequate appropriation, for the study and investigation of the tuberculosis problem. Thus it will be seen that legislation is actively engaged thruout the country in providing for its physically defectivs thru tuberculosis. Another incapacitating disease which in recent years has grown to large proportions is that of the heart. For example, in New York in 19 14 the deaths from heart disease increast from 74 to 169 per one hundred thousand, and other cities have had a sim- ilar experience. As with the child with latent tuberculosis, so with the child with slight or latent cardiac disease. Especial care in its education is equally necessary, and especial vocational training, so that it may learn an occupation adapted to its dam- aged heart. The wage-earner, likewise, with cardiac disease would seem to deserv the same consideration as the tuberculous wage earner. It would appear, therefore, that in the near future some public recognition and provision should be made for this class of defectivs, if they continue to increase in the future as rapidly as in the past. DISCUSSION. Dr. Charles Bernstein, Rome, N. Y.: Authorities agree that there are approximately 32,000 feeble-minded, or one in every 300 people, thruout the State of New York. Feeble-minded now Cared For. The number of feeble-minded in institutions specially designed for their care are as follows: 200 In the Syracuse State Institution for Feeble-Mlnded Children 550 In the State Custodial Asylum for Feeble-Minded Women 800 In the Rome State Custodial Asylum 1550 In the Craig Colony for Epileptics 1200 In the Letchworth Village 300 New York City Institutions on Randall's Island 1600 Total in public institutions for feeble-minded 6000 It is estimated that there are in other institutions not designed for their care as follows: In state prisons and jails (estimate 15 per cent.) 1500 In girls' reformatories (estimate 40 per cent.) 400 In boys' reformatories (estimate 20 per cent.) 900 In almshouses (Report of State Board of Charities) 1700 In state hospitals 1 500 Total 6000 Out of an establisht feeble-minded population of 32,000, about 6,000 are cared for in institutions designed for them, and about 6000 are confined in institutions not intended for their care, while about 20,000 or almost two- thirds of the whole, are at large in the community. An Opportunity for Economy. With reference to the 6,000 feeble-minded who are cared for in prisons, reformatories, state hospitals and almshouses, the state could be a large finan- cial gainer by providing for them in custodial institutions. At the Rome State Custodial Asylum, 1,530 inmates are humanely cared for at $2.90 per week. The same class of inmates are cared for at the boys' reformatories at $4.66 per week, at the girls* reformatories at $5.47, and state hospitals $4.00. If all these persons were transferred to an institution such as the Rome State Custodial Asylum, they would relieve these institutions of a most troublesome and undesirable class, making room for inmates of the proper class, obviating the necessity of enlargement. The money thus saved would build ample institutions for the care of these people and cut down the cost of their main- tenance from 20 to 50 per cent. In view of the large number of the feeble-minded and socially unfit in New York State requiring state care and treatment and especially manual and industrial training, so that such cases may be saved from lives of crime and immorality and a large percentage of them made happy, industrious and even useful laborers and thus their services so far as possible returned to the commonwealth and the individuals trained to self-support under supervision and able to do the work for which there is a great but unanswered demand, namely farm labor and domestic help ; Especially as there is at present such great demand on the part of the citi- zens of the state for greatly enlarged facilities for custodial care of the really feeble-minded: 20I We believe that the time has come when something much less expensiv and many times more practical and natural than the physical custody of brick walls and iron enclosures and large per capita expense is possible and practical to meet the conditions outlined for a larger percentage of these cases. First, we have enuf institutions for the present (when such institutions are completed and made available) for the first reception and training of the feeble-minded children. With better facilities for manual, industrial and vocational training in our public school system to take the place of the lack of opportunity for appren- ticeships, as existed in the past, many of the border-line cases will be saved in community life and will never need asylum or custodial care. Second, from now on we should devote our energies toward enlargement along the line of colonization so as to so far as possible rehabilitate and re- turn the services of these inmates to the state and its citizens, thus vacating many of the $800.00 and $1,000.00 beds in our existing institutions and mak- ing them available for the further extension of the training of younger and more socially dangerous cases. Third, the . services of many of the female adult cases could well and economically be made available to large centers of population for doing domes- tic work, hand laundry and sewing, and thus in no way be materially com- peting with nativ or naturalized American labor. (At least 20 per cent., and I believe 40 per cent., of all feeble-minded and border-line cases can be very successfully and economically so handled.) Fourth, there is ample opportunity for colonization of all the available adult trained males on various parcels of state-owned lands and abandoned or undevelopt farms where such labor is especially desirable and at the same time the individual is rendered happy, contented and self-sustaining in an environment well suited to his mental state. We have carried on colonization along these lines among the feeble- minded for the past eight years and have proved it practical, economical and entirely feasible in every way. We have five farm colonies with 20 inmates and farmer and wife on each where the 22 people are living comfortably in the old farmhouse on 100 or more acres of land, each such farm having cost the State between $5,000 and $10,000, whereas, it costs to build large brick buildings at least $500 for every inmate. These colonies are entirely self-sustaining, including all expense and 5 per cent, on the investment. We also have one colony for girls in a rented house in the city of Rome where 42 girls under the supervision of a matron and a social worker are sup- porting themselves, doing domestic work, hand laundry and sewing. These statements are not based on theory or abstract thought but rather are they based on concrete experiences, the results of twenty years' work with 202 and study of the 3,000 feeble-minded who have past thru this asylum since its organization in 1894, 1500 of whom are in custody here at the present time. Farm Colonies. Eight years ago (see 12 th annual report) our first farm colony was opened with 20 trained boys and a man and wife on a farm of 180 acres, costing $10,- 000, laying one mile from the Asylum; two years later another farm colony was instituted on an adjoining farm of 20 acres, costing $5,000, laying between the first farm colony and the Asylum farm, and by dividing the acreage of the larger farm with the smaller one, making two colonies of 100 acres and 20 inmates each. Two years later another outlying farm of 300 acres, five miles from the Asylum, was rented for $650 per year for use in growing fodder and pasturage and stabling our large herd of growing young stock. This farm is still rented and at present has thereon 100 growing steers which will be used for beef, also 40 head of growing cows (we have not purchased a cow in twelve years but have grown from our best calves all the cows we have, 140 at present). Two years ago we purchased a neighboring farm of 60 acres for $5,000 and by expending $2,000 on the buildings we have very comfortable housing accommodation for 30 boys, who, with their house father, care for 40 acres of garden, in which all the small fruits and vegetables, except potatoes, which are grown on the rented farm, for our family of 1,800 are grown. This year we have arranged to rent another farm, a good dairy farm, of 273 acres, one mile from the Asylum, for $1,000 per year, on which we will establish a colony of 20 inmates and a dairy of 40 milch cows, their milk to be used entirely for making butter, of which we are at present making 100 pounds per day, nearly all we need for our regular dietary, in addition to pro- ducing all the milk needed. Agricultural Operations. We are at present operating 1000 acres of land, 600 acres of which we own and 400 of which is rented, and during the year have produced food supplies to the value of $90,000, at a cost to the state of $46,000 for labor, seeds, fer- tilizer, farm utensils, stock feed, renewing farm equipment, etc. The products included 135,000 gallons of milk, 27,538 pounds of butter, 5,300 pounds of beef, 70,000 pounds of pork, etc. We actually butchered forty-two and one- half tons of pork between October i, 1914, and April i, 1915. The $46,000 cost of farming operations is included in the $149.97 which it cost us per capita for maintenance this year and such home products represent one- fourth of the total cost of maintenance, or otherwise one-third of the net cost of such maintenance to the state. With a larger acreage of land up to one acre per inmate we can continue to show a largely increast percentage of home products or self maintenance. 203 Girls' Colony. The following announcement was made at the opening of the Colony: Rome, N. Y., Oct. 7, 1914. A Working Girls' Home has been establisht at 209 W. Thomas St., telefone number 172-J, where girls are available for domestic work, sewing, etc., by the day, week, or month. The girls going out from this place to work are capable of doing all kinds of domestic work except special cooking. They are only able to do common cooking. Their services may be secured by telefone. The rate is fifty cents per day or thirty cents per half day, and their services will be available for employment at any time on short notice. Settlement for services will be paid direct to the manager of the Home. Bills will be regularly rendered weekly for such services. These girls are not defectivs, but are girls who have been orphans and have never known the natural home, and when later in life they have gone out into the world they have been unable to get along because of lack of proper home training and natural worldly experience, as the result of which they were sent to this Asylum for study, care and training, and we are sending them out to work, after having been thoroly trained and tested here to see if they can get in touch with the world imder normal conditions and thus learn to be self-sustaining and have their entire freedom. This colony is carried on in a rented house in the city, which constitutes the girls home and social center, presided over by a housekeeper, or matron, with a social visitor to inspect their work, their street deportment, and to accompany them to moving picture shows and other social diversions and to assist them in purchasing their clothing, etc. We hope in this way to have many of these girls learn thru experience normal social reactions and family life and thus to return the services of many of these willing and competent domestic workers to society and in this way lighten the load and make state care and supervision possible for all of this class of dependents who positively need such care, and incidentally in connection therewith we have establisht the most positiv test possible as to the ability of some of these cases to rehabili- tate or support themselves, all of which we can never be positiv of in a con- siderable number of these border-line cases until some such world test has act- ually been applied. Of the 67 girls who workt thru this colony during the last year 42 remained at the end of the year and twenty-five were returned as follows: Nine for social offenses, such as flirting on the street, boisterous on the street, noisy at the colony, etc., only two were really serious social failures; nine of the younger girls because they had not had sufficient training and seven others were retiumed because of sickness or because their services were worth more to the institution than they were getting outside, namely^ $3.50 a week, and they preferred to live and work at the Asylum. The very markt improvement occmring in these parole cases is most favora- bly commented on by all who come in contact with such cases and there is no doubt but that it is this lack of these normal experiences in life which caused their previous failure. 204 FINANCIAL REPORT, GIRLS' COLONY. OCT., 1914, TO OCT., 1915. Total amount earned during the year $3,278.91 DISBURSEMENTS. Colony girls (cash and clothing purchased) 1,863 . 85 House rent 375 . 00 Furniture and furnishings 321 . 84 Salaries 405 . 00 Provisions 19.01 Material for clothing (colony) 10.48 Expenses (water rent, telefone, lighting, traveling expenses, enter- tainments, car-fare, etc.) 273 . 56 Balance 10. 17 $3,278.91 Plan for Further Colonization. There are large tracts of undevelopt and abandoned lands generally scat- tered about the State, many of these owned by the State, such as those re- verted from tax sales and State loans which are at present controlled by the State Land Board and the State Conservation Commission, which lands (such as a tract of 8oo acres in Chenango County, and another of 700 acres in Blenheim, Schoharie County, the General Kerkimer farm of 160 acres in Herkimer County, another of 400 acres near McConnellsville, in Oneida County, and many others listed by the State Department of Agriculture, and regarding which I have consulted with them), are well adapted for the use of male adult feeble-minded as colonies on which, thru the expenditure of very small amounts of money for equipment, such inmates at the rate of 10 to 20 to each 100 acres, depending on the condition of the land, can be made nearly, if not entirely, self supporting, such colonies to be managed as a branch of the larger institutions; and, too, a portion of the services of such inmates would be available to the surrounding farmers when they were in need of additional labor, which at present they are unable to secure. The State has purchased the General Herkimer homestead and farm of 160 acres at Little Falls, 40 miles east from Rome, directly on the line of the New York Central Railroad and the Erie canal, and we propose that we use 140 acres of the farm for a colony on which the boys will earn their living and make the other 20 acres into a park surrounding the historic mansion and burial place of General Herkimer, and thus save the State the expense of such original work and care and upkeep. On the State Fair Grounds at Syracuse, the buildings stand vacant 355 days in the year and the State spends large amounts of money for common labor for the upkeep of the grounds. We propose that they allow us to take 100 trained boys there to live in the buildings and do the common labor for them, possibly remaining there all winter and devising industries for winter occupation and camping under tents during the week while the State Fair is on. The buildings are good new concrete buildings with good toilet facilities 205 and all we should need extra would be a small inexpensive heating plant, or stoves could well be used, and here is an opportunity with very little ex- pense to the State to house at least i,ooo trained feeble-minded boys, develop- ing occupation or industries for them as the number gradually increases, such as the situation may at the time warrant. There are along the banks of the newly constructed Barge Canal and its tributaries large parcels of land which were needed during process of con- struction, or were purchased as a part of a whole parcel of land, which are now lying idle or yielding little or no income to the State, regarding which we are now in correspondence with General Weatherspoon, Superintendent of Public Works, regarding their use by this Asylum as farm lands. There are two especially desirable pieces of such State lands, river bottom and meadow lands, on the banks of Lake Delta (817 acres in all), lying three or more feet above high water line, which would make a most desirable place for a farm colony for trained boys, and in the meantime the property could thus be developt and made of much greater value to the State. This land, even tho owned by the State, is at present squatted on by sur- rounding farmers and Italian road laborers. It is located on river flats north and east of Lake Delta and would make a most prosperous farm colony because of the great fertility of the soil in that region. Representatives of the State Department of Forestry have recently con- ferred with us regarding placing a colony of boys at Indian Lake to grow trees and do reforestration, as it is very expensiv to transport trees and get labor there to do the work as at present carried on. We have, under the super- vision of the Forestry Department, reforested 40 acres of reverted State loan lands three miles south of Rome, and also about 20 acres of waste land on the Asylum farm. Another scheme is to colonize on abandoned or unoccupied farms. On nearly every cross-road in each township are to be found such farms. I would colonize on such farms, if possible, and here, in addition to earning their living on the farms and improving the land and buildings, the boys can spare about one-half of their time helping the surrounding farmers who are much in need of such assistance and thus the boys help to support themselves in that way and during the spring and fall and at other odd times they could pick all the stone available and crush and distribute such stone on the small cross-roads, which serv as the connecting links between State improved roads, and in this way further contribute toward the uplift of the rural commimi- ties. The Board of Supervisors of Oneida County has this road improvement scheme under advisement at present. When these farms, thru good cultivation, become sufficiently valuable, they could well be vacated as colonies and the enhanced value, thru sale or otherwise, thus revert to the State or become available for further multi- plied colonization, for with the large number of the moron type knocking at 2o6 our doors for entrance to-day there is no fear that we will soon exhaust the supply of either abandoned or deserted farms or morons. This naturally leads us to the thot, might not each county in the State well have a county farm colony for trained adult male feeble-minded under good management and state supervision, whereon all the necessary food material such as milk, butter, beef, vegetables, pork, eggs, fowls, etc., re- quired for the almshouses and hospitals and orphans belonging to such county, could be produced with such labor? Such county colonies might be main- tained somewhat after the plan known as the Wisconsin system, wherein the state reimburses the county to the extent of $ioo for all cases cared for by the county and in return the county reimburses the state, likewise for all cases cared for by the state. The Wisconsin system certainly has to its ad- vantage the fact that it tends to keep the burden of the defectiv and dependent classes closer to the home and the local community whence the burden origina- ted and thus serv to prevent the tendency which is very prevalent in New York State for the towns and counties as well as individuals to unload their defectiv and dependent burden directly on the State rather than have them in local institutions at local expense or the families have the stigma, as they often feel, of their local presence. It is very noticeable that during the past decade the type of the feeble- minded coming to our doors for admission has greatly changed and that whereas ten years ago 80 per cent, were idiots and imbeciles and only 20 per cent, border-line cases or morons, now only 20 per cent, are of the idiot and imbecile class and 80 per cent, morons and border-line cases. I believe that one reason for so many more than ever before of these cases appearing as social failures or misfits is that machinery has to a great extent displaced conmion hand labor and more highly organized society depends more on co-operativ movements and thus demands more specialized ability of its individual constituents in order for them to succeed, less low-grade and common labor being demanded or used, and therefore it becomes us to endeavor to rehabili- tate these social misfits or failures and if possible get them back in touch with normal working conditions thru specialized training (agricultural, do- mestic and household work) and thus not only render themselves self-sus- taining but to also save them to something better than lives of institutional servitude. Especially in view of the fact that a constantly increasing number of border- line cases are appearing at our institutions and at Rome, if nowhere else, many very doubtful cases (this possibly due to the workings of the law, Chap- ter 448 of Law of 1 912, which allows us to take doubtful cases for observa- tion and study) in which diagnosis by the best experts will differ as the case is seen one day or another, there remains to us, if we are at all conscious of the extreme responsibility placed upon us, but one sure test as to the mental competency and capacity of the case to lead a normal life and that is after thoro training the world test as provided for by law imder Chapter 448, Laws of 1912 (parole law). 207 Many of these cases having never lived in normal or reasonable homes in which to learn normal home and family life and many others having lived as children in great congregate institutions, where little or no manual and in- dustrial training and especially no normal family domestic training was avail- able, and having thus become institutionized, the only fair treatment for these doubtful cases, after giving them such training, is to give them one or more favorable trials in a normal well selected family and thus an opportunity to round out such domestic training and experience, for does not every normal child develop thru experience and right habit-forming opportunities, that is, world experience and parental advice when in danger, and it is this method we are following in the working girls' colony in Rome, our boys' farm colonies and our parole system. During the past ten years I have seen many boys and girls thus rehabili- tated and the fact that a few fail on the first trial or repeatedly is no sure criterion that our judgment of the case was fallible for I have many times seen these very same cases of failure, almost immediately when placed in another new environment, succeed and from thence on make good and pos- sibly the previous experience in failure was one of the best lessons such cases could have had. (Were not all of us tried by our parents and friends many times and often at the point of social failure except that an in- dulgent parent was at hand to try us again and again until we eventually found oiu-selves?) The State of New Jersey has found it desirable to pass a law requiring that special or tmgraded classes in the pubUc schools of the state shall be carried on in every school district in which there are ten or more children who are unable to make the grades or fallen behind in their regular graded class work, and New York State in its larger cities has estabUsht many such special or ungraded classes, especially in New York City, Yonkers, Rochester, Buffalo, Albany, Syracuse and Utica, and the work is gradually extending, and there is no doubt that with better facilities for manual, industrial and vocational training in oiu: pubUc school system to take the place of the lack of oppor- tunity for apprenticeships as existed in the past, many of the border-line cases will be saved in community life and will never need asylum or custodial care. A report made by Miss Farrell, Director of Special Classes in the New York City Schools, in an address before the New York State Teachers' As- sociation, held at Rochester in November, and the report publisht in the jomnal called "Ungraded" for December, throws interesting light on this subject. She states that a study of 350 children from these classes who had been in training in the New York City Schools between 1907 and 19 14 and had left the schools, shows that 192, over one-half, were succeeding at occupa- tions along the line of that which they had learned in the special class work; and that 86 others were employed and cared for at home helping at industrial 208 occupations which were done in the home along the line of work they had learned to do at the schools, such as sewing, artificial flower-making, etc., 31 had been employed but were at present temporarily out of employment and only 18 had proven to be so defectiv that it was necessary to send them to institutions, and only 3 had fallen into the hands of the law for social offenses. In view of these facts there is no doubt at all but that after these border- line cases have been trained in our institutions they should be given an op- portunity to demonstrate whether or not they are able to support and care for themselves, and that further special class work, including manual, indus- trial and vocational training, should be establisht in all the public schools in New York State to give all these cases a fair chance before they fail and are sent to institutions. At least 20 per cent, of all our cases and 40 per cent, or more of all border- line cases will thus be saved to useful and happy lives outside of custodial institutions. Chapter 445 of the Laws of 19 12 has practically been of little use as an eugenic measure in this State. The law has been made applicable so far as possible at present, to but one case, a male inmate of this Rome Asylum, and that only to the extent of taking the case before the Supreme Court in Sep- tember, 1 9 15, for an argument as to the constitutionality of the law, the idea being to carry the case to the Supreme Court of the United States as rapidly as possible. It seems that little or nothing is to be gained toward the control or ex- termination of the defectiv classes thru the application of this measure, as it is apparently legislation in advance of public enlightenment if not contrary to public opinion; and, too, were it applied and the cases ttuned loose in the community no doubt the increast spread and ravages of venereal disease would cause such increase in both physical and mental degeneracy that the number of defectivs and dependents thus created would more than offset any diminution in number of defectivs and dependents to be hoped for as a result of sterilization, and as a moral issue society can never afford to stultify itself to the extent of endeavoring to diminish the cost of care and treatment of the defectiv classes thru an act of human mutilation and then set such human wreckage adrift a prey of, or a danger to, his brother man. THE STATE AND THE INSANE. By Richard H. Hutchings, M.D.. Superintendent of the St. Lawrence State Hospital, Osdensburg, N. Y., and Lecturer on Psychiatry, Syracuse University. The thesis which I shall try to maintain is that the rapid in- crease, during the last generation, in the number of insane per- sons confined in our state hospitals and asylums is due to the laws governing the admission, detention and discharge of patients in those institutions. Dr. Henry M. Hurd has pointed out^ that owing to pioneer conditions the care of the insane in America did not develop in a natural way to evolve a system that was adopted to the needs of the country. On the contrary, the dependent classes early became identified with each other. If harmless the insane were bid off each year with other paupers to the person who would care for them at the lowest figure. If excited or destructive, they were placed in pens or cages in the almshouses or in jails. Utter neglect was the rule and no thought seems to have been given to anything except custody. The first institutions to be establisht for their care were organ- ized by private philanthropy, the Pennsylvania Hospital, the Hartford Retreat, Bloomingdale Hospital, the Friends Asylum, the McLean Hospital are examples. These splendily endowed hospitals, though most of their patients are from the well-to-do class, stiU care for a number of indigent cases. It is only when the magnitude of the undertaking became apparent that the states began to make provision for this class in special institu- tions.2 It is rather remarkable that as soon as the states made provision for the insane, however poor and incomplete that provision was, private philanthropy no longer concerned itself with the subject. Though millions of dollars are given annually to hospitals for phys- ^ "institutional Care of the Insane in the U. S.," American Journal of Insanity, 1915. • 2 It is true that the hospital at Williamsburg was established by the Colony of Vir- ginia and one at Columbia by the State of South Carolina, but according to Dr. Hurd they were at first not free institutions but only received patients whose expenses were paid. 2IO ical diseases practically none is given for the benefit of the insane, and though education is admittedly a function of the state, yet our large universities are, many of them, richly endowed. Even when the states began to make provision for this class it was done re- luctantly. The case of New Hampshire may be cited: Philanthropists viewed with distress the neglected condition of the insane in county houses and in families where the pauper insane had been "bid off" to the lowest bidder. Petitions poured in upon the legislature for the establishment of a State hospital. Physicians delivered addresses before the legislature, philanthropists urged the measure session by session and the Governors were most importunate in their annual messages and yet for eleven years the agitation continued before an institution was established at Con- cord.' Is it to be wondered at that the welfare of the insane abandoned by private charity and unwillingly monopolized by the states, which still pursued a niggardly policy of provision and care, is still one of the greatest issues before the people to-day? When I state hospitals were established it became necessary to enact laws for their regulation. Viewed against this historical back- ground, it can easily be seen how it came about that the laws then enacted and not yet wholly repealed were admirably designed to foster the accumulation of vast numbers of chronic patients in these institutions. The fundamental error, shared alike by the law makers and the public, was and is to regard insanity as a condition and not as a disease and has resulted in the domi- nance of the idea of custody and not of prevention and cure. The finality of commitment was the prevalent idea in the pub- lic mind. It assumed that once immured behind the walls and barred windows of a lunatic asylum there was little prospect that the unfortunate person would ever be released. Hence it was important to be sure that no other course was possible under the circumstances. The presumption being that the patient was henceforth to be deprived of his liberty, such authority could not with safety be left to medical men but was a question that could only be determined by the courts. In some of our states the in- sane person must, even at the present time, be brought into the presence of a judge and jury and after the usual procedure of a » Hurd, Op. cit. 211 criminal trial, be duly acquitted or convicted of having a disease which requires or entitles him to be treated in a special institu- tion. Little thought was given to any feature of the case but that of danger to himself or others. In the State of Oregon, even yet, the petitioner who seeks to obtain admission to a state hospital for a relative or friend, must make affidavit that he is dangerous to the public peace and well- fare. It is true that physicians were called in to examine and give evidence and in some states one or two were required to be jurymen, but the public seemed unwilling to place much authority in their hands and the final decision of what was essentially a medical question was left in the hands of the court. The modern view of the detention for treatment of the insane corresponds more nearly to our conception of the measure of quar- antine. Insanity is a disease, the treatment of which is best carried out in a special institution, and during the attack the patient is possibly dangerous to himself or others, hence his de- tention in this special institution, even against his will, is justi- fiable. The analogy goes still further. An insane person who is neither dangerous to himself nor others and for whom further treatment does not offer any prospect of cure, cannot with justification be detained if he can be suitably cared for elsewhere. The public accepts the quarantine regulations of our boards of health and acquiesces in them so that interference by the court is almost unknown. This is due to two factors. The first is, the public is able to recognize the necessity of sequestration and second, there is no fear that the detention will be unduly pro- longed. We need not concern ourselves with the suggestion that segrega- tion of the insane is advisable lest their offspring swell the ranks of the dependent classes in the next generation. In the first place the insane, contrary to popular belief and in contrast to the feeble- minded classes, are not as prolific as the normal population. In the second place insanity is not transmitted as such. What is transmitted (except hereditary syphilis) is a diminished capacity for adaptation to the world of reality, a diminished resiliency 212 to withstand the buffeting of fortune. Whatever this subnormal condition, which we call insane heredity, may be it is the heritage of the family and is shared perhaps equally with the patient by his brothers and sisters and if all are not insane it may be only because some were fortunate enough to escape the difl&cult ad- justment in life which the patient encountered and broke upon. Or the strain was softened or modified for them by the existence of other interests in life to which they could turn and which acted as safety valves. It will be futile to limit the offspring of an in- dividual patient and to encourage it in his brothers and sisters. It will be more practical for us to busy ourselves with removing the obstacle from the pathway along which the cripples must walk rather than to confine cripples indoors lest they fall. How shall we go about to remov-e these obstacles or to strengthen the feeble so that they may yet walk in safety? The old notion that insanity comes without warning like light- ning from the sky, striking whom it would, has been completely abandoned. It is now recognized with great clearness that it is the culmination of a long series of faulty adjustments to life which oft-times have their beginning in childhood. Because we have seen that insanity seemed to occur by preference in certain families, we have been too willing to cover up our ignorance of the true nature of its etiology by calling it hereditary, but a closer examination of the hereditary influence in a given family reveals only contradictions except in the case of feeblemindedness, the con- sideration of which should be kept entirely distinct from insanity. If we look upon heredity in insanity as only a predisposition to faulty habits of adjustment the problem of the prevention of insanity becomes far more workable and at once it is seen to re- semble that great scourge of the human race, tuberculosis, for which so much is being done by measures of prevention, and for the oc- currence of which heredity was once a sufficient excuse. If we substitute for Koch's bacillus the faulty habits of adjust- ment the analogy becomes very close. In each case we have an individual susceptible to injury by a certain cause but he will continue in health if the cause can be avoided. Looked at from this point of view, mental hygiene is easily 213 thought about and can be effectively taught in the pubHc schools, from the lecture platform and wherever thinking people assemble. It is the duty of the profession to disseminate the principles of mental hygiene as is being done in the case of tuberculosis and where else should we look for leadership in this movement except to the hospitals for the insane? Why have the hospitals for the insane not taken a more active part in this movement? The answer is, because they have not recognized the opportunity. They have been working with the ashes and cinders, amid the ruins of once fair structures and had no knowledge of the faulty construction of the building or of the nature of the combustibles that were stored in it. This is where we get a view of the baleful results of the laws to which I have already alluded. The state, in the exercise of its monopoly of the treatment of the insane, says who shall be treated and when the treatment may begin. He must be dangerous, he must be suicidal, the public peace and welfare must be menaced by his presence, therefore in the majority of cases he must be incurable. It mat- tered not that the patient himself felt that something was going wrong with his mind and fearful for his sanity knocked at the door of the asylum and asked for help. **No indeed," he was told, "We only take in lunatics, the fact that you ask for admis- sion indicates that you have reason and judgment. Go away until you become certifiable." But few of the States permit voluntary admissions and those only in recent years. The wealthy and progressive state of Ohio tolerates voluntary patients in its state institutions, but lest their numbers should overtax the existing facilities for car- ing for the chronics the number in each hospital is limited to five. The situation is exactly the same as if the hospitals for tuber- culosis should refuse to receive the incipient cases and admit only those in the advanced stages of the disease. New York has provided for voluntary admissions since 1909, and last year 425 such cases were treated in the state hospitals, and the recovery rate in this class is high. 214 The scope of my paper does not justify a detailed discussion of practical measures of prevention and I shall say only enough to point out the importance of this work. That much can be done in this direction has become manifest by the recent advances in our knowledge of the role of syphilis and alcohol, two definite and easily preventable causes which together account for more than a quarter of the admissions directly and enter as a contribu- tory factor in a much larger proportion. Some very useful work is now being done in demarking the various types of individuals, the characteristics of which are shown at an early age. Hoch has pointed the way by his delinea- tion of the shut-in child, among the ranks of whom nearly all the cases of dementia praecox are later recruited. The burden of the custodial care of the unrecovered patients has grown greater year by year. In the State of New York, with 10,000,000 inhabitants caring for 33,000 insane, the annual increment is about one thousand patients, which is the equiva- lent of a new large hospital every second year. That State for next year has appropriated for the support of the insane the sum of $8,136,076 and it is estimated that to relieve the present over- crowding and provide reasonably for the future, $25,000,000 should be made available at once. At first glance these look to be staggering figures, but that State is growing in population at the rate of 200,000 per annum and has a large proportion of foreign born among whom the ratio of insanity is much higher than among the native population. It is my conviction, based upon observation of 25 years, that if there is any increase at all in insanity in the native popula- tion it is relatively small. State hospitals have become popular, the old horror of them is passing away and there is an increasing tendency to commit to them old and harmless dements whose care at home was a matter of duty and family pride a generation ago. More than half of our patients are beyond fifty years of age. No sooner is the old person removed from the household, be- cause of some transient excitement or depression which renders his further care at home diflftcult, than the family re-adjusts 215 itself to his absence. The finaHty of commitment is accepted, often the family disintegrates, the members taking up new in- terests, the house may be disposed of. A few months later the excitement or depression has passed off and he is again in his former condition of quiet dementia and could be suitably cared for in a private house, but no home is open to him. One of that year's increment is accounted for. As it is important to provide for early treatment, it is equally important to provide for prompt discharge when residence in the hospital offers no further benefit to the patient or the com- munity. The state hospitals should be training schools for physicians and nurses desirous of doing special work in psychiatry and their facilities under the direction of competent instructors should be made more generally available, both for students and for post- graduate work. The number of physicians in general practice who have had an adequate training in psychiatry is deplorably small and they are to be found as a rule only in the larger cities. The result is that early symptoms of mental disorders escape recognition or are treated with tonics or hypnotics where often a searching inquiry into the patient's history would reveal the true cause to be a conflict, perhaps a difficult domestic situation, to which he cannot adjust himself but which the advice and author- ity of the physician could speedily remedy. Until this is done medi- cation is useless and foolish. Two recent cases come to mind as illustrations, both women with symptoms of melancholia, loss of interest in life and discouragement. In one case a mother- in-law, and in the other a sister-in-law were eliminated from the family by my advice with happy results. Neither of these patients attributed their depression to its real cause but supposed as their physicians did, that it had a physical basis. It cannot be expected that the general practitioner will acquire more than the fundamentals of psychiatry but even these have not been given in the medical schools with but few exceptions and only recently. The revolutionary changes in our concep- tion of the nature and causes of mental disorders which have been taking place during the last ten years have left the general prac- 2l6 titioner far behind. The result is that the knowledge which has been gained of the nature and particularly the causes of mental disease are not being utilized in a practical way. That the care of the insane must remain a state monopoly is inevitable from the magnitude of the undertaking and the time has now come when for his own protection it must do more than care for the advanced cases committed by the courts. It must take measures to conserve the mental health of its citizens in as vigilant and practical a way as the boards of health now deal with communicable diseases. This can be done by fostering the establishment, under state supervision, of local agencies in cooperation with the state hospitals, such as psychopathic wards in general hospitals, mental clinics or dispensaries and the em- ployment of physicians 1 and nurses as field agents to assist in the care of patients in their homes. There should be established, under state supervision and with state aid, in one local hospital in every town, a psychopathic ward for the early treatment of mental cases requiring such care and a dispensary where physicians may come with their patients for consultation and advice. The physicians in charge of this work should be attached to the staff of the nearest state hospital and, to insure thorough cooperation with and control by the parent institution, he should receive at least a part of his remuneration from the state. The attempts of small political divisions as counties and towns independently to care for the insane have not worked out suc- cessfully. This is so well known as to require no elaboration in this paper, but the state hospitals are, in nearly every state, in responsible hands and the standards are as good as the legisla- ture will support. Hence the suggestion that the local psycho- pathic wards and dispensaries should be placed in charge of physi- cians who are members of the staff of the state hospital and subject to its authority. Such details of men for special duties are common in the army as instructors in military schools, etc., and with a minimum income guaranteed such positions would 1 The suggestion to employ physicians for this work is not new. Connelly, as long ago as 1820, suggested the employment of externes for this purpose. 217 prove attractive to the older and best qualified men in the ser- vice. In this way very close cooperation could be secured be- tween the hospital and the local establishments. Every patient would first be under the care of the resident alienist and only upon his advice and for satisfactory reasons would he be passed on to the state hospital, and as soon as was deemed advisable the patient would be returned to him for observation and care during convalescence. This would help to prevent the loss of interest in the patient by his family. Many unrecovered cases could live at home in safety and comfort under his tutelage, where now, with no trained supervision, the hospital authorities feel reluctant to discharge them. That psychopathic hospitals diminish the number of commit- ments to state hospitals has already been demonstrated. The Psychopathic Hospital at Ann Arbor, Mich., found it necessary to commit only 28 per cent, of its patients. The Psychopathic Hospital at Syracuse, N. Y., committed only 95 of the 245 patients admitted and apparently insane, 38 per cent. Pavilion F, the Psychopathic Ward of the Albany General Hospital, the pioneer institution of this kind and one that is exceptionally well organ- ized and conducted, last year cared for 410 patients, of whom only 113 were committed to state hospitals, 27 per cent. The average period of treatment was 23 days and the average number of patients in the Ward was 25. Dr. J. M. Mosher, the attending specialist in mental diseases (and who was formerly first assistant physician in the St. Law- rence State Hospital), makes the following comment in his annual report : As the feasibility of the treatment of mental diseases in a general hospi- tal has become more widely known during the thirteen years of operation of Pavilion F, there has followed a growing appreciation of the fact that ab- normal conditions of the mind are not necessarily attended by loss of personal responsibility, or so complete defect of judgment as to render the victim unable to acquiesce in measures taken for his relief. Intelligent appreciation of his condition, sympathy with his distress, coming with an opportimity to place him under systematic treatment, and without formality, publicity or legal technicality, all contribute to his acqui- escence in the suggestion that he enter the hospital. In many cases the res- 2l8 toration to health is relatively rapid, and the recovery of many patients in a comparatively short time, has been a surprising revelation of the effec- tiveness of an institution of this kind. Results of an encouraging kind have followed the establish- ment of mental dispensaries in Massachusetts and New York and the reports show that the attendance has been unexpectedly- large. Briggs and Stearns,^ in a report on the work being done along this line in Massachusetts, say: **At the end of seven months we can say that the out-patient department has proved a success and has met the fondest hopes of the board." At one of these dispensaries in the City of Boston 358 visited in one month. We shall make little real headway against what is popularly called "the rising tide of insanity" until facilities are provided for adequately dealing with the incipient cases. The public appears to have almost no proper conception of this problem. The unfortunate terms "sane" and "insane" are real hindrances to progress: it would be well for us if they could be blotted from the dictionaries. Any degree of mental illness or inefficiency is important enough for thorough investigation and correction; and let us not confuse the issue by consideration of such subjects as legal responsibility, testamentary capacity, etc., which are lawyers' terms and not useful in the consideration of the case as a medical problem. If we could stop thinking about insanity and provide hospitals, dispensaries and clinics for the treatment of mental illness of all degrees we should, for a time at least, have more work to do but would make some real progress w^here now we are marking time. Dr. Ray Lyman Wilbur: I have just come in but I want to particularly thank the author for this paper. We have tried in California to get the public interested in the care of the insane along the lines indicated therein but have found it very difficult to do. The matter requires the coordinated efforts of the physician and the lawyer. The legal profession is loath to give up the insane man to the physi- cian. I feel that we should confer with the bar associations of the different 1 L. Vernon Briggs, M.D., and A. Warren Stearns, M.D.: "Recent Extension of Out- patient Work in Massachusetts State Hospitals." American Journal of Insanity, 1915. 219 states of the Union and try to convince them that they ought to join with us in asking for new legislation along this line. We know the facts from the medical standpoint; we know the statistics, and it seems to me that we should appeal strongly to the attomeys-at-law in their various organizations to help us correct the very gross and barbaric abuses associated with the care of the mentally'sick that we allow now to go on in this Republic. Dr. Tom A. Williams, Washington, D. C. : This is an exceedingly important matter of practical expediency, and can be approacht from many different angles. I speak from the angle of the man who sees these various patients when they are in the incipiency, and is con- scious of the difficulties of handling such persons under the present legisla- tion. While we ought to find these patients in the incipiency of the disease, it is not always done because the average medical man cannot recognize them ; and because the patient who loses his grip will not go to the only place where he at present can go, viz., to the asylum for the insane. I know this from personal observation. A patient has often refused to allow his doctor to call me because he thinks I will commit him. It is obvious, therefore, that we must make it easy for the sick man to seek assistance without the fear of being interned. There is only one way, viz., that the man who feels himself that he is losing his mental grip shall regard himself as merely a case of "nerves," as the laity call it, and be willing to go to the general hospital as any other sick man would. This is not done, because in the ordinary, general hospital the man in charge is not fully equipt for this work. He has no con- ception of the problem he is dealing with. The fact that so much can be done for these cases has been amply proven. For instance, while detailed to the Naval Hospital in Washington, Captain Sheehan from his experience decided that the Federal Asylum for the In- sane was not the place for the incipient case in a navy man, but that such cases should be treated in the general hospital. The naval authorities who were opposed to his plans are now enthusiastic about what has been done for the men and officers in this very clinic. The secret of success is that the man in charge of such an organization must be a neurologist, a medical man, a psycho-pathologist and a psychiatrist, thus covering the whole of the dis- orders of the nervous system. There is now an effort to make the insane hospital available to the public. It cannot be done; there will always be the stigma. Treatment must be given the incipient cases thru the general hospital in special neurologic or nervous service. I believe that is the easiest solution of the whole problem. It has long been done in Paris, where the psychiatric and neurologic services are taken advantage of with great readiness by the people of that city. THE NECESSITY FOR MEDICAL EXAMINATION OF PRISONERS AT THE TIME OF TRIAL. By Paul B. BowBRS, M.S., M.D., Med. Supt., Indiana Hospital for Insane Criminals, Michigan City, Ind. There is very adequate excuse for presenting an address of this title. Evidences of the gross miscarriage of justice and of the inadequate protection afforded the pubHc are to be found in every penal institution of this country. I wish it to be under- stood as a preface to my remarks, that what I have to say is de- void of maudlin sentiment and the chief purpose that I have in mind is the protection of the public from the individuals who offend society and violate her laws by reason of deliberate vicious- ness, or from social or economic determinism, or because of men- tal unsoundness. Every year society is unjustly sending to prison hundreds of insane and feeble-minded persons who, in the course of their mental disturbances, have violated the penal laws. And this culpable practice of punishing the mentally sick in penal institutions should "in the course of justice," cease. Society is being poorly protected when it sends insane and mentally defective individuals to penal institutions and then re- leases them uncured from custody, merely because their sentences have expired. Yet this irrational procedure is being practiced continuously by our courts and boards of parole in all the states of the Union. Up to the present time, far more attention and consideration have been given to the legal classification of crime and to its various modes of punishment, than have been given to the crim- inal himself. Probably 50 per cent, of all juridical proceedings are concerned with criminality, and yet our jurists placidly and contentedly continue to study their books instead of men, searching in pon- derous and ancient volumes of citations, resurrecting decisions from the legal grave-yard of the dead past and with these crumb- 221 ling, moth-eaten and time-worn precedents, they attempt to regu- late the anti-social conduct that springs from a disordered men- tality. Let us briefly survey the results of committing insane and mentally defective individuals to prison. When a defective delinquent has been discharged or paroled from custody merely because he has spent a certain time in prison, he returns to society a more defective and viciously inclined individual than he was previous to his incarceration and it is almost certain that he will return to prison on a new charge, and the same foolish ex- periment with all its attendant expense will be repeated. In a recent study that I made of one hundred recidivists all of whom had been convicted not less than four times, twelve of them were insane, twenty-three were* feeble-minded, ten were epileptic, and in each instance the mental defectiveness bore a direct causal relation to their crimes. No less than one hundred and eighty trials have been held for these persons; it is reported by good authority that it costs no less than $i,ooo to convict a prisoner, so at this rate the lowest possible expense to the com- monwealth was $180,000. And, four times each one of these defective individuals had been released to prey upon society and no permanent good whatsoever has been accomplished. The presence of insane persons in penal institutions is ex- tremely detrimental to discipline, for they cannot be punished as a normal prisoner should be, because of their defective sense of responsibility, and advantages are taken of this humanitarian leniency by the more intelligent prisoner to commit offences against the rules. No less than seventy-five per cent, of the men who appear before the disciplinary officer of the Indiana State Prison are mentally defective. What have been the reasons that this outrage has been per- mitted to exist as a blot upon the escutcheon of our social jus- tice? Why have we stigmatized mentally sick individuals as criminals? The answer is to be found in our ignorance of the psychology of crime, in the spirit of laisser faire of the legal fraternity who have always been exceedingly slow to eradicate the evils of our legal procedure and who have ever sought the pro- tection of bristling, misleading technicalities and that much abused 232 , legal phrase "constitutional rights" when legal reforms have been imminent. While admitting that the constitutionality of any- legal procedure must be determined, it is at once appreciated by every fair-minded person that all social reforms of a legal nature have usually met with serious opposition, possibly be- cause these suggested changes have been thought, at least for a while, to be too radical and revolutionary. Since these mentioned ills and many others attend our criminal law practice, the question at once arises, what shall we do in the matter? It is at once apparent that our defective methods of dealing with prisoners spring from a number of various causes which are complexly related and no one single remedy that might be offered will be a panacea for the relief of them, but I am of the firm belief that the medical and psychiatric examination of prison- ers at the time of trial would go a long way in the solution of the vexing criminal problems. Under no circumstances should there be any attempt to abridge the right of trial or for the court physician to usurp the authority of the judge or jurors but it is obviously apparent that the court should be supplied with scientific data concerning the alleged criminal. The facts of the violation of law should be first care- fully determined by the court and the report of the mental in- vestigation be submitted to the judge before the sentence has been pronounced, except in those cases where the alleged criminal is so manifestly insane that he cannot in the least comprehend that he is being tried. This information would furnish the judge and court with the knowledge that would enable them to more accurately decide whether the individual should have a suspended sentence or be sent to prison, to a hospital for the insane, or placed in the hands of a probationary officer. It is well understood that such a change in our criminal methods would be met with a storm or protest from our legal friends. They very probably would consider such a change extremely idealistic and impracticable ; that it would interfere with the func- tions of the jury and that the right of the defendant to employ witnesses would be curtailed and upon casual consideration, these objections seem to be logical and valid. But when we re- 223 fleet that the real purpose of the law is justice and truth and not the preservation of hair-splitting technicalities, we cannot hold these objections to be of great worth. The medical examination of prisoners would correct in a large measure the evils that attend the employment of medical experts. Much of the criticism which is unjustly and malignantly heaped upon the qualified and honest psychiatrist would be done away with and many of the unqualified practitioners who are posing as mental experts and thereby bringing ill-repute upon the med- ical profession would be eliminated from court practice. It is the height of medical absturdity to permit a general practitioner who is without knowledge and experience in psychiatry, to give opinions and statements in coiuts which are likely to affect the life or liberty of an individual. Our present method of em- ploying expert testimony is productive of but little good and of a great deal of harm. Our present system makes the alienist an interested party to the issue in question and it is exceedingly difficult for the alienist no matter how well qualified and honest, to give testimony that is entirely satisfactory to his own con- science and to the merits of the case in hand. Now the physicians are hired by the plaintiff and the defendant and pitted against one another in a wordy battle for the display of wits by lawyers who are skillful rhetoricians, who cunningly and skillfully, by the use of dialectics, suppress medical facts dangerous to their own purposes and lay undue stress on non- essentials if they can thereby gain any advantage over their opponents. Very equivocal hypothetical questions are presented which are often not supported by salient facts and the doctor is required to answer the unproven statements without the privilege of due and careful consideration. The individual of the hypothetical question and the person on trial often seem to bear only the faintest traces of kinship to one another. To correct some of these wrongs that I have enumerated, the court should appoint a physician who is qualified by training and experience in the science and practice of psychiatry. This physician should be a part of the personnel of the court and it 224 should be his duty to sociologically, physically and mentally examine every prisoner at the time of his arrest and trial. A carefully written detailed report should be made out and presented to the court for the instruction of the judge and jiurors. If this were the case, many of the unnecessary trials that are now being held would be done away with and much needless expense would be saved. Under this procedure, the malignerer would be de- tected and the insanity dodge would become very much less popular. Many of the individuals suffering from the incipient insanities, whose crimes are but the expression of mental disease, would have their psychical disorders discovered early enough that they might be sent to hospitals for the insane for cure in- stead of being forced to linger in prison cells medically neglected and misunderstood. That the results of the examinations may be accurate, logical, uniform and impartial, a definite outline of examination should be adopted and should be strictly adhered to both in spirit and application. The steps of examination should be as follows: a. An accurate family history should be obtained having a special reference to the inheritance of disease especially insanity, feeble-mindedness, epilepsy and criminality, together with a care- ful siUT^ey of the social conditions. b. An accurate personal history of the accused. c. An accurate physical and neurological examination of the accused. d. An accurate mental examination which should follow the latest methods employed in modern hospitals for the insane and schools for the feeble-minded. e. A complete typewritten statement of these findings should be made including a brief conclusion, diagnosing the intelligence of the criminal, his moral nature, the criminal type to which he belongs and the degree of his dangerousness to society. A copy of this report should be filed with the records of the case in the cotui: where the trial is held and with the State Board of Correc- tions and Charities open to public inspection at any time. The physician in his routine examination of prisoners charged with crime would find every variety of the essential psychoses 225 and all anomalous psychotic states represented and unless the alienated individuals committed crimes of violence and dis- played dangerous criminal tendencies it would be apropos to send these persons to the ordinary hospitals for the insane. The medical examiner would find another class of mentally defective prisoners comprised of the instinctive or bom criminals, the dangerous epileptics and paranoiacs, the sexual perverts and the morally insane. The most dangerous of all insane patients is the one who har- bors in the recesses of his diseased mentality systematized delu- sions of persecution. This is especially true of the paranoiac, who many times appears to be intellectually normal and occa- sionally, aside from his paranoidal tendencies, he may be the superior to the average individual. The proper perspectives of life are impossible for the paranoiac since each instance and circumstance is colored and tinged by an abnormal sensibility and reaction to the most common place and trivial affairs. The paranoiac in the stage of persecution, out of the most in- significant circumstance, constructs a nebula of persecutory ideas which are intangible and obscure. Finally these hazy, indistinct ideas of persecution take on a more definite character, and then step by step, supportive and contributive ideas are formed and elaborated which build up a definite, systematized, delusional preconception or system of thought, through which must pass every idea that is translated into action. This delusional formation is so closely and intimately connected with the whole of consciousness, that it regulates and dominates the individual's manner of feeling, thinking and acting. It is easy to see, therefore, that any paranoiac is a potential homicide while harboring delusions of persecution. Should he believe that his supposed enemies have designs upon his life, or that they desire to make him the butt of their ridicule, or the object of some diabolical conspiracy, it is not at all strange that the persecuted should ttun persecutor. The types that have just been mentioned should not be con- fined in the ordinary prisons nor should they be sent as unwel- come guests to mingle and associate with the ordinary innocent 226 and non-dangerous insane. These types of mentally defective prisoners are the first brands of insubordination and mutiny and they are a perpetual menace to the discipline of any institu- tion and possibly to the lives of institutional officials. To confine them in common asylums would be * * * * injtuious, for they preach sodomy, flight, and revolt and incite the others to robbery, and their indecent savage ways, as well as the terrible reputation which often pre- cedes them, make them objects of terror and repulsion to the quieter patient and their relatives, who dread to see their kin in such company. The medical examination of prisoners would make it neces- sary for every penal institution to have a psychopathic depart- ment in those states which are without a separate hospital for the care of the criminal insane, for the care of those persons charged with crime who are found insane at the time of trial, and for those prisoners whose state of mental enfeeblement makes it impossi- ble for them to adjust themselves with safety to all concerned to the routine of prison life. This conception of providing an institution for this class of irresponsible offenders against the penal law is slowly permeating the social conscience and there are now about twelve such institutions in the United States. Our country has been extremely slow in recognizing the need of such institutions and the honor of establishing them belongs to England. A department for the special care of the criminal in- sane was instituted in 1786 at the Bedlam Asylum. Later, in 1850, another one was opened at Dundrum, Ireland. In 1858, such an institution was set aside at Perth, Scotland, and the famous Broadmore Hospital came into existence in 1863. The individuals sent to the hospitals for the criminal insane should remain there until they cease to be a source of danger to be at large. Their period of incarceration should be permanent unless a cure is affected. It goes without saying that these hospi- tal or psychopathic annexes to prisons should be in the control of alienists who have had experience in the care of prisoners as well as the insane. The law governing the commitment of persons to a hospital for the criminal insane should be so constructed that its consti- tutionality cannot be questioned. It should be so drawn that 227 while the individual prisoner will receive all due protection, society will also be protected from the person mentally responsi- ble, but who seeks to evade the responsibility of criminal acts by a plea of insanity. The law on this subject should embrace the following principles: If it should be found by the court alienist that the alleged criminal was suffering with insanity at the time of the commission of his criminal act and by reason of his mental unbalance the criminal intent to commit a crime was lacking, he should not be convicted or punished. But he should, for the safety and welfare of society, be confined in a hos- pital for the criminal insane until his sanity is so restored that he would no longer be dangerous and not until then. Or, if it should be found by examination that the defendant had been insane at the time of the commission of his dangerous act, but that he was sane at the time of trial and that a recurrence of his insanity is highly probable, he should be committed to a hospital for in- sane criminals for a long period of observation and treatment. In order to further safeguard the integrity and to guarantee the reliability of the medical examination of prisoners which has been advocated in this paper that it ma}^ be thoroughly scientific, reliable and fair, the court alienists must be chosen from a quali- fied group of physicians who by reason of their training, experience and integrity are fitted for this important work. Political in- fluence must be absolutely barred in the selection of official ex- perts that the desired end may not be frustrated. The individuals eligible to appointment should be designated by the state medical society. If medical examination of prisoners was instituted as a matter of routine practice in our criminal courts, a very material im- provement would follow for the following reasons: a. The ordinary insane persons would be separated from the usual class of criminals and the mentally sick could be given the proper treatment in the proper institutions early in the coiurse of their diseases. b. The dangerous insane, the morally insane, the sexual per- verts, and the habitual criminals would be segregated and sent to hospitals for the criminal insane permanently or until a cure was affected. 228 c. Prisons would cease to be a dumping ground for all classes of defectives. d. Society would be very much better protected than it is now, for mental defectives and habitual criminals would not be released to fiui:her prey upon the public. e. There would be an enormous saving of money now uselessly spent in needless trials of incurable defective delinquents. /. Much valuable data concerning criminalistics would be ac- cumulated that would put our criminal procedure on a more rational basis than exists at present. DISCUSSION. Dr. Tom A. WilHams, Washington, D. C: On account of the lack of personal experience in this field my acceptance of the invitation of the Chairman of the Program Committee will have to consist of a number of truisms only. I am very sorry that I cannot contribute anything at all to the discussion. The first truism is that if the person is sick to the point of interference with judgment or will, he may not be liable before the court. Therefore he should be examined to determine his responsi- bility before the court term rather than during or after the trial. The ex- amination of a prisoner should be made not by a partisan but by an expert. The expert's attitude toward the prisoner must be one of sympathy rather than judicial solemnity. It is the province of the physician merely to diag- nose, not to say anything about the disposition; the verdict is a matter for the court, and depends upon the law at the time of the trial. We doctors see further than the lawyer, but we forget that the lawyer is administering that already written in the statutes; he cannot go beyond that which is writ- ten down in the law. A great objection made by lawyers in criminal cases to this procedure (examination of the mentality) is on the groimd of personal rights. In insane cases, however, it is the business of the state to examine the condition of the patient and deal with him accordingly. There is no new abrogation of personal rights when it is the state which acts in that capacity toward the criminal who may be insane. It is a truism that if a person is diseased to the point of serious interference with perception, judgment or will, that he cannot be held responsible before the court. The rational course is therefore to ascertain responsibility before court trial. The very nature of a crime may make it sufficient to show that its author is insane. For instance: self-depreciation, or boasting of lack of any precau- tions or ridiculous purposelessness are in themselves evidence of mental unbalance, as is an accompaniment of maniacal fury or a sudden impulsion. 229 The physical condition may raise a presumption of insanity, as in puerperal infanticide, alcoholism or the menstrual epoch which often is the determining cause of impulsions to steal, arson and fugue or epilepsy, which tends to crimes of violence with amnesia. Delusional ideas, of course, are presimiptuous of irresponsibility, especially where they are religious, persecutory, litigious or political. This is especially so in early states of general paralysis. Psychological disturbances, such as that of the pathological liar, have to be considered, too. The examination of a prisoner should be made not by a partisan but by an expert, that is to say, a person really qualified to make an impartial estimate of the prisoner's status medico-psychologically. The expert's attitude towards the prisoner must be one of sympathy rather than one of judicial solemnity; otherwise the subject will scarcely be able not to conceal his real thought because of fear or definace. The latter is particularly difiScult to disarm in the systematised delusional insane, who are endeavoring to dis- simulate their morbid ideas. The contrary type, those who simulate insanity, must also be guarded against by the expert. But it is very difficult to deceive an experienced psychiatrist in this respect. For no insane individual is absurd in every- thing. This intentional absm-dity of answer, the sly look, the lack of a proper expression of excitement or indifference or true melancholy or stupidity or of pride or inattention, the absence of the denial of his insanity, along with the lack of such physical concomitants as insomnia, relativ analgesia, constipa- tion, capricious appetite, or the modification of the temperatm-e, pulse, respira- tion and vaso-motor innervation will make the examiner very chary of de- claring a prisoner insane; and sedulous observation will then surely unmask the simulator. The declaration that every simulator is ipso facto insane is only possible by stretching of the word insane to comprise every mental abnormality; whereas insanity is merely a convenient term of jurisprudence to apply to those persons adjudged incapable of managing themselves and therefore not responsible to society for their behavior. Dr. James H. McBride, Pasadena, Cal.: Many people are of course bom with a predisposition to insanity who have had no immediate insane ancestors, and for this reason we should give heredity in insanity a wide interpretation. If all the pronounced hereditary insanity were to-day swept away, the disorder would continue to occur, because the conditions that produce brain degeneracy and insanity are always acting. The great majority of the cases of insanity come from the homes of the poor where poor food, over-crowding, and other degrading conditions associated 230 with extreme poverty, act to produce insanity and allied conditions such as feeble-mindedness, prostitution, criminality, and physical disease. The chief causes of insanity are at bottom economic, and bad housing is the more common visible form of bad economic conditions. The slum and the near slum and the unhealthy influences associated with them are responsi- ble for an immense amount of physical disease and mental disorder. The sltun conditions of oiu: cities, and those of our villages and farms, which are not uncommon, are yearly sending their victims by thousands to our insane asylums. Insanity will continue to increase until these condi- tions are remedied. We will reduce the amoimt of occurring insanity when we recognize that the causes of the disorder are largely economic, and act accordingly, and not till then. All our fine talk about the moral and mental causes of insanity really means httle. They need to be related to the plain, every-day influences of the individual's home, those influences that make or unmake health and character. I am glad Dr. Wilbur spoke of the commitment of the insane. The Con- stitutional provision that no one shall be deprived of liberty without due process of law, means that a jury trial is necessary to confine an insane per- son, and many of the states have held that the certificate of two physicians and a court of record constitute a sufficient jury in the case of an insane person. Dr. Hutchings: The subject of heredity is one upon which authorities differ more or less and I am glad that it was referred to in the discussion. We have insufficient data relative to heredity to justify us in basing any definite opinion and for that reason I have deliberately turned away, in my own work, from attaching much importance to it. After all, heredity means only this: that here is a person who should take better care of himself in certain ways because he has probably inherited a nervous system which cannot stand as much strain in the way of bad habits of living from the standpoint of the physical health or from bad mental habits, such as worry, fretting, etc. Once the situation is understood and the individual is taught how to take care of himself, even a bad heredity need not necessarily result in mental trouble. It is far more practical to devote our attention to the precipitating causes and deal with them in some definite way than to allow ourselves to become stifled by the predestination idea that attaches to heredity. Reference was made to the matter of commitment. In many cases com- mitment is unnecessary. The patient can be persuaded by his relatives to come to the hospital voluntarily and admissions of this sort ought to be en- couraged. The way into the hospital and the way out of the hospital should be made easy. We should approach as near as we can to the general hospital in that respect. Still I recognize that commitment will be necessary in a considerable number of cases of paranoiacs and others lacking insight, who 231 would refuse to come to the hospital voluntarily or who after they come would refuse to remain and who might be dangerous to themselves or others. Dr. Bowers: The system of the Simon-Benet examination has been a delectable morsel for the public palate; newspapers and popular jom^als have been over- flowing with articles upon the value of this system. I am not unaware of the valuable work being done under this scale of mental measurement but grievous mistakes are made when it is not employed by adequately trained specialists. INDEX Accidents, Social insurance against — (workmen's compensation laws). Frederick L. Van Sickle, M.D., Olyphant, Pa 54 Andrews, John B., Ph.D., New York City. Health insurance 77 Baldy, John M., M.D., Philadelphia. Examination for license to prac- tise and hospital intemeship 37 Biggs, Hermann M., M.D., Albany, N. Y. The New York State sani- tary code, how enacted — its scope and legal status 125 Bowers, Paul, M.D., Michigan City, Ind. The necessity for medical examination of prisoners at the time of trial 220 Child labor. Standards applicable to — . Helen L. Sumner, Ph.D., Washington, D. C 164 Children, Our social readjustments and the relation of the state to motherhood and — . George A. Hare, M.D., Fresno, Cal 7 Civil positions. Legislation creating — for physicians. John B. Mc- Alister, M.D., Harrisburg, Pa 46 Colwell, N. P., M.D., Chicago. Legislation regulating the practice of medicine, preliminary and medical education 24 Defective, The physically — . E. O. Otis, M.D., Boston 189 Drink problem and legislation, The. John Koren, A.B., Boston 140 Education, Legislation regulating the practice of medicine, preliminary and medical — . N. P. Colwell, M.D., Chicago 24 Evils, Legislative protection of the people from the — of patent medi- cines and medical fakers. F. F. Lawrence, M.D., D.Sc, LL.D., F.A.C.S., Columbus, O 154 Examinations for license to practise and hospital interneship. John M, Baldy, M.D., Philadelphia 37 Hare, George A., M.D., Fresno, Cal. Our social readjustments and the relation of the state to motherhood and children 7 Health insurance. John B. Andrews, Ph.D., New York City 77 Health insurance. The relation of medical benefits of — to existing health agencies. B. S. Warren, M.D., Washington, D. C iii Housing reform through legislation. Lawrence Veiller, New York. ... 179 Hutchings, Richard H., M.D., Ogdensburg, N. Y. The state and the insane 209 Industries, Medicine and the — . George M. Price, M. D., New York City 183 Insane, The state and the — . Richard H. Hutchings, M.D., Ogdens- burg, N. Y 209 Insurance, Health — . John B. Andrews, Ph.D., New York City 77 Insurance, Social — against accidents (workmen's compensation laws). Frederick L. Van Sickle, M.D., Olyphant, Pa 54 233 Insurance, The relation of medical benefits of health — to existing health agencies. B. S. Warren, M.D., Washington, D. C iii Insurance, Unemployment — . Rufus M. Potts, Springfield, 111 90 Interneship, Examination for license to practise and hospital — . John M. Baldy, M.D., Philadelphia 37 Interstate sanitary relations. William Colby Rucker, M.D., Washing- ton, D. C 131 Kelley, Mrs. Florence, New York City. Women as wage-earners 176 Koren, John, A.B., Boston. The drink problem and legislation 140 Lawrence, F. F., M.D., D.Sc, LL.D., F.A.C.vS., Columbus, O. Legisla- tive protection of the people from the evils of patent medicines and medical fakers 154 Legislation creating civil positions for physicians. John B. McAlister, M.D., Harrisburg, Pa 46 Legislation, Housing reform through — . Lawrence Veiller, New York City 179 Legislation regulating the practice of medicine, preliminary and medical education. N. P. Colwell, M.D., Chicago , 24 Legislation, The drink problem and — . John Koren, A.B., Boston. .. . 140 Legislative protection of the people from the evils of patent medicines and medical fakers. F. F. Lawrence, M.D., D.Sc, LL.D., F.A.C.S., Columbus, O 154 License, Examinations for — to practise and hospital interneship. John M. Baldy, M.D., Philadelphia 37 McAlister, John B., M.D., Harrisburg, Pa. Legislation creating civil positions for physicians 46 Medical benefits. The relation of — of health insurance to existing health agencies. B. S. Warren, M.D., Washington, D. C 11 1 Medical examination, The necessity for — of prisoners at the time of trial. Paul Bowers, M.D., Michigan City, Ind 220 Medical fakers. Legislative protection of the people from the evils of patent medicines and — . F. F. Lawrence, M.D., D.Sc, LL.D., F.A.C.S., Columbus, O 154 Medicine and the industries. George M. Price, M.D., New York City. 183 Medicine, Legislation regulating the practice of — , preliminary and medical education. N. P. Colwell, M.D., Chicago 24 Motherhood, Our social readjustments and the relation of the state to — and children. George A. Hare, M.D., Fresno, Cal 7 Necessity for medical examination of prisoners at the time of trial, The. Paul Bowers, M.D., Michigan City, Ind 220 New York State sanitary code, how enacted — its scope and legal status. The. Hermann M. Biggs, M.D., Albany, N. Y 125 Otis, E. O., M.D., Boston. The physically defective 189 Our social readjustments and the relation of the state to motherhood and children. George A. Hare, M.D., Fresno, Cal 7 234 Patent medicines, Legislative protection of the people from the evils of — and medical fakers. F. F. Lawrence, M.D., D.Sc, LL.D. F.A.C.S., Columbus, O 154 Physically defective. The. E. O. Otis, M.D., Boston 189 Physicians, Legislation creating civil positions for — , John B. Mc- Alister, M.D., Harrisbturg, Pa 46 Potts, Rufus M., Springfield, 111. Unemployment insurance 90 Practice, Examinations for license to — and hospital interneship. John M. Baldy, M.D., Philadelphia 37 Practise of Medicine, Legislation regulating the — , preliminary and medical education. N. P. Colwell, M.D., Chicago 24 Price, George M., M.D., New York City. Medicine and the industries. 183 Prisoners, The necessity for medical examination of — at the time of trial. Paul Bowers, M.D., Michigan City, Ind 220 Relation of medical benefits of health insurance to existing health agen- cies. The. B. S. Warren, M. D., Washington, D. C 11 1 Rucker, William Colby, M.D., Washington, D. C. Interstate sanitary relations 131 Sanitary code, The New York State — , how enacted — its scope and ^v ^ legal status. Hermann M. Biggs, M.D., Albany, N. Y 125 Sanitary relations, Interstate — . WiUiam Colby Rucker, M.D., Washington, D. C 131 Social insurance against accidents (workmen's compensation laws). ^'^^ Frederick L. Van Sickle, M.D., Olyphant, Pa 54 Standards applicable to child labor. Helen L. Sumner, Ph.D., Wash- ington, D. C 164 State and the insane, The. Richard H. Hutchings, M.D., Ogdensburg, N. Y 209 State, Our social readjustments and the relation of the — to motherhood and children. George A. Hare, M.D., Fresno, Cal 7 Sumner, Helen L., Ph.D., W^ashington, D. C. Standards applicable to child labor 164 Trial, The necessity for medical examination of prisoners at the time of — . Paul Bowers, M.D., Michigan City, Ind 220 Unemployment insurance. Rufus M. Potts, Springfield, 111 90 Van Sickle, Frederick L., M.D., Olyphant, Pa. Social insurance against accidents (workmen's compensation laws) 54 Veiller, Lawrence, New York City. Housing reform through legisla- tion 179 Wage-earners, Women as — . Mrs. Florence Kelley, New York City. . 176 Warren, B. S., M.D., Washington, D. C. The relation of medical bene- fits of health insurance to existing health agencies iii Women as wage-earners. Mrs. Florence Kelley, New York City 176 Workmen's compensation, Social insurance against accidents ( — laws). Frederick L. Van Sickle, M.D., Olyphant, Pa 54 "^1 THIS BOOK IS DUE ON THE LAST DATE STAMPED BELOW AN INITIAL FINE OF 25 CENTS WILL BE ASSESSED FOR FAILURE TO RETURN THIS BOOK ON THE DATE DUE. THE PENALTY WILL INCREASE TO SO CENTS ON THE FOURTH DAY AND TO $1.00 ON THE SEVENTH DAY OVERDUE. JUL 22 1938 ¥:>'=T:n 1 n ■tm. APR 281341 M ^ ^^^ APR 29 1943 REC'D I..D APR 2 0'64 -7 PM ^^^ e l;..y 4W»y'w>'* 7m'53Si N REC'D LD J'JiJ rB5-8AM 12lan'6lTPf wiBf'v'? tyi 51 V ' fir # asiui'^x 4^ LD 21-95m-7,'37 4K. 1 %f\J% ^•^Or- LJJfc-J^l'JiiMiiWm ^ 36667^ UNIVERSITY OF CALIFORNIA LIBRARY . V /c ■f: