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 depression to employ the unemployed upon public works of permanent character.

I do not care to take up the time of this body upon the question of taxation, 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 problem 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 public improvement and having rendered a public service by increasing the opportunity for employment.

Dr. George A. Hare, Fresno, Cal.:

I do not think that the American Academy of Medicine or any other organization has ever listened to a more intelligent discussion of the broad aspects of insurance than we have had presented to-day. To me the subject has been an intensely interesting one. Upon the western coast this question is claiming a great deal of attention, and the discussion this afternoon has been exceedingly direct and edifying.

Dr. Van Sickle, closing:

There are four great bodies in the United States concerned in this social study: (1) The State, in which we might include the United States Government; (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 certainly reliev the state and local municipalities of a large amount of expense from pauperism. If social insurance is to operate upon the scheme of the

smallest cost to the greatest number we must have coöperation. Dr. Andrews brought to our minds the fact that there is a continuous demand for coöperation 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 administrativ commissions should be given greater discretion in granting additional medical aid. This is especially true in Pennsylvania under workmen's compensation. 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 administrativ commission ought to have the power to say that all the medical aid necessary-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 insurance bill of the Association for Labor Legislation the medical experts who are coöperating with us in drafting the measure discuss this question of remunerating physicians. These medical experts have not reacht definit conclusions, but offer for discussion four possible methods, including a compromise, which has workt well elsewhere, between the capitation and the visitation 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 mentioned, and to counteract some of their obvious disadvantages. As Dr. Alexander Lambert, chairman of the social insurance committee of the American 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, however, other groups, outside of the public health officers, who take a different view of the manner in which health insurance should be administered. Many

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 establishment 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 employer, which has become a very vital issue in this country. Under workmen'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 activly interested in preventing union organization in the plant than in safeguarding the physical condition of the applicant. In health insurance, on the contrary, with employer and employe paying equal amounts, the situation 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 coöperation 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 coöperation suggested is that which brings success to all undertaking. I appreciate your calling me again, but I feel I can say nothing further. 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 directorate composed of equal number of employers and employes in certain dis

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 words, 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 detailing to those federated bodies, medical officers of health departments to act as medical referes and relieve the practicing physician of the responsibility 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 referred to the administrativ board which passes on the question of admitting or of deporting the immigrant. That plan suggested to my mind the practicability of its being used to solve this problem. The medical officer, therefore, from the health department would have little to say in the administration 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-prevention. I did not mean that the health department should take over the administration. As to the statement of Dr. Andrews that in medical matters "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 appointment in an important executiv department of the state is calculated to obtain 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 circular 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 thruout the State of New York. An important factor in the campain then inaugurated was the New York State Charities Aid Association, which, in co-operation with the New York State Department 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 committees 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 considered. 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