UNITED STATES PUBLIC HEALTH SERVICE RUPERT BLUE, Surgeon General VITAL STATISTICS A DISCUSSION OF WHAT THEY ARE AND THEIR USES IN PUBUC HEALTH ADMINISTRATION BY JOHN W. TRASK Assistant Surgeon General United States Public Health Service SUPPLEMENT No. 12 TO THE PUBLIC HEALTH REPORTS ApeIL 3, 1914 [SECOND EDITION] WASHINGTON GOVERNMENT PRINTING OFFICE 1914 UNITED STATES PUBLIC HEALTH SERVICE RUPERT BLUE, Surgeon General A DISCUSSION OF WHAT THEY ARE AND THEIR USES IN PUBLIC HEALTH ADMINISTRATION BY JOHN W. TRASK Assistant Surgeon General United States Public Health Service SUPPLEMENT No. 12 TO THE PUBLIC HEALTH REPORTS April 3, 1914 [SECOND EDITION] WASHINGTON GOVERNMENT PRINTING OFFICE 1914 U-iMl^ \A^.; HEALTH OFFICEES AND OTHER PERSONS ENGAGED IN PUBLIC HEALTH -Wore, jPHTSICIANS AND MEDICAL STUDENTS CAN OBTAIN COPIES OF THIS PUBLICATION BY ADDRESSING THE SURGEON GENERAL, UNITED STATES PUBLIC HEALTH SERVICE "WASHINGTON, D.C. V D. OF 0. OCT 20 1914 CONTENTS, Introduction. 7 Vital statistics 8 Definition 8 Development 8 Based on population 9 Population statistics 9 Source of data 9 Nature of census information 10 Sources of error in census enumerations 10 Fluctuation in population 11 Estimates of population 12 Arithmetical method 12 Geometrical method 13 Marriage statistics 14 Marriage rates 15 Factors influencing marriage rates 15 Uses of marriage registration 17 Birth statistics 17 Registration in England 17 Registration in the United States 18 Colonial period 18 Post-colonial period 19 Recent development 20 Source of data 21 Nature of information secured by registration 21 Standard birth certificate for the United States 22 Birth rates 1 22 Rate per 1,000 population 22 Rate per 1,000 women of child-bearing age 23 Rate of legitimate births per 1,000 married women of child-bearing age (15 to 44, or 15 to 49 years of age), and of illegitimate births per 1,000 unmarried wom.en 24 Sources of error in birth statistics 24 Uses of birth registration and statistics 25 Legal record 25 Uses in public health administration 25 Factors influencing birth rates 26 Morbidity statistics 27 Morbidity statistics in England and Wales 28 Morbidity statistics in Russia 29 Morbidity statistics in the United States 29 Advocated by American Medical Association and others 29 First developed in Massachusetts 30 Early development in Michigan 34 Present status. 35 (3) Morbidity statistics — Continued. Page. The notifiable diseases 37 The model State law for morbidity reports 37 The, results of notification in certain States and cities 39 Diphtheria 40 Measles. 40 Typhoid fever - 41 Source of statistical data 42 Nature of information secured by morbidity notification 45 The standard notification blank 45 Sources of error in morbidity statistics 46 Uses of morbidity reports and statistics 47 Morbidity rates 48 Crude morbidity rates 48 Specific morbidity rates 48 Fatality rates 49 Hospital statistics and sickness insurance records 49 Factors influencing morbidity rates 49 Notification of occupational diseases 50 Mortality statistics 51 Registration of deaths in England and the United States 52 United States registration area for deaths 52 Source of data 53 The standard death certificate 54 Sources of error 54 Uses of death registration 59 Death rates - 59 Crude death rates 59 Death rates for short periods 60 Specific death rates 60 Standardized death rates 61 Factors affecting death rates 62 Nonresidents — hospitals and institutions 63 Migration 63 Birth rate - 64 Marital condition 64 Infantile mortality 68 Life tables 68 Acknowledgments 69 TABLES. Table 1. — Showing growth of population in certain countries in millions, 1800 to 1910 11 Table 2. — Number of persons married per 1,000 population in certain countries, 1892 and 1911 16 Table 3. — Birth rates (exclusive of stillbirths) per 1,000 population in certain countries, 1886 and 1911 26 Table 4. — Diphtheria — Cases notified, case rates per 1,000 population, number of cases notified for each fatality (death) registered, and fatality rates per 100 cases, in States and cities haviag 10 or more cases notified for each death registered, 1912 40 Table 5. — Measles — Cases notified, case rates per 1,000 population, number of cases notified for each fatality (death) registered, and fatality rates per 100 cases, in States and cities having 50 or more cases notified for each death registered, 1912 - 40 Page. Table 6. — Typhoid fever — Cases notified, case rates per 1,000 population, number of cases notified for each fatality (death) registered, and fatality rates per 100 cases, in States and cities having 7 or more cases notified for each death registered, 1912 41 Table 7. — Showing for the period 1886-1895, the number of deaths per 10,000 persons according to their marital status in France, Prussia, and Sweden 64 Table 8. — Death rates (exclusive of stillbirths) per 1,000 population in certain countries, 1886 and 1911 64 Table 9. — Comparison of mortality of males and females, by age groups; death rates per 1,000 population 65 Table 10. — Death rates per 1,000 persons at different age periods in New York City, with increase or decrease percentage from all causes for the years 1868 and 1907 65 Table 11. — Infantile mortality — Deaths of children under 1 year of age per 1,000 birtlis (exclusive of stillbirths) in certain countries, 1892 and 1911 68 Table 12. — ^Approximate life tables for the city of New York based on mor- tality returns for the triennials 1879 to 1881 and 1909 to 1911 69 CHARTS. Chart 1. — -Population of the United States in millions, 1810 to 1910; and of Massachusetts in hundred thousands, 1765 to 1910 13 Chart 2. — Number of persons married per 1,000 population per annum — Eng- land and Wales— 1840 to 1910 15 Chart 3. — Births (including stillbirths), persons married, and deaths (exclud- ing stillbirths) registered per 1,000 population per annum — Michigan — 1871 to 1911 16 Chart 4. — Bhths and deaths (exclusive of stillbirths) per 1,000 population per annum — England and Wales — 1840 to 1910 23 Chart 5. — Births and deaths (exclusive of stillbirths) per 1,000 population per annum — Massachusetts — 1850 to 1910 24 Chart 6. — Smallpox — Number of cases notified per annum in Michigan from 1883 to 1912 33 Chart 7. — Smallpox — Number of cases notified per annum for each death reg- istered— Michigan— 1883 to 1912 34 Chart 8. — Scarlet fever — Number of cases notified per annum for each death registered— Michigan— 1884 to 1910 35 Chart 9. — Measles — Number of cases notified per annum for each death regis- tered— Michigan— 1890 to 1910 36 Chart 10. — Diphtheria — Number of cases notified per annum for each death registered— Michigan— 1884 to 1910 42 Chart 11. — Diphtheria — Fatality rate (number of deaths registered per annum per 100 notified cases) — Michigan — 1884 to 1910 43 Chart 12. — Births and deaths (exclusive of stillbirths) per 1,000 population per annum — German Empire — 1886 to 1911 60 Chart 13. — Births and deaths (exclusive of stillbirths) per 1,000 population per annum— France— 1886 to 1911 62 Chart 14. — Births and deaths (exclusive of stillbirths) per 1,000 population per annum — Massachusetts — 1871 to 1911 63 • Chart 15. — Infantile mortality (deaths of infants under one year of age per 1,000 births per annum, exclusive of stillbirths) — German Empire, France, England and Wales, Denmark, Sweden, and New Zealand— 1892 to 1911 67 Chart 16. — Infantile mortality (deaths of infants under 1 year of age per 1,000 births per annum, exclusive of stillbirths) — England and Wales — 1840 to 1910. 67 6 APPENDIX. Early registration in England — Order of Thomas Cromwell, Vicar General Page, under Henry VIII (1538), requiring the clergy to record baptisms, marriages, and burials 71 The model State law for morbidity reports 71 The standard morbidity notification blank 74 Hospital discharge certificate 75 Notification of occupational diseases, United States — Abstracts of State laws and regulations 76 California 76 Connecticut 76 Illinois 76 Kansas 76 Maine 77 Maryland 77 Massachusetts 77 Michigan 77 Minnesota 78 Missouri 78 New Hampshire 78 New Jersey 79 New York 79 Ohio 79 Pennsylvania 79 Wisconsin 80 Occupational diseases required by State laws to be reported (table) 80 Occupational diseases — Information to be given in reports by physicians (table) ' 81 Occupational diseases — Other provisions of the several State laws (table)... 82 The model State law for the registration of births and deaths 83 The standard birth and death certificates 92 United States standard certificate of birth 93 Supplemental report of birth 93 United States standard certificate of death 94 VITAL STATISTICS. A DISCUSSION OF WHAT THEY ARE AND THEIR USES IN PUBLIC HEALTH ADMINISTRATION. By John W. Trask, Assistant Surgeon General, United States Public Health Service. Vital statistics are the statistics of life. Morbidity statistics are the statistics of disease. Mortality statistics are the statistics of deaths. Birth, death, and migration statistics relate to population movement. Statistics of births and of immigration show population increment. Statistics of deaths and of emigration show population decrement. Statistics have suffered in reputation because of the seeming truth of the trite statement that one can prove anything by figures. In reahty figures are but evidence upon which conclusions may be based. If the evidence is faulty and the faults are not perceived, errors in judgment may result. But this is true of all evidence upon which opinions are based and is no more true of figures and statistics than it is of other kinds of evidence. Statistics are derived from the collection and numerical classifica- tion of observations relating to certain facts or events. They are usually limited to the systematic collection and classification of data relating to relatively large classes of events. In the maldng of sta- tistics the first and essential step is the recording of observations. After the observations have been noted a numerical compilation of their frequency or of the frequency of certain of their conditions or attributes is possible. The derived statistics being but a numerical classification or analysis of the recorded events depend primarily for their usefulness upon the accuracy of the original records of facts. They depend secondarily upon the accuracy of statistical classifica- tion and compilation. The original notation of facts and of the occurrence of events is usually secured in one of two ways, by enumeration or by registration. Observations relating to the population are made for example by enumeration at the decennial censuses. The census enumerators go from house to house and secure certain information regarding each individual. The enumerators are the observers who secure the original data. Statistics of population are made by the classification of the information thus obtained and the numerical compilation of the frequency of certain attributes. On the other hand, the notation of facts relating to deaths is secured by registration. For each individual who dies there is regis- (7) 8 tered wifcli an oflicial Imowii as a registrar certain information regard- ing the deceased and the cause and time of death. Here the observers who record the original data are the physicians, members of f amihes, and undertakers. From the classification and compilation of the information thus recorded mortahty statistics are made. Statistics of population depend for their accuracy upon the correctness of the records made by the enumerators and mortality statistics upon the accuracy of the information registered in death certificates. The statistical method is in itself dependable, although it is true that statistics may be vitiated by the use of inaccurate or incomplete data as a basis or of faulty methods in classification and compilation. Conclusions drawn from statistics by those who attempt to use them may be quite erroneous, but this is more often due to the limitations of the user than to the limitations of the statistics. The most com- mon error in the use of statistics is perhaps the comparing of numerical statements or ratios which are too dissimilar to allow of comparison. To make dependable statistics the original observations and records from which they are derived must be true and accurate, and the classification, compilation, and analysis must be done by com- petent individuals. The value of statistics when thus handled is shown by the use made of life tables by actuaries of life insurance societies and companies. Vital Statistics. Definition. — Vital statistics may be defined as statistics relating to the life histories of communities or nations. They pertain to those events which have to do with the origin, continuation, and termination of the lives of the inhabitants. They commonly include statistics of births, marriages, and deaths, and the conditions attend- ing these events. With these are usually also classed statistics of the occurrence of disease — morbidity statistics. Morbidity statistics, however, differ markedly from the others in their manner of collection and uses, so that to a greater degree than any of the others they constitute a class by themselves. Guilfoy has given a descriptive definition which in slightly abbre- viated form is that vital statistics are "the numerical registration and tabulation of population, marriages, births, diseases, and deatlis, coupled with analyses of the resulting numerical phenomena." ^ Development. — Vital statistics are not a thing of recent origin. Their development to their present form, however, is comparatively modern. The Egyptians, Greeks, and Romans made census enumer- ations. Some of the ancients, notably the Romans, required also the registration of births and deaths. The statistical treatment of the records was, however, comparatively limited. During the last 1 Guilfoy, W. 11., Vital statistics in the promotion of public health, Nevv^ York Medical Journal, Nov. 5^ 1910. 9 century and a half, and more particularly tlie last 50 years, the treat- ment of vital statistics has been undergoing a rapid evolution. In their present developed form they give a fund cf useful informa- tion otherwise unobtainable. They have become an essential to every well-organized community and nation. They give a composite picture of the life history cf a people which can be secured in no other way. They furnish a m.eans of comparing the life history of one community cr people with that of others and of the present with the past. Based upon population. — All vital statistics are baaed upon the population. The frequency of births, marriages, sickness, and deaths is expressed in terms of the population, usually as rates giving the number for each 1,000 inhabitants or class of inhabitants. In com- paring different communities or different periods, births, marriages, deaths, and the incidence of disease must be based upon a common unit of population. The first requisite to useful vital statistics is statistics of population showing the number of inhabitants, classified according to age, sex, nativity, race, and occupation. It would be desirable, if possible, to have also a classification according to econo- mic status, as birth, siclaiess, marriage, and mortality rates fre- quently vary with the incomes of individuals or households. An understanding of population statistics is therefore the primary essential to the comprehension or use of vital statistics, and statistics of population •will be first considered. POPULATION STATISTICS. Source of Data. The principal source of information regarding population under existing conditions is a census enumeration. For the United States these enumerations are made every 10 years. The last census was taken as of April 15, 1910. In the United States a census has been taken every 10 years since 1790, in Great Britain every 10 years since 1801. In taking a census it is desirable in so far as possible to take it at a time when the greatest number of people will be at their usual homes. A midwinter census would find many people absent from the Northern States and an unusual number in southern winter resorts. A midsummer census would find an unusual number at the seashore and at other summer resorts. A number of the States take a census midway between the United States decennial censuses, so that they have an enumeration of the population every five years. As the only source of definite iziformation as to population is the census enumeration, and as the population is continually changing, in most cases increasing, it is necessary to make estimates of the population for the periods between the census enumerations upon 10 wliicli to base rates for the various vital events and especially for the accurate computation and expression of marriage, birth, death, and sickness rates. Nature of Census Information. The taking of a census consists usually of more than a mere enumer- ation of ail persons living at the time the census is taken. It includes the recording of certain information regarding each individual. In taking the 1910 United States census the following information relat- ing to each individual was recorded by States, counties, and town- ships, viUages or cities: Name; address; sex; color or race; age at last bu'thday; whether single, married, widowed, or divorced; number of years of present marriage; mother of how many children, total number born, number now hving; individual's place of birth, place of birth of his father and mother; year of migration to the United States; whether naturalized or alien; whether able to speak English, and if not, the language spoken; the individual's occupation, the kind of work done and the industry or business in which employed; whether an employer, employee, or working on own account ; whether employed or out of work April 15; whether able to read and 'write; whether attending school; whether he owns the home in which he lives ; whether a survivor of the Union or Confederate ili'my or Navy ; whether blind in both eyes, or deaf and dumb. From the information thus obtained the statistics of population are made. By the classification and numerical compilation of this data it is possible to ascertain the composition and distribution of the population as to sex, color or race, age, marita,! status, fecundity, nativity, occupation, literacy, blindness, and deaf-mutism. Sources of Error in Census Enumerations. A certain number of individuals wih be enumerated both at the place Vv^here they happen to be and at then* proper residences. A few wiU be missed entirely. However, the degree of error thus caused will not be great. The margin of error in the securing of ages is greater. The age recorded is customarily intended to be the age in years at the last birthday. The ages given for children under 5 years old are likely not to be accurate due to the tendency to give the age of a child between 6 and 12 months of age as 1 year old and that of a chUd between 1 and 2 years old as 2 years of age. This tendency to give the age at the next birthday persists up to about the fifth year, although it is perhaps greatest during the first and second year. To avoid the error thus arising, the United States census records the ages of children under two yeai-s of age in years and months. For example, a child 6 months of age is recorded as six-tweKths of a year old and a child of 17 months of age as 1^ years old. 11 Women 15 to 20 years of age are prone to give their ages as betv/een 20 and 25 years. Adults over 25 years of age frequently do not know their exact ages and are prone to approximate their ages as being 30 or 40 or 50 years, and to a less extent at 35 or 45 or 55 years. The result is that there is at each census an exaggerated number of ages of 30, 40, 50 years, and also a lesser exaggeration of ages 35, 45, 55, and 65 years. Individuals over 80 years of age are prone to give their ages as greater than they really are. There is also a considerable margin of error in the recording of occupation. This is due largely to an imperfect understanding of what is wanted and to the multiplicity of occupations and a lack of knowledge as to their proper designation. Fluctuation in Population. Populations are constantly changing. Individuals are continually being added by immigration. In the United States, and more par- ticularly in some sections of the United States, considerable numbers are annually being added in this way. Immigration is also an impor- tant factor in the growth of population in certain South American countries. South Africa, New Zealand, Austraha, and Canada. Populations suffer a continuous diminution by reason of emigi-a- tion. This is especially true of some European countries. Migrations not only may affect the population of a country as a whole but also may alter the distribution of people within a country. There is in many countries a constant movement of people from rural localities to the cities and from one locality to another. All populations are also being increased by births and suffering losses by deaths. The rate of change, however, resulting from births and deaths is usually comparatively constant or alters gradually, while the changes due to migrations may be exceedingly irregular. Tlie increase in the population caused by the excess of bbths over deaths is kno'WTi as the natural increase. A country in which the birth and death rates are equal and in which the factor of migration is neghgible wUl have a fixed population. The increase of population in certain countries is shown by the fol- io v/ing table: Table 1. — Showing groivth of population of certain countries in millions, 1800 to 1910. 1800 1830 1860 1890 1910 France 27 16 35 25 17 10 32 24 45 29 21 11 3 2 12 36 29 68 34 25 15 4 3 31 38 38 92 40 30 17 6 4 62 39 Great Britain and Ireland .. . 44 Russia in Europe Austria 49 Italy 34 Spain 19 Belgium . .. 7 Sweden 2 5 5 United States 92 12 Estimates of Population. The frequency of births, marriages, or deaths is usually expressed as the number occurring during the calendar year per 1,000 population. The figures thus given are known as the birth, marriage, or death rates and are computed upon the mean population — that is, the number of inhabitants estimated to have existed at the middle of the year, July 1. These estimates are necessary for all dates except those on which census enumerations are made. For the making of estimates there are two methods commonly used, known, respectively, as the arithmetical and the geometrical methods. In each method the populations at the last two census enumerations form the known quantities from which the estimates are derived. AritJimetical metJiod.- — In the arithmetical method it is assumed that the increase or decrease in population which occurred between the last two census enumerations took place in equal amounts during" each intercensal year and will continue to take place annually in like numbers until the next census shall have been taken. Thus, given a city which had a population of 50,000 at the 1900 census (June 1, 1900) and one of 61,850 at the 1910 census (Apr. 15, 1910), the increase during the intercensal period (9 years and lOJ months) would be 11,850 and the annual increase according to the arithmetical method would be 61,850-50,000 ml , or 1,200 If it is desired to estimate the population as of July 1, 1906, for the purpose of calculating annual rates, this is done by adding to the population as it existed June 1, 1900, the sum of 1,200 for each year intervening between the date of enumeration (June 1, 1900) and the date for which the estimate is to be made (July 1, 1906). There being 6 years and 1 month between these dates, the calculation would be 50,000 + (e^L X 1,200) = 57,300. This same annual increase is also assumed to occur until the next census shall have been taken, so that if it is desired to estimate the population for July 1, 1914, take the population at the preceding census (Apr. 15, 1910) and add 1,200 for each year intervening be- tween its enumeration and the date for which an estimate is desired (July 1, 1914). There being 4 years and 2 J months between these dates, the calculation would be 61,850 + (4^ X 1,200) = 66,900. This method assumes the same amount of increase each year and is analogous to the calculation of simple interest. It does not take into account the fact that with the annual increase in population the 13 number of persons of marriageable age and therefore the number of married persons will be greater each year and consequently the number of births. The growth due to natural increase (the excess of births over deaths) is analogous to the increment of compound interest, and where this factor (the natural increase) is the principal one affecting the population growth estimates of population made by the arithmetical method are unsatisfactory, and especially so where the estimate is made for a date several years away from a census enumeration. Where the excess of births over deaths is the con- trolling factor in population growth the geometrical method of mak- 1770 1780 1790 1800 I8I0 1820 1830 1840 1850 I860 1870 1880 1890 1900 1910, 90 / / BO / / 70 / / f 60 y / / 50 / / 40 ^ ' / I ^ 30 ?k /' ii i^ / y EO / / ,-/• t^ ^ ^ y -a ch ■h 6j^ "" 10 ^ M^ ^ hti — - r f -^ tJ — - □ ■^"" U Chart L— Population of the United States, in millions, 1810 to 1910; and of Massachusetts, in hundred thousands, 1765 to 1910. ing estimates, being based on the principle of compound interest, is more accurate. Where the chief factor in population change is migration, or where the relative importance of natural mcrease is much affected by migration, the arithmetical method may be the more accurate. The arithmetical method has been the one found most reliable in the United States and is the method used by the Bureau of the Census. The method best adapted to a given popu- lation can be ascertained by taking the last two intercensal periods and finding whether the rate of increase during the last intercensal period was, when based upon the increase during the preceding inter- censal period, at the rate indicated by the arithmetical or the geo- metrical method. Geometrical method. — As previously stated, the geometrical method is based upon the principle of compound interest. 14 Assuming a decennial census, let P = population ill 1900. . P' = population in 1910. T = the annual increase per unit of population. Then the population would be — In 1901=P (1+r) In 1902 -P (l+r) 2 In 1903=P (1+r) 3 In 1910 (P')=P (!+?-) '' p— (l+r-)^° p- = l+r andr = yp — 1 In practice the calculation would be made vdth the aid of a table of logarithms, and given the value of v the estimated population for any intercensal or post censal date is readily obtained. For post censal dates the estimated population would be — In 1911 =P' (1+r) In 1912 = P' (1+r)^ In 1913-P' (HTr)2 ^ift year = P' (1+r) ^ The registrar general of England and Wales uses the geometrical method for England and Wales as a whole and a modified method for lesser subdivisions. Marriage statistics are of interest because of the information they give regarding the social life of the people and the establishment of families and households, and because of the relation of marriages to population growth through their influence on the birth rate. Their consideration naturally precedes that of birth statistics. The data for marriage statistics are obtained by the registration of marriages. The common custom in the United States is to require persons desiring to marry to obtain first a license from a designated official. This hcense is presented to whoever performs the marriage ceremony. The person officiating is required to register the mar- riage. Those responsible for the completeness of marriage records are therefore in this country usually the clergy and justices of the peace. There is seldom much difficulty in securing complete records of marriages, and the amount and value of the information given by marriage statistics depend upon the nature and extent of the facts recorded relating to the contracting parties. In England and Wales marriage statistics are compiled by the registrar general of marriages, births, and deaths. In this country 15 the official responsible for tlie compilation of marriage records varies in tlie several States. The United States Bureau of the Census has compiled statistics of marriage and cUvorce in the United States from 1867 to 1906. These were pubhshed in 1909. Marnage rates. — Marriage rates may be expressed as the number of marriages for each 1,000 population. While this method gives cer- tain information of a definite character and is useful for comparing different years of the same community and different communities of similar population composition, it is not useful in comparing popu- lations in which the proportion of single persons of marriageable age is not the same. For the j^urpose of comparing marriage rates, therefore, the more exact method is to express the rate as the number of marriages or persons married for each 1,000 unmarried, divorced, and widowed, of marriageable age, usually those over 15 years of age. 184-5 1850 1855 i860 1865 1870 !&75 1880 1885 1890 1895 !900 1905 1910 "^ . 18 16 ^ -^ ~= _™ — »-. ^ \ '^^ ^' \ y L^" "^ N 14 n U-' X \z to _ 1 L J J _=. Chart 2.— Number of persons married per 1,000 population per annum— England and Wales— 1840 to 1910. The curve shows the mean annual rate for quinquennial periods. Factors influencing marriage rates. — Marriage rates are usually in- fluenced by economic conditions. National prosperity increases the rate, economic depression reduces it. For the same reasons it is influenced by the demand for labor and the rate of wages. The rela- tion of the adopted standard of living to the average v/age has a similar effect. In the absence of other factors, the marriage rate is usually a fair index of the relation of average income to standard of living. The marriage rate may also be affected by the frequency of divorce and remarriage. A high birth rate tends to increase the marriage rate in succeeding years. In communities such as minuig towns and new industrial centers the marriage rate may be Umited by the pres- ence of a relatively small number of marriageable women. The marriage rate in a city may be fictitiously high, due to the fact that many couples from the surrounding country and small towns may go there for the purpose of being married, returning then 16 to their homes. In a country affected by emigration a relatively largo proportion of the migrants are apt to be young men and women, 1875 1880 1885 1890 1395 I3G0 1905 (910 — / \ / \ £ /rt /?3 / ■^ / \ / -^ / \ / \ / / V /I l\l 1 / \ ^ \, A \, / \ / \| ■^ / V — \ / \ / \ \ / ... ^ s, y \ ^ J — /7 \ /- •'* ... \ ,,' jf Y ^ .-. M xr n'c A ^, ^^ \ ^ .'• > ■^ / \ - / N ■ '' ■'^ , .— ... y ... ' > ^ A '/ ^ / ^^ ,' ' -'' "-■ >^ / / ^ ^ y ^ 1 / — 1 \ / 1 / ' \ , / / D, ICL s / / ^ ^ /■ \ ^ ■^ k /' s 1 / \ r / ^ \ / \ 1 s / Chart 3.— Bii'ths (including stillbirths), persons married, and deaths (excluding stillbirths) registered per 1,000 population per annum— Michigan— 1871 to 1911. the women frequently following after the men have become located. This naturally affects the marriage rate of the home country. Table 2. — Number of persons married per 1,000 population in certain countries, 1892 ayidWll} Country or State. 1S92 1911 Australian Commonwealth 13.5 15.7 13.5 15.4 12.2 15.1 15.9 18.4 9.3 14.9 14.4 12.5 12.7 15.4 14.1 19.0 16.9 11.4 17.6 Austria 15.2 Denmark . 14.4 England and Wales 15.2 Finland 12.0 France 15.5 15.7 Hungary. 18.5 10.7 Italy 15.0 The Netherlands 14.3 17.4 12.5 21.0 13.4 20.6 14.2 11.7 18.8 18.0 18.6 18.6 20.9 1 Taken from the Seventy-fourth Annual Report of the Registrar General of Births, Deaths, and Mar- riages in England and Wales, 1911, except the rates for Massachusetts, Michigan, and Connecticut, which were taken from the State reports. 17 ' ■ Uses of marriage registration.— The purpose of the registration of a marriage is largely to protect the home and family. It furnishes reliable evidence upon which to base the legitimacy of children and the dower rights of women. BIRTH STATISTICS. Statistics of births are of interest mainly because of their relation to population growth, the excess of births over deaths being known as the "natural increase." Growth of population has been the object of concern to nations largely because of its effect in deter- mining the future military strength and the number of men available for purposes of offense and defense. The practically stationary popu- lation of France has for some time been the subject of comment, but with her limited territory it is a question whether the people as a whole are not better off with the present population than they would be with a larger one. More people mean greater congestion and more intense competition. During the last century Great Britain, Ger- many, Austria, and Russia have trebled in population. Had France done the same, she would now have nearly 80 millions of people, and it is doubtful whether this would have added to the happiness and welfare of the race. It is undoubtedly better to have a people proportionate in number to land area and natural resources than to have a teeming population with the consequent economic problems. It would seem more in keeping with modern ethics to strive for a people composed of intelli- gent, physically sound individuals free from disease and properly housed, fed, and clothed, whose da3^s furnished time for both labor and recreation under conditions which conduced to physical and mental welfare and not to deterioration, rather than to strive for mere numibers. To the health officer and sanitarian birth statistics have only casual interest. Birth registration, however, which furnishes the data from which the statistics are made, is important not only in public health work but in other ways as well. Registration in England. Registration of baptisms, marriages, and deaths in England dates back to 1538, when Thomas Cromwell, Vicar General under Henry VIII, issued injunctions to all parishes in England and Wales requiring the clergy to enter every Sunday in a book kept for the purpose a record of all baptisms, marriages, and burials of the preceding week.^ A copy of the order will be found in the appendix, page 71. 1 "The Parish Registers of England," by J. Charles Cox. 55256°— 14 2 18 August 24, 1653, Parliament passed an act taking the parocMal registers from the clergy and placing them in the custody of laymen called "parish registers" who were to record all marriages, births, and burials. Later this duty reverted to the clergy. The office of registrar general of births, marriages, and deaths was established in 1836 and pursuant to an act of Parliament civil regis- tration was begun July 1, 1837. In 1870 the registration of births and deaths was made compulsory, with a resulting improvement in the returns.^ Registration in the United States. In legislation the registration of births^ marriages, and deaths were formerly usualty associated and provided for by the same laws. Since 1900, however^ this has not been generally true in the United States, where the practice has developed of providing separately for the registration of births and deaths. COLONIAL PERIOD. In 1632 the Grand Assembly of Virginia passed a law requiring a miaister or warden from ererj parish to be present annually at court on the 1st of June and present a register of all burials, christenings, and marriages. In 1639 Massachusetts Bay colony adopted a requirement for the keeping of records of marriages, births, and deaths. In 1646 the Plymouth colony enacted a law providing that the clerk or someone in every town should keep a record of all marriages, births, and burials. In 1692 Massachusetts put the registration of births and deaths on a more definite basis by the enactment of the following law; Chapter 48. an act for the registering of births and deaths. For preventing of great tincertainty and inconvenience that may happen for want of a particular register of births and deaths — . Be it enacted by the Governor, Council and Representatives in General Court assembled, and by the authority of the same, That every town clerk within this province shall be and is hereby impowred and required to take an account of all persons that shall be born, or shall dye, within each town, respectively, and the precincts thereof, and fairly to register in a book their names and surnames, as also the names and surnames of their parents, with the time of their birth and dearth. And the clerk shall demand and receive the fee of threepence, and no more, for each birth, or death by him so registered, to be paid by the parents or others nextly related to or concerned with the party born or dying. And if any shall refuse ox neglect to give notice to the town clerk of the birth or death of any person that they are so related to or concerned for, or to pay for registring as abovesaid by the space of thirty days next after such birth or death, every person so refusing or neglecting, and being (upon the complaint of any town clerk) thereof convicted before a justice of the peace mthin the same county, 1 Vital statistics, Newsholme, 1S99. 19 shall forfeit and pay Tinto such clerk the sum of five shillings, to be levied by distress and sale of the offender 's goods by warrant from such justice, if payment thereof be not made within four days next after conviction as aforesaid. And every town clerk diall give forth from the registry a fair certificate, under his hand, of persons born or dying in the town, to any who shall desire the same; and he shall receive sixpence and no more for every certificate so given. (Passed February 17, 1692-3.) POSTCOLONIAL PERIOD. In 1795 Massachusetts passed a law repealing the 1692 act and requiring parents to give notice to the town clerk of births and deaths of children, householders to give notice of those in their households, and persons in charge of institutions of those occurring in their respective institutions. The town clerks were requhed by the same law to keep a record of all births and deaths coming to their knowledge. In the case of births the date of birth and the names of the parents were to be recorded. A penalty of $1 was pro- vided for failure to report a birth or death. In 1842 Massachusetts passed the following act providing for the registration of births, marriages, and deaths: An Act relating to the registry and returns of births, maiTiages, and deaths. Be it enacted by the Senate and Souse of Representatives, in General Court assembled, and by the authority of the same, as folloivs: Sec. 1. The clerks of the several towns and cities in the Commonwealth shall, annually, in the month of May, transmit to the secretary of the Commonwealth a certi- fied copy of their record of the births, marriages, and deaths of all persons within their respective towns and cities, which may come to their knowledge; slull state the num- ber of births and marriages, and the number of deaths, with the name, sex, age (and if an adult male, the occupation), and the names of the diseases of which all persons have died, or are supposed to have died, together with the cause or causes of the death of all such deceased jjersons, so far as they may be able to obtain a knowledge of the same fi'om physicians or others; and any clerk who shall neglect to make such return, shall be liable to a penalty of ten dollars, to be recovered for the use of any town or city where such neglect shall be proved to have existed. Sec. 2. The secretary of the Commonwealth shall prepare and furnish to the clerks of the several towns and cities in this Commonwealth, blank forms of returns, as herein before specified, and shall accompany the same ^vith such instructions and explana- tions as may be necessary and useful; and he shall receive said returns, and prepare therefrom such tabular results as will render them of practical utility, and shall make report thereof annually to the legislature, and generally shall do whatever may be required to carry into effect the objects of this act, and of the several provisions of the Revised Statutes not inconsistent with this act. (Approved by the Governor, Mar. 3, 1842.) In 1844 ]Massachusetts passed another law amplifying the preceding and requiring the town clerks to number the births registered and to record them in the order in which received, showing in separate columns the date of birth, place of birth, name of child, sex of child, name and surname of one or both parents, occupation of father, residence of parents, and the time of making the record. Marriages 20 were also required to be numbered and recorded in tlie order received, the record to sliow the date and place of marriage; the name, resi- dence, and official station of the person performing the ceremony; the names and surnames of the contracting parties and the residence, age, civil status, occupation, and the nam.es of the parents of each; and the time when the record was made. Deaths were likewise to be numbered and recorded in the order received, the records to show the date of death; the name, surname, sex, civil (mpaital) status, age, occupation, place of death, place of birth, and names of parents of the decedent; the cause of death; a,nd the time the record was made. The school committee of each town and city was to ascertain an- nually in May the births which had occurred during the preceding- year and to report them with all required data to the town clerk. Persons solemnizing marriages were to keep proper records and make returns to the town clerks once a month. Sextons or other persons having charge of burial grounds were to keep records of burials and make returns monthly to the town clerk. The law of 1844 placed the responsibility for the registration of births upon the school committee, for the registration of marriages upon the persons officiating, and for the registration of deaths upon persons in charge of burial grounds. Most of the other States have from time to time passed laws requir- ing the registration of births. Many of these laws have been faulty and incapable of enforcement. The returns have also suffered in most instances from the absence of particular efforts at enforcement so that in very few locahties have the records been at all complete. RECENT DEVELOPMENT. The American Medical Association has for many years taken cog- nizance of the need for improved registration of births, marriages, and deaths. As early as 1846 a committee was appointed to consider ways and means for improving the registration of births, marriages, and deaths. In 1855 the following resolutions were adopted by the association: Resolved, That the members of the medical profession throughout the Union be urgently requested to take immediate and concerted action for petitioning their several legislative bodies to establish offices for the collection of vital statistics. Resolved, That a committee of one from each State be appointed to report upon a uniform system of registration of marriages, births, and deaths. Of recent years merited attention has been given to the subject of bkth registration by the Bureau of the Census, the American PubHc Health Association, the American Medical Association, and other similar bodies. The recently estabhshed Children's Bureau of the Federal Government has, since its organization, been especially active in urging the need of better reoistration. 21 A model bill for the registration of births and deaths recom- mended for enactment by the several State legislatm-es has been drafted and indorsed by the American Medical Association in con- sultation with representatives of the Bmeau of the Census, the Children's Bureau, the American Pubhc Health Association, the American Bar Association, and a number of other organizations and societies national m scope. (For copy of model bill see appendix, pp. 83-92.) The essential features of this law have been adopted by a number of States. It is important that other States should also enact it, for it is without question as effective a law as any that has been proposed for adoption in this country. It is also highly desirable that the laws of the several States on the subject be uniform, if the Bureau of the Census is to compile the records for statistical purposes. The power to legislate on such matters resides with the individual States. The only means the Bureau of the Census has of preparmg national bhth statistics is to com- pile the records registered in the several States under State laws. This is done by makmg copies of the birth certificates registered in the various States and from these copies taking the data for statistical tabulations. The adoption of a uniform law would therefore have distinct advantages, even if it were possible for State legislatures individually to draft better ones. Source of data. — While the data from which population statistics are derived are obtamed by direct enumeration, the data from which birth statistics are compiled are gotten by registration. The usual requirement is that whenever a child is born either the attending phy- sician or midwife, or, in their absence, the parents or the head of the household in which the birth occurred, shall register with an official designated for the purpose certain information regarding the chfid and its parents. Nature of information secured hy registration. — The information re- quired to be registered concernmg each child born usually includes certain facts relating to the child and the circumstances of its bkth, together with certain items concerning the parents. The essential facts are the name of the child, its sex, date and place of birth, and whether born alive or stiUborn, and the names and residence of the parents. There are many other items of information concerning births which are of the greatest value and serve various purposes, such as the age, color, nativity, and occupation of the parents, whether the child is a single birth, a twin, or triplet, and whether legitimate or illegitimate. These facts are usually required to be stated. The items registered serve two principal purposes. They serve, first, to identify the child and to establish its age and parentage, and, second, to furnish statistical data. 22 While in the enumeration of the population the original observer, upon the accuracy of whose work population statistics largely depend, is the census enumerator; in birth registration the original observer, upon whom dependence must be placed, is usually the physician attendmg at the birth, sometimes the midwife, and in the absence of these the parents. Bu'ths are usually required to be registered with an official ap- pointed for the purpose and known as a registrar. Customarily it is the same official with whom deaths are registered. Not uncommonly a small fee is paid to the person making the registration or filling out the certificate. This custom, however, is likely to create in the minds of many the idea that the registration is a matter of discretion — that if the fee is not wanted there is no compulsion to file the certifi- cate and that the forfeiting of the fee annuls the obligation. This is especially true in the United States, where phj^sicians and midwives have in many instances not yet come to realize that the importance of proper registration may mean so much to the child and its parents that no accoucheur has completed his task nor fulfilled his obligations to the child and its mother until an accurately filled out certificate has been filed with the registrar. The failure to file such a certificate is such a neglect of the mterests of both patients, the child and the mother, that it would seem proper to class it as malpractice. Standard hiriJi certificate for United States. — The standard form of birth certificate approved by the Bureau of the Census and recom- mended for use in the United States appears on page 93 of the appen- dix. The dimensions of the certificate as used are 6| by 7|- inches. Frequently the child is not named until some time after birth, so that it is impossible to insert in the certificate the full name of the infant. To meet this difficulty the Bureau of the Census recommends the use of a ''supplemental report of birth" which is to be filled in after the child has been named and filed with the registrar, who attaches it to the original certificate. See Appendix, p. 93. Birth Rates. There are several ways of expressing the birth rate. Each method of statement gives information not given by the others. Rate per 1 ,000 population. — The birth rate may be expressed as the number of bu'ths occurring during a year for each 1,000 of the popula- tion. This is known as the crude birth rate, and is based upon the total estimated mean population for the year — that is, for the calendar year, the population estimated as of July 1. The crude birth rate shows the net result to the community of the several factors governing reproduction- — the number of women of child-bearing age, the number of those who are married, the frequency of illegitimacy, etc. In con- 23 junction with the crude death rate it shows the ratio at which the com- munity is reproducing itself by natural increase. It is a quite satis- factory basis for comparing the bnth rate of different years for the same community or that of different communities having populations of similar composition. It is unsatisfactory for the comparison of populations havmg different proportions of females of child-bearhig age or of married women — a mining town or new industrial center may have comparatively few women ; a fashionable residential distric t 1845 185Q 1855 I860 1865 1870 ,1875 1880 1895 1890 I8S5 1900 19 05 1910 A/5 36 _J— ' -»= — =_ «« ~» Ik a> ri ■M ? r^ L> \ s -_ 34 ^ ^ N s 3a <— - *«- N \, s ■^ 30 •^ V •nj *>», iB v= *>. \ s E6 N £4 fi bs th s _^ *H EE * ^ •*«* K U" ^ =^ r— J ■--J / aij^ 3j*i ^ N EO N N 10 H = <^ — — ~~ __ — \ 16 N V V 14 IE ... — 1 _, „__.^_ „». _ ,^_ ^ . __ U Chart 4.— Births and deaths (exclusive of stillbirths) per 1,000 population per annum— England and Wales— 1840 to 1910. The curve shows the mean annual rates for quinquennial periods. may have a relatively large female population, most of which consists of unmarried servants. Boie 'per 1,000 women of cJiild-hearing age. — Birth rates maybe expressed as the number of births occurring during the year per 1,000 women of child-beaiing age. For this purpose the female popula- tion between the ages of 15 and 45 years as determined by census enumeration, or by estimation for interceiisal and post censal years, is taken. The proportion of women of these ages in the population having been ascertained by a census, the same relative proportion is assumed to be maintained until a succeeding census shows a change. 24 This method gives rates that furnish a much better basis for the comparison of different communities, in as much as it gives the births in proportion to the number of potential mothers. It is not, however, satisfactory under all conditions, and the method next described yields more useful information. Rate of legitimate hirtlis per 1,000 married women of child-hearing age {15 to 4.Ji.or 15 to 4-9 years of age) and of illegitimate hirtlis per 1,000 unmarried women of child-hearing age. — In different communities the proportion of married and single women may differ considerably and consequently comparison of their crude birth rates or of rates based on the number of women of child-bearing age would jdeld con- paratively little useful information. The proportion of married 1855 I860 1865 1870 \m 1880 1835 1880 1895 1900 1905 m ^ V £8 ^ \ ^ A \ / ■Xs. ^ 26 \ o\ r^ ij^ \ ,/ / \ \ i^ >* \ ^ ■^ \ K 24- \ ^ ^ ZZ 20 f <., A \ A / \ \, / / \ ^ ^ -— -^ \ 18 .1 \ / N f X \ 16 s ■-- 14 „ L L L- Chart 5.— Births and deaths (exclusive of stillbirths) per 1,000 population per annum— Massachusetts — 1S50 to 1910. The cun^e shows the mean annual rate for quinquennial periods. women in industrial communities is usually considerably larger than it is in residential suburbs, where there are greater numbers of female servants. To make allowance for these differences in popula- tion composition the most useful method of stating the birth rate is in terms of the number of legitimate births per 1,000 married women of child-beariaig age (15 to 44 years or 15 to 49 years) and the number of illegitimate births per 1,000 unmarried women of this age. Sources of Error in Birth Statistics. The principal sources of error in birth statistics are to be found in defective registration. There is no reliable check by which the failure tcf register births can in all cases be detected. In many foreign coun- tries the people have become accustomed to register births and ap- parently their returns are quite complete. The registration of 25 . illegitimate births, however, is alwaj^s less complete than that of the legitimate. In the United States the people, as a whole, have in most sections not become accustomed to the registration of births. This is undoubtedly due in part to a rapidly changing population continually receiving large numbers of immigrants from various foreign countries — immigrants who are ignorant of our registration laws and have little opportunity of learning their requirements — and in part to the abserice of effort by the authorities to enforce the laws. As checks upon the completeness of birth registration registrars frequently use the death returns of young children and especially of mfants, checking up each recorded death with the birth records to see whether the birth of the child had been registered. The notices of births appearmg in newspapers are also often used for the same purpose. If in cities dealers were required to keep a record of all sales of baby carriages, cribs, and high chairs tiiis might be of use as a further check until the population shall have become thoroughly used to registration. Also, if aU. christenings were required to be notified by those officiating, this too would be of assistance. Uses of Birth Registration and Statistics. Birth statistics are of use in ascertaining the natural increase of the population (excess of births over deaths). They also give valuable information regarding the effective fertihty or fecundity of the race and of the frequency of illegitimacy. These matters are of interest to the economist and the statesman. The possession of birth statis-. tics also furnishes the basis for the present accepted means of stating the infant mortality rate, as wiU be explained later. The data from which the statistics are made, the registered births, are on the other hand of value to the community in many ways, and to the health officer among others may be especially useful. Some of the uses wUl be enumerated. Legal record. — The registration of a child's birth forms a legal record that is frequently useful and may be of the greatest importance. It establishes the date of birth and the child's parentage and legiti- macy. It may be required to establish the child's age for attendance at public schools, for permission to work in States where children below a certain age are not allowed by law to be employed; to show whether a girl has reached the age of consent, whether individuals have attained the age when they may marry without the parent's per- mission; to estabhsh age in connection with the granting of pensions, miUtary and jury duty, and voting. It may be necessary in con- nection with the bequeathing and inheritance of property or to furnish acceptable evidence of genealogy, and in fact may be impor- tant and useful in possible events too numerous to mention. Uses in 'public health administration. — Registration of births shows where the babies are and makes possible such observance and pro tec- , 26 ' tion as the health department desh-es to extend. With bu'th regis- tration it would be possible for the health authorities to see that the babies are vaccinated against smallpox. This is on© of the uses made of registration in England. It would also be possible to see that the babies in poor famiUes have proper food and adequate attention. The observation of infants under 2 weeks of age would bring to hght some cases of ophthalmia which otherwise might cause serious injury to vision and at times total blindness. Table 3. — Birth rates {exclusive of stillbirths) per 1,000 population in certain countries, 1886 and 1911.1 Country or Stat«. 18S6 1911 35.4 38.3 32.4 32.8 35.3 23.9 37.0 45.6 23.2 37.0 34.6 33.1 31.2 42.2 32.9 42.0 36.7 29.8 2 22.2 25.4 2 21.3 27.2 31.4 26.8 24.4 29.1 18.7 28.6 35.0 23.2 Italy 31.5 27.8 26.0 25.9 43.0 25.6 36.2 31.2 23.8 24.8 25.7 23.0 1 Taken from the Seventy-fourth Annual Report of the Registrar General of Births, Deaths, and Mar- riages in England and Wales, 1911, except the rates for Connecticut, Massachusetts, and Michigan, which were taken from the State reports. - Includes stillbiiths. Factors Influencing Birth Rates. Birth rates are directly influenced by the number of women, and particularly of married women, of child-bearing age in the population. The child-bearing period of life for women may be considered as that between the ages of 15 and 49 years; the ages between 25 and 44 years are for most races of the north temperate zones, however, those mainly productive. The economic and social status of the population may also affect the birth rate. In many countries at present the poorer families have considerably more children per family than have the weU-to-do; in fact to some extent the number of children per marriage seems to be inversely as the family income. On the other hand, to a degree poor economic conditions are hable to discourage or delay marriage, so that married couples are relatively fewer and older when married, with fewer resultmg offspring. The adoption of a more expensive standard of hving may produce the same results as depressed eco- nomic conditions, fewer and delayed marriages. 27 The birth rate is also affected by the habits and customs of the people, by their desire to have children or their desire not to have them. Also a high infant death rate is usually accompanied by a high birth rate and, conversely, a low infant death rate by a lov/ birth rate. MOMBIDITY STATISTICS. Morbidity statistics are the statistics of sickness and disease. They show the occurrence of diseases and their relative prevalence in different locahties and at different times. They differ from mortahty statistics in that as relates to disease, mortality statistics are the statistics of fatal cases only, while morbidity statistics niclude all cases. In the life of the mdividual, after birth the next event included in vital statistics which usually occurs is sickness. Disease has perhaps a greater influence in determmmg the happmess and efliciency of the individual and of the community than any other factor. It also has a direct bearing on the individual's longevity even when in itseK not fatal, for every attack of sickness probably does some injury and leaves the huuian machine impaired to a degree. In speaking of the usefulness of morbidity registration, Farr has said : It will be an invaluable contribution to therapeutics, as well as to bygiene, for it will enable the therapeutists to determine the dui-ation and the fatality of all forms of disease under the several existimg systems of treatment in the various sanitary and social conditions of the people. Illusion will be dispelled, quackeiy, as completely as astrology, suppressed, a science of therapeutics created, •suffering diminished, life ehielded from many dangers.^ Morbidity statistics have not evolved apace with those of births, marriages, and deaths. This is due to the different purposes they serve. The branches which have to do directly with the growtn of population were first developed, probably because of the need of the information which they gave in connection with taxation and military enlistment. IMorbidit}'^ statistics, on the other hand, are contem- porary with our comparatively recently acquired knowledge of the causes of diseases and their manner of spread. Their need has been felt only with the advent of present day pubhc health administration, which in turn has been activated in large measure by the story of the causes of death told by mortality statistics. Morbidity statistics had their origin in the requirement of the notifi- cation of cases of certain dreaded diseases, notably smallpox. With the appointment of health officers and the establishment of health depart- ments .the notification of other diseases has been requhed. As knowl- edge of the causes of diseases and their manner of spread has been obtained and health departments have been faced with the respon- 1 Cited by Newsholme, Vital Statistics, 1899. sibility of controlling maladies found to be preventable, the list of notifiable diseases has grown, for those responsible for public health administration have found that it is impossible to effectively control a disease mthout prompt information of when, where, and under what conditions cases of the disease are occurring. No epidemiologist would think of attempting to control an outbreak of yellow fever or cholera without inaugurating a dependable system whereby he would receive prompt and accurate information of the occurrence of cases. It is just as impossible to effectively control tuberculosis, typhoid fever, scarlet fever, industrial lead poisoning, or any other preventable disease without a knowledge of the occurrence of cases. The requirements for notification of the preventable diseases and the extent of their enforcement may be taken as an index of the intelli- gence and efficiency of health administration in a community. Morbidity Statistics in England and V/a!es. In England beginning with the year 1911 the medical officer of the local government board has compiled statistics of the incidence of the diseases notifiable in England and Wales. These diseases are small- pox, typhus fever, scarlet fever, diphtheria, typhoid fever, puerperal fever, erysipelas, plague, cholera, relapsing fever, tuberculosis, pul- monary tuberculosis (added Jan. 1, 1912, all forms made notifi- able Feb. 1, 1913), cerebrospinal fever (added Sept. 1, 1912), and acute poliomyelitis (added Sept. 1, 1912). The local sanitary officers are required by a general order of the local government board, promul- gated December 13, 1910, to transmit to the medical officer of the board each Monday a statement of the cases notified to them during the preceding week. The medical officer of the local government board is the chief sanitary officer for England. Statistics of births, mar- riages, and deaths, on the other hand, are compiled in the office of the registrar general. The experience leading to the present system for morbidity reports in England and Wales was similar to that through which the United States is now passing. Soon after the establishment of the civil registration of deaths in England in 1837 it became evident that a record of fatal cases (deaths) only did not give the kind of information necessary for the control of disease and that sanitary officials must have knowledge of the occurrence of the nonfatal as well as of the fatal cases, and that this information should be received early in the course of the disease, for when received after the termination of the case it has little other than statistical value. Various men, societies, and associations advocated at different times plans for the notification of sickness throughout the country. The British Medical Association as far back as 1865 made repeated efforts to have adopted a uniform system for morbidity reports. m Morbidity Statistics in Russia. In Russia S3,nitary regulations adopted in 1905 require that all physicians, whether engaged in private practice or in Government service, shall forward to the local sanitary inspector havmg jurisdic- tion a monthly report of patients treated by them both in private practice and m hospitals, the reports for the patients in private prac- tice and those in hospitals to be made separately. In addition to this every case of infectious disease is to be reported at once. A heavy penalty is unposed for failing to report. Every hospital and clmic is also required to keep a detailed record of its patients and report regu- larly to the sanitary inspectors. The data received by the local sani- tary officials in the monthly reports from hospitals and practitioners are compiled and forwarded annually to the chief sanitary inspector of the ministry of the interior on forms printed for the purpose. The chief sanitary inspector at St. Petersburg compiles these reports of the occurrence of sickness throughout the empire and publishes them annually. The sickness records for Russia include all parts of the empire. Among the infectious diseases for which morbidity statistics are com- piled are smallpox, scarlet fever, diphtheria, measles, whooping cough, influenza, typhus fever, typhoid fever, dysentery, cholera nostras, Asiatic cholera, epidemic gastroenteritis, mumps, erysipelas, septice- mia and pyemia, rheumatic fever, croupous pneumonia, tuberculosis, malaria, scabies, trachoma, syphilis, soft chancre and gonorrhea. Statistics are also compiled for mental diseases, traumatic affections, and vaccinations for smallpox. Morbidity Statistics in the United States. Advocated hy American Medical Association aTid others. — The need of havmg mformation of the prevalence and geographic distribu- • tion of diseases has been realized by physicians in the United States for many years, and the subject has repeatedly come before the American Medical Association m one form or another. At the meet- ing m 1855 the following resolution offered by Dr. J. W. Thomson was adopted: Whereas few subjects of greater interest and importance could be presented to the consideration of the American Medical Association, now representing most cf the States and Territories of the Union, than the attainment of a correct medical topot graphy of each, with a history of its prevailing diseases, and most successful treatment of the same : Therefore be it Resolved, That with this view and conviction, this associatiou appoint a special com- mittes for each State and Territory represented, of members, whose duty it shall be to report upon its medical topography, epidemic diseases, and the most successful treatment thereof, and that the same shall continue to hold their office for three years. 30 Resolved, That aa other States and Territories, not now represented, become so by- delegates duly appointed to this national association, similar committees shall be appointed for like purposes, and that they also shall hold their office |or three years. Resolved, That in the appointment of gentlemen of education and experience in the affairs of their own State, we have the best guarantee that the important objects we seek will be more satisfactorily accomplished, and the profession as well as the public interest thereby better served. Resolved, That the committees heretofore appointed by this association at its session in Charleston for a similar object be, and the same are hereby, discharged. At this same meeting Dr. J. G. Orton introduced a resolution sup- plementing the preceding. The resolution, which appears not to have been adopted, was in part as follows : Resolved, That each county medical society, or (in parts of the country where such has not been established), any duly organized medical association, be requested to amend its constitution by attaching theretmto the following article: ■"It shall be the duty of each member of this society to keep a faithful record of the diseases which may fall under his observation during each month, according to the classification adopted by this convention in May, 1847, stating the age and sex, occu- pation and nativity of the patient, the average duration of the disease, and finally, their recovery or death, and to report the same in writing to the secretary, on or before the first day of February of each year, who shall transmit a digest thereof to the State Medical Society and also to the appropriate committee appointed by the American Medical Association for its reception. " Resolved, That each incorporated hospital, infirmary, and asylum be invited to fur- nish a copy of their annual reports for tJie use of the committees of their respective States. Resolved, That the State committees appointed by this association to report on the prevailing diseases of their respective localities, shall receive and arrange a digest of the reports transmitted to them by the secretaries of the various county societies, and report the same at the annual meeting of this association. In 1859, Dr. W. C. Rogers, in an address on "The registration of dis- eases"^ stated: "The necessity for a system of registration has long been felt. " He then cites the foUowmg quotation from an editorial in the British Medical Almanac of 1837 : The first step in medical statistics, after having determined the mortality, is to ascer- tain the number of attacks of sickness at different ages, to which a population is liable, and the numbers constantly ill. First developed in Massachusetts. — In 1874 the State Board of Health of Massachusetts inaugurated a plan for the weekly volun- tary notification of prevalent diseases. A letter was sent in No- vember, 1874, to 168 physicians in the State, asking them to report weekly. One hundred and fifteen physicians agreed to do so. In 1875, 79 additional physicians agreed to report. The letter solicit- ing the assistance of the physicians is of special interest because it 1 Transactions Medical Society State of New York, 1SS9, p. 202. 31 represents one of the earliest and most important steps in the sys- teDiatic collection of morbidity reports. The letter follows: Commonwealth of Massachusetts, State Board of Health, Boston, November 1, 1874. Dear Sir: The State board of health is very desirous of getting weekly infonna- tion of the diseases prevalent in all parts of Massachusetts. The object is certainly one of great importance — positive knowledge of the health of the people, as well as of the diseases which, at any time and place, are present, or which threaten to ex- tend as epidemics. lu order, however, to attain this end the board will need the cooperation of a large and select number of physicians, in full general practice, in various parts of the State. We, therefore, take the liberty of asking whether you will consent to be one of tliis number — ^to report weekly during the next year (1875) the diseases prevalent in your vicinity. The inclosed sample postal card will indicate the proposed method; it will be observed that an endeavor has been made to rediice to the minimum the expendi- ture of time and trouble incident to the service asked of busy medical men. The board has appointed Dr. F. W. Draper, of Boston, to be the registrar of this new bureau of health correspondence. He will compile from the returns received a concise weekly bulletin of prevalent diseases to be reported to the secretary of the board, and published, with appropriate comments, for the information of the people. At the endoitheyearasummary of the accumulated observations will be prepared for pub- lication in the annual report of the board. If the board is successful in securing the cooperation of physicians in the accom- plishment of this plan, the practical results will be of essential value not only to the State at large, but to private individuals. To medical men, in particular, such a weekly synopsis of prevalent diseases would be possessed of obvious interest. It is not out of place to remark also that the present scheme is the first practical attempt in any part of the world to make a systematic weekly registration of diseases. It is hoped that you Avill consent to assist the board in executing a purpose which is capable of being developed to very useful ends. If you will please to signify your willingness to un- dertake the service alluded to, the proper blanks will be forwarded. We have the honor to be, very respectfully, yours, Henry I. Bowditch, David L. Webster, J. C. Hoadley, Richard Frothingham, T. B. Newhall, R. T. Davis, Chas. F. Folsom, Members of the State Board of Health. 32 ■ The information called for by the postal card form referred to and its typographical arrangement are shown by the following repro- duction : Massachusetts Report Card, 1874. Report of diseases prevalent during the iveeh ending Saturday, , 1875. '03 « n ' o°-3e •a -w- g 2 6 -« O " o iS S g g o oT " 03 -2 ^ .g © C! ro ^^ 4J CO ■^ > e>0 03 ^3 § gj'cS.B Bronchitis Cholera Infantum Cholera Morbus Croup (Membraneous) . Diphtheria Diarrhoea Dysentery Influenza Measles Pneumonia Rheumatism Scarlatina SmaU-pox Typhoid Fever Whooping-cough Mild. Remarks . -M. D. Dr. F, W. Dra,per was placed in charge of the work and made registrar of the bureau of health correspondence. The opening paragraphs of his first report were as follows : The desirability of a trustworthy method for the registration of prevalent diseases is undisputed. Sanitarians have repeatedly expressed the want, but have failed hitherto to realize its fulfilment. They know how much greater would be their power to protect the public health if data of the local development and progress of disease were promptly afforded to them. They recognize the fact that the utility of such a registration is amply illustrated in the control which boards of health exercise during invasions of smallpox, prompt measures of prevention by isolation being thereby made possible for the defense of the entire community. In a still broader sense, they see the great advantage which would result from the opportunity to study the rise and fall of epidemics, and the development of diseases whose cause lies in local and preventable conditions. 33 Hitherto health authorities have relied on the registration of deaths as affording a basis for their active operations in behalf of the public welfare, as -n-ell as for generali- zations in sanitary science. A persistently high rate of mortality is an indication that sometliing is wrong in the sanitary condition of the community reporthi" it- it is a signal that so far as that region is concerned, influences are at work which demand speedy investigation and, if it be possible, prompt removal. Therefore the registra- . tion of mortality has always been acknowledged as an invaluable adjuvant to sanitary administration. But it is obvious that the death rate does not represent the actual state of the public health, the real amount of sickness, or its real character at any given time in any community. An entire hamlet may be smitten by an epidemic which makes no impression on the l)ills of mortality. The schools of a township may be forced to take an unseasonable vacation by a general invasion of whooping cough, which may cause J885 1890 1895 1900 1905 1910 ' 7000 \. 6000 k. \ 5000 i \ 4000 1 1 \ 300O 1 1 2000 1 A \ / / / \ ipoo 1 / ff /' u s^ =™ s= _g. ^ b „ __ /] Chart 6.— Smallpox— Number of cases notified per amium in Michigan from 1883 to 1912. a comparatively small number of deaths. Mild scarlatina, or diphtheria, or even smallpox may sweep through a village and be the occasion or only a few funerals. On the other hand, an exceptionally severe outbreak of infectious diseases may be attended with a fatality out of all proportion to the number sick, and thus become the source of erroneous inferences. So that it seems eminently desirable that a registra- tion of diseases should in some way be put into operation, not to take the place of mortality registration, but to supplement it. Massachusetts and Michigan were pioneers in the collection of information regarding the prevalence of disease. In 1884 Massachusetts passed a law rec|uirmg householders and physicians to report immediately to the selectmen or board of health of the town all cases of "smallpox, diphtheria, scarlet fever, or any other disease dangerous to the public health." Penalty for failure on the part of the householder was made a fine not exceeding $100. The penalty for failure of physicians was a fine of not less than nor more than $200. 55256°—!^. 3 34 Early development in Michigan. — Tlie plan which the Mx^ssachusetts State Board of Health adopted in 1874 of furnishing postal-card blanks to voluntary correspondents for the pui^ose of collecting weekly information of the prevalence of disease was "adopted by the Michigan State Board of Health in 1876. In its annual report for the year the State board of health in referring to the matter states "A knowledge of the nature and extent of prevalence of at least the several prominent diseases throughout the State has from the first organization of the board been considered desirable.'' In 1883 Michigan passed a law requiring householders, hotel keepers, keepei^ of boarding houses, or tenants, to report immediately 1885 1890 1895 1900 1905 1910 Chart 7.— Smallpox— Number of cases notffied per annum for each d eath registered— Michigan— 1883 to 1912. to the health officer or board of health all cases of "smallpos, cholera, diphtheria, scarlet fever, or any other disease dangerous to the public health."^ The notice was to state the name of the patient, the name of the disease, and the name of the householder or hotel keeper giving the information; also the address where the patient was to be found. Physicians were similarly requu-ed to report cases, and when the physician reported a case the householder or hotel keeper was not required to do so. The Michigan law seems to be the first one looking to the compre- hensive collection of information in regard to the prevalence of disease, and for a number of years the work was carried on with 35 intelligence and perseverance under the able supervision of Dr. Henry B. Baker, secretary of the State board of health. Dr. Baker was truly a pioneer in this work and many years ahead of his time in his appreciation of its importance. Present status. — In the United States the authority to require the notification of cases of sickness resides in the respective State legis- latures. In some of the States authority has been given to the State boards of health to cover the subject by regulations. In most instances local authorities have the right to supplement the State requirements by such additional ones as may be needed. The laws 1885 i890 1895 1300 1905 1910 ,40 35 '30 ,/ ^ / 25 y — / s y ^' \, / \ ;eo ^ / S ^ / A f k / / \ \ / 15 / \^ ^ / / \ / / 10 V ,\ r 5 _ ^ Chaet 8. — Scarlet fever — is umber of cases notified per annum for each death registered— Michigan— 1884 to 1910. and regulations of the several States differ widely, as do also the efforts made to enforce them. The common and most general plan is to require that the original report be made by the physician to the local health officer imme= diately on diagnosis of the case. The local health officer forwards to the State health department, either immediately or at intervals, a transcript or a summary of the notifications received by him. In a number of States these reports by the local health departments are made to the State authorities daily, in some weekly, in one State twice a month, in several States monthly, and in a few States at longer intervals. In the States in which the reports are made daily the State health department is in a position to keep constantly informed regarding the prevalence of the notifiable diseases. The same is in less measure true when the reports are made weekly. 36 ■When the reports are made at longer intervals the current value of the information to the State department is largely lost. In two States physicians are required to report the notifiable diseases directly to the State health department. This, in effect, makes the State health officer also the local health officer and respon- sible for the control of the notifiable diseases, the control of disease 1 1890 1895 1900 1905 1910 ' 300 1 j- / 1 250 — — 1 1 / 1 [ 200 r ISO 100 ] k — \ \ •^ \ 50 \ / "** ^ / Ss ^ / Chakt 9. — Measles— Number of cases notified per annum for each death registered — Michigan — 1800 to 1010. and the notification of cases being inseparable, the latter giving the necessary information by which to direct action in the former. In some States the laws relating to morbidity reports specify that cases of certain classes of disease shall be notifiable. These classes have been variously stated, the wording being in some instances that ''all cases of contagious or infectious diseases dangerous to the pubfic health shall be reported," in others "aU communicable diseases," or "aU contagious diseases," or ''all diseases dangerous to the pubfic health." When the requirements have been stated in general terms in this way their enforcement has been especially difficult unless the diseases included have been specifically enumerated. 37 The Notifiable Diseases. The followmg-named diseases are those specified by the various Stats requirements, with the number of States in which each is notifiable: • Actinomycosis Anthrax Barber's itch Beriberi Cancer. Cerebrospinal meningitis Chagres fever Chicken-pox Cholera (Asiatic) Colibacilosis Dengue Diphtheria Dysenteiy Echinococcus disease Epidemic dysentery Amebic dysentery Erysipelas FaAms FUariasis Follicular conjunctivitis German measles Glanders Gonococcus infection Hookworm disease Impetigo contagiosa Leprosy Malaria Malta fever Measles Mumps Ophthalmia neonatorum Paragonimiasis (lung-fluke disease). Paratyphoid fever Pellagra Plague Pneumonia Poliomyelitis Puerperal fever 6 15 1 3 3 23 1 21 41 1 8 46 3 1 6 1 1 8 13 5 7 1 28 9 1 31 7 14 2 3 8 28 11 Pi.abies Relapsing fever Rocky Mountain spotted fever. . Scabies , Scarlet fever Septic sore throat Smallpox Syphilis Tetanus Tetanus infantum Trachoma Trichinosis Tuberculosis: All forms Communicable forms Laryngeal Pulmonary Typhoid fever Typhus fever Whooping cough Yellow fever Venereal diseases Mental deficiency (including lepsy) Occupational diseases: Arsenic poisoning Brass poisoning Carbon monoxide poisoning Lead poisoning Mercury poisoning Natural gas poisoning Phosphorus poisoning Wood alcohol poisoning Naphtha poisoning Bisulphide of carbon poisoning.. Dinitrobenzine poisoning Caisson disease (compressed-air illness) epi- 10 4 3 1 45 I 49 G 8 1 11 6 29 1 6 10 35 31 27 35 2 12 5 1 14 12 1 12 5 1 1 1 12 The Model State Law for Morbidity Reports. Since eacli State has exchisive authority within its jurisdiction over the requirements for the notification of disease, any comi:)rehensive plan that may be developed for morbidity reports and morbidity statistics must be the result of combined effort and cooperation and the enactment by the several States of similar requii'ements. It implies also an adequate enforcement of these requirements. The question of State morbidity reports is one of the most difficult prob- 38 lems to be solved by the State authorities. A mimber of States have been endeavoring earnestly to solve the problem within their respec- tive jurisdictions. Considerable progress has been made in several instances. The question is an important one, and is bound to re- ceive much consideration during the next decade. Tlie State health authorities in conference with the Public Health Service had the matter under consideration for some time and in June^ 1913, approved a model State law for morbidity reports. (See appendix pp. 71-74.) The model law makes the following-named diseases notifiable: Group I. — Infectious Diseases. Actinomycosis. Anthrax. Chicken-pox. Cholera, Asiatic (also cholera nostras when Asiatic cholera is present or its impor- tation threatened). Continued fever lasting seven days. Dengue. Diphtheria. Dysentery : (a) Amebic. (6) BaciUary. Favus. German measles. Glanders. Hookworm disease. Leprosy. Malaria. Measles. Meningitis: (a) Epidemic cerebrospinal. (6) Tuberculous. Mumps. Ophthalmia neonatorum (conjunctivitis of newborn infants). Paragonimiasis (endemic hem^optysis). Paratyphoid fever. Plague. Pneumonia (acute). Poliomyelitis (acute infectious). Rabies. Rocky Mountain spotted (or tick) fever. Scarlet fever. Septic sore thi'oat. Smallpox. Tetanus. Trachoma. The provisions of the model law slightly amended have already been adopted by the State of Kansas through regulations promul- gated December 1.3, 1913. As opportunity affords other States will undoubtedly take similar action. Group I. — Infectious Diseases — Continued. Trichinosis. Tuberculosis (all forms, the organ or part affected in each case to be specified). Typhoid fever. Typhus fever. Whooping cough. Yellow fever. Group II. — Occupational Diseases AND Injuries. Arsenic poisoning. Brass poisoning. Carbon monoxide poisoning. Lead poisoning. Mercury poisoning. Natm-al gas poisoning. Phosphorous poisoning. Wood alcohol poisoning. Naphtha poisoning. Bisulphide of carbon poisoning. Dinitrobenzine poisoning. Caisson disease (compressed-air illness). Any other disease or disability contracted as a result of the nature of the person's employment. Group III. — Venereal Diseases. Gonococcus infection. Syphilis. Group IV. — Diseases op Unknown Origin, Pellagra. Cancer. 39 The Results of Notification in Certain States and Cities. The completeness of the reports of the notifiable diseases in States and cities in which there is registration of deaths may be estimated with some degree of accuracy by comparing the number of cases reported with the number of deaths registered as due to the same cause. In doing this, however, it must be borne in mind that we do not know the fatality rates of many diseases, for up to the present time there have seldom been satisfactory morbidity records of suf- ficiently broad appUcation to permit of the determmation of such rates, and it must also be remembered that the f ataHty rates of many diseases vary in different epidemicg, and from year to year, and with the seasons and geographic location. To show the possibilities of notification and the results being obtained in certain diseases in those States and cities in which noti- fication has been developed to a degree approaching most closely one that is satisfactory, the following tables are presented. The diseases selected are diphtheria, measles, and typhoid fever. To this list others might be added. In the diphtheria table only those States and cities are included in which 10 or more cases v/ere reported for each death registered; in the measles table only those States and cities in which at least 50 cases were reported for each death regis- tered; and in the typhoid fever table only those in wliich 7 or more cases were reported for each death registered. One of the most interesting features of these tables, and one to which the reader's attention is invited, is the relatively large num-ber of cases reported in some cities and States for each death. The relatively small num- ber of fatal cases suggests the existence of fatahty rates much lower than those commonly beheved to prevail. The material for these tables was taken from the Public Health Reports,^ The data was originally obtained by the Surgeon General of the Public Health Service from the health departments of the several States and cities. The deaths given in the 1912 mortality statistics of the Bureau of the Census, which are now available, difl'er slightly in number in most instance from those used, but the differences are p.ot enough to affect appreciably the ratios of cases to deaths. To explain the wide differences in fatality rates in the several cities and States one should bear in mmd the possibility that the virulence of the diseases may at times vary and that the skill and facihties of practicing physicians for diagnosing certain affections may differ in the several locahties. 1 Public Health Reports, Jan. 16, 1914, and Apr. 3, 1914. 40 DIPHTHERIA. Table 4. — Cases notified, case rates jper 1,000 population, number of cases notified for each fatality {death) registered, and fatality rates per 100 cases, in States and cities having 10 or more cases notified for each death registered, 1912. States and cities. STATES. Connecticut District of Columbia , Massachusetts , Montana New York , Utah Virginia CITIES. Boston, Mass Cleveland, Ohio NewYork N. Y , St. Louis, Mo Cincuuiati, Ohio Los Angeles, Cal Newark , N . J New Orleans, La San Francisco, Cal Washington, D. C Denver, Colo Indianapolis, Ind Providence, K. I Rochester, N. Y St. Paul, Minn Seattle, Wash Albany, N.Y Birmingham, Ala Cambridge, Mass Columbus, Ohio Dayton, Ohio Grand Rapids, Mich Nashville, Term Richmond , Va Salt Lake City, Utah Spokane, Wash Syracuse, N. Y Worcester, Mass England and Wales (1911) London (1911) Cases. 1,941 393 5,433 139 18,141 328 2,875 1,539 2,605 13, 533 2,548 638 433 1,098 1,072 326 393 377 633 848 495 392 224 328 220 264 415 582 100 91 206 159 66 422 411 47,747 7,404 Fatal cases (deaths). 191 15 473 12 1,641 24 92 102 166 1,125 170 60 25 91 58 28 15 12 35 75 16 23 11 29 14 26 39 43 10 7 8 3 5 24 26 Case rate per 1,000 population. 1.758 1.146 1.555 .342 1.904 .833 1.363 2.164 4.363 2.672 3.578 1.646 1.121 2.973 3.056 .752 1.146 1.637 2.563 3.605 2.148 1.472 .807 3.224 1.464 2.450 2.141 4.835 .846 .806 1.567 1.571 . 545 2.938 2.701 1.32 1.64 Fatality rate per 100 cases. 9.84 3.82 8.70 8.63 9.04 7.31 3.20 6.62 6.37 8.31 6.67 9.40 5.77 8.28 5.41 8.58 3.82 3.18 5.52 8.84 3.23 5.86 4.91 8.84 6.36 9.84 9.39 7.38 10.00 7.69 3.88 1.88 7.57 5.68 6.32 10.26 8.45 Number of cases notified for each fatahty. 15 16 12 15 11 17 12 18 12 26 31 18 11 31 17 20 11 16 10 11 14 10 13 26 53 13 18 16 9.75 11.83 MEASLES. Table 5. — Cases notified, case rates per 1,000 jwpidation, number of cases notified for each fatality {death) registered, and fatality rates per 100 cases, in States and cities having 50 or more cases notified for each death registered, 1912. States and cities. Cases. Fatal cases (deaths). Case rate per 1,000 population. Fatality rate per 100 cases. Number of cases notified for each fatality. STATES. 6,537 1,638 10,392 1,675 22, 423 65,299 3,117 116 7 189 20 286 1,049 11 5.630 4. 778 1.7S5 2.233 6.421 6.854 7.892 1.77 .42 1.81 1.20 1.27 1.60 .35 56 District of Columbia 234 55 84 Massachusetts 78 New York 62 Utah 283 41 Table 5 — Cases notified, case rates per 1,000 population, number of cases notified for each fatality {death) registered, and fatality rates per 100 cases, in States and cities having 50 or more cases notified for each death registered, 1912 — Continued. states and cities. Cases. Fatal cases (deaths) . Case rate per 1,000 population. Fatality rate per 100 cases. Number of cases notified for each fatality. CITIES Boston, Mass Chicago, 111 Cleveland, Ohio New York N. Y St. Louis, Mo Cincinnati, Ohio Los Angeies, Cal Milwaukee, W is New Orleans, La San Francisco, Cal Denver, Colo Indianapolis, Ind Rochester, N. Y St. Paul, Minn Albany, N. Y Birmingham, Ala Cambridge, Mass Dayton, Ohio Hartford, Conn Richmond, Va Salt Lake City, Utah... Spokane, Wash Syracuse, N. Y Toledo. Ohio 5,666 6,784 2,230 39,018 6,549 2,715 253 2,316 324 3,451 72 3,556 2,002 282 437 868 1,015 643 663 851 1,074 1,133 605 1,350 111 7.967 119 2.956 34 3.735 671 7.704 73 9.197 34 7.005 1 .655 25 5.785 2 .923 47 7.961 1 .313 12 14. 400 28 8.694 1 1.058 2 4.295 9 5.777 10 9.421 7 5.342 12 6.425 1 6.473 2 10.611 6 9.364 7 4.213 27 7. 635 1.95 1.75 1.52 1.72 1.11 1.25 .39 1.07 .61 1.36 1.39 .33 1.39 .35 .45 1.03 .98 1.08 1.81 .12 .18 .53 1.15 2.00 253 93 162 73 72 296 71 282 218 96 101 92 55 851 537 188 86 50 TYPHOID FEVER. Table 6. — Cases notified, case rates per 1,000 population, number of cases notified for each fatality (death) registered, and fatality rates per 100 cases, in States and cities having 7 or more cases notified for each death registered, 1912. states and cities. STATES. Connecticut District of Columbia Maryland Massachusetts Utah Virginia CITIES. Boston, Mass Cleveland, Ohio Philadelphia, Pa Newark, N. J Denver, Colo Providence, R.I Seattle, Wash Birmingham, Ala Bridgeport, Conn Cambridge, Mass Grand Rapids, Mich Hartford, Conn Lowell, Mass Richmond, Va. . .: Salt Lake City, Utah Worcester, Mass England and Wales (1911) London (1911) Cases. 924 585 1,795 2,088 549 4,330 460 271 1,514 193 498 206 149 490 68 55 316 76 86 208 163 70 13, 730 1,024 Fatal cases (deaths). 128 78 229 269 57 260 57 38 200 26 30 24 20 56 8 5 40 4 10 22 17 5 2,416 145 Case rate per 1,000 population. 0.795 1.706 2.387 .597 1.390 2.054 .647 .454 .942 .523 2.163 .876 .537 3.261 .532 .511 2. 674 .737 .791 1. 582 1.611 .460 .38 .23 Fatality rate per 100 cases. 13.85 13.33 12.75 12.88 10.38 6.00 12.39 14.02 13.21 13.48 6.02 11.65 13.42 11.43 13.80 9.09 12.66 5.26 11.63 10.58 10.43 7.14 17.62 14.16 Number of cases notified for each fatality. 7.2 7.5 7.8 7.8 9.6 16.6 8.1 7.1 7.5 7.4 16.6 8.6 7.4 8.7 7.2 11.0 7.9 19.0 8.6 9.5 9.6 14.0 5.68 7.06 42 As the result of Dr. Baker's work Michigan has records of the prev- alence of a number of communicable diseases from the early eighties. These records show that durmg the 15 years, 1882 to 1896, inclusive, there were in Michigan 1,320 reported cases of smallpox, mth 314 deaths, and a fatality rate for the period of 23.8 per cent. During the succeeding 14 years, 1897 to 1910, inclusive, the State of Michigan had 38,243 reported cases, with 361 deaths, and a fatality rate for the period of 0.94 per cent. During the 10 years, 1884 to 1893, inclusive, Michigan had an annual average of 3,909 reported cases of diphtheria, with an average of 913 deaths, and a fatality rate of 23.4 per cent. During the 17 years, 1894 to 1910, inclusive, the average annual 1885 1890 1895 1900 1905 1910 Q '8 V — / V— NJ / \ 7 / A / 6 / 5 <» s / ^ \ __^ / ' / s / .— ■ "^ K \ / — - f 4 3 Z u _ — Chart 10.- -Diphtheria— Number of cases notifled per annum for each death registered — Michigan- 1884 to 1910. number of reported cases was 3,133, the average number of deaths 529, giving a fatality rate of 16.9 per cent. During the 27 yearsy 1884 to 1910, ]\iichigan had an average of 4,288 reported cases of scarlet fever, with' an average of 277 deaths, and a fatality rate of 5.3 per cent. The ]\lichigan records for measles go back only as far as 1890, and during the 21 years, 1890 to 1910, inclusive, the average number of cases reported annually was 10,995, with an average number of deaths of 148, giving a fatality rate based upon reported cases and deaths of 1.3 per cent. Source of Statistical Data. The manner of collecting the data from which morbidity statistics are compiled is closely allied to the registration method used for births. The data consist of the reports of cases of disease made usually by physicians and in some instances by the heads of families and house- holds. The original observers then, upon whom morbidity statistics depend chiefly for their completeness, are the practicing physicians. This is necessarily so, for neither the health department nor any other branch of government can keep in such close touch %vith the hves of the people as to be in a position to know of the occurrence of disease. The physician is the one, who because of the very nature of his woi'k and his relation to the community, is best able to have this information and furnish it. He comes in contact with the sick to a degree others do not. The health officer can not know of the 1385 1890 1895 1900 1905 I9!0 jp i ^M. V A \ / \ \ \ / 15 ^ 1 J s I i f \ / N «=^ \ / 1 N, r \ \ 1 i \ j 1 \ \ 1 1 — \ "—=( 1 1 ' \ k' \ K (10 _ _ ____ Lj _j ^ ■^ Chart 11. -DipMlieria— Fatality rate (number of deaths registered per amiura per 100 notified cases)— Michigan— 1884 to 1910. presence of disease except as it is reported to him by physicians. Experience has shown that there may be hundreds of cases of a dangerous infection in a city and the health officer not know of its presence in the absence of notification. Unfortunately many practicing physicians have httle knowledge of the methods of health administration and in common with people in general frequently expect the health department in some mysterious manner to control disease without placing upon them the burden and privilege of cooperating by the notification of the occurrence of cases. The practicing physician, whether he recognizes it or not, or is so recognized by the community, is essentially an adjunct of the health department, for unless he performs his part the health department is in large measure helpless. 44 Among practicing physicians, at least in the United States, there has at times been the feehng that the knowledge of a disease in a patient is privileged information which they should not be called upon to impart. In communities where the laws require the notifica- tion of the disease this feeling has no legal basis and the physician who does not make report is not a law-abiding citizen. But aside from the legal aspects of the matter there would seem to be httle justification for such a course. Every physician has a number of individuals or f amihes who look to him, and properly so, not only for treatment, but also for such reasonable protection from disease as he is able to give. The failure to report the occurrence of a case of communicable disease in one patient may lead to its spread to others among his clientele whose rights he has ignored. He therefore violates the intent and spirit of the ethical principle of the protection of patients among whom must be considered the well together with the sick. The notification of disease is in the interests and for the protection of the community, and as his patients are usually members of the community their interests are ignored and because of the anti- social whim or supposed convenience of the individual affected with a notifiable disease they are deprived of the protection they have a right to expect. It would seem that the physician who fails to report his cases of preventable diseases required to be notified may properly be considered as actively obstructing public health adminis- tration. Related in thought is the following quotation from an address by Prof. Victor C. Vaughan.^ However, no medical man treats any infectious disease without, at the same timo, rendering a service to the public. He takes care of his case of diphtheria, or scarlet fever, or measles, and at the same time he renders a larger service to the public in preventing the spread of infection. * * * In the future the training of the medical man must be developed largely with a view to his broader relations to the public. His proper function must be to prevent, rather than cure disease. The physician's duties are to become more and more largely official in the sense that his services are to be rendered to the community, and not exclusively to the individual. The health department laboratory may be, and in many places is, an important factor in giving information of the occurrence of cases and prevalence of certain diseases. By having a diagnostic laboratory with a trained personnel at the service of the practicing physician the health department becomes not only a consultant performing gratuitous service for the physician but at the same time secures early and accurate information of many cases which other- mse might not be properly diagnosed and therefore not reported. A record of every positive diagnosis made by the laboratory should be sent to the epidemiological bureau or other division of the health 1 Pennsylvania Medical Journal, November, 1913. 45 department responsible for the control of disease and should for purposes of morbidity records constitute notification of the case when accompanied by such necessary information as the name, age, sex, and address of the patient. There would seem to be no good reason why the services of the health department should not be at the disposal of the community for the diagnosis of all diseases. Nature of Information Secured by Morbidity Notification. It is the practice for health departments to furnish to physicians notification blanks upon which the reports are to be made. In some instances these are in the form of post cards, wliich have proper spaces indicated for notation of the requii-ed information. These cards re- quire the physician to affix a stamp before mailing them to the health department. A far better practice is that employed by many States and cities of supplying physicians with postal-card forms which do not require additional postage before mailing. The information relating to the reported cases which physicians are required to give varies in the several States. It has usually been cus- tomary to require the physician, in making his report, to include all the data regarding the case desired by the health department. In the majority of instances no further data regarding these cases are secured by the health ofiicials. While it may be impracticable in most in- stances to change this practice at the present time, it must be recog- nized that a local health department should prefer to collect its data regarding each case itself, and should not be wilhng to depend upon the physician's report for its epidemiologic information. Logically, the only information which the physician should be depended upon to give in his report is the occurrence of a case, or a suspected case, of a given disease in such and such a person at such and such an address. He might properly be required to add to this such data as are matters of record or easily verified, such as the age, color, and sex of the patient, and simitar information. The local health department, however, should be reluctant to depend upon the diagnosis of the practicing phy- sician, unless the diagnosis has been verified by a trained diagnos- tician in the service of the department itself. This has been the practice during recent outbreaks of such diseases as yellow fever and plague. It is also the practice in certain other instances. It must necessarily become the practice whenever a determined effort is to be made in the control of any preventable disease. The Standard Notification Blank. The standard notification blank (see appendix, p. 74) approved by the State and Territorial health authorities of the United States in conference with the Pubhc Health Service at their tenth annual conference in June, 1913, calls for the following information: 1. Date. 2. Name of disease or suspected disease. 46 3. Patient's name, age, sex, color, and address. (This is largely for purposes of iden- tification and location.) 4. Patient's occupation. (This serves to show both the possible origin of the disease and the probability that othera have been or may be exposed.) 5. School attended by or place of employment of patient. (Serves same purpose as the preceding.) 6. Number of persons in the household, number of adults and number of children. (To indicate the nature of the household and the probable danger of the spread of the disease.) 7. The physician's opinion of the probable source of infection or origin of the disease. (This gives important information and frequently reveals unreported cases. It is of particular value in occupational diseases.) 8. If the disease is smallpox, the type (whether the mild or virulent strain) and the number of times the patient has been successfully vaccinated, and the approxi- mate dates. (This gives the vaccination status and history.) 9. If the disease is typhoid fever, scarlet fever, diphtheria, or septic sore throat, whether the i^atient had been or whether any member of the household is en- gaged in the production or handling of milk. (These diseases being frequently spread through milk, this information is important to indicate measm'es to i^re- vent further spread.) 10. Address and signature of the physician making the report. These reports are to be made on postal cards fiirnislied for the purpose and mailed immediately to the local health department, so that proper measures can be taken to prevent the spread of the disease or to find the focns or source from which the case originated, that the occurrence of additional cases may be prevented. These reports are then to be forwarded to the State department of health, but before being forwarded the local health department is to note thereon : 1. Whether the case was in^^estigated by the local health department. 2. V/hether the natm-e of the disease was verified. 3. What measures were taken by the local health department to prevent the spread of the disease or the occurrence of additional cases from the same origin. The standard notification blank has been adopted in two States. Sources of Error in Morbidity Statistics. The errors in morbidity statistics are due principally to incomplete notification — that is, to the failure of physicians to report all cases of the notifiable diseases. More cases of disease usually occur than are reported. This can never be entirely overcome, for many diseases vary in severity under different conditions, and some cases are so mild that their true nature is net recognized, and frequently they do not come to the attention of physicians. The cases notified are usually correctly diagnosed, for physicians do not generally report cases until they are practically sure of the diagnosis, as the case remains an evidence of faulty diagnosis if a mistake is made. Then, too, physicians naturally wish to report only 47 those cases required and to know whetlier a given case is one of these he must first be reasonably sure of his diagnosis. The errors in morbidity statistics are therefore chiefly tliose of incompleteness. In this they resemble birth statistics, although the degi'ee of incompleteness, due to the difference in the nature of the two, is usually greater in morbidity statistics. They differ from mortality statistics, in which the principal source of error is incorrect statements of cause of death. Due to the control possible over the disposal of bodies of the dead, it is not difficult iu most communities to obtain practically complete registration of deaths. It is, however, exceedingly difficult to secure correct state- ments of the causes of death. The physician feels compelled to give a diagnosis in each death certificate and usually does so even when he is uncertain of the nature of the malady, realizing probably that the body will be buried and that there will be nothing to show the error if one is made. The tendency is then in morbidity reports for the diagnoses to be correctly given, but not all cases reported, while in the registration of deaths the tendency is for the recording of practically all deaths but the fihng of many incorrect statements of the causes of death. Uses of Morbidity Reports and Statistics. In health administration, morbidity reports^ — that is, reports of cases of sickness — serve several purposes, which may be briefly stated to be as follows: 1. In the communicable diseases morbidity reports show Ibhe occurrence of cases which constitute foci from which the disease may spread to others, as in scarlet fever, typhoid fever, tuberculosis, or yellov/ fever, and make it possible to take proper precautions to pro- tect the family of the patient, his associates, or the community at large. 2. In some diseases morbidity reports make it possible to see that the sick receive proper treatment, as in ophthalmia neonatorum, diphtheria, and, in certain cities, tuberculosis. The reporting of cases of ophthalmia in the nev\^born makes it possible to save the sight of some mf ants who v/ould otherwise not receive adequate treatment until after much damage had been done. In diphtheria the health department can be of service in furnishing antitoxm. Some cities furnish hospital or other relief to consumptives who would other'svise be without proper treatment. 3. In diseases that are not communicable, such as those due to occupation or environment, reported cases show the location of con- ditions v/hich are causing illness or injury. This makes it possible to remedy the faulty conditions, so that others may not be similarly injured. 48 4. In certain diseases, of which the cause or means of spread is unknown, morbidity reports show their geographic distribution and varying prevalence and the conditions under which cases occur. This information has great potential value in attempts to ascertain their causes and means of spread. 5. Reports of the occurrence of disease are necessary to show the need of certain sanitary measures or works and to control and check the efficiency of such measures or w^orks when put into operation. In pulmonary tuberculosis such reports show the number of consump- tives in the community and the need of sanatoria. In malaria they show the prevalence of the disease, the need for drainage and other antimosquito work, the efficiency of such work when in operation, and when a change in the prophylactic measures or additional ones are necessary. In typhoid fever they show faults in the water supply or in the control of the production and distribution of milk or in the dis- posal of excreta m special localities. 6. Morbidity reports when recorded over a period of time and properly compiled become a record of the past occurrence of disease. They show the relative prevalence of disease from year to year and under varying conditions. They show the effect of the introduction of public-health measures and of sanitary works. They give a his- tory of disease not obtainable m their absence. Morbidity Rates. " Crude morbidity rates.' — Morbidity rates may be expressed as the number of cases of a given disease occurring during a year per 1,000 of the total population, or the rate may be expressed as the number of cases per 10,000 or per 100,000 population. Giving the rate per 1,000 population has the advantage of employing the same popula- tion unit as that used for expressing birth, marriage, and death rates. It has, however, what has been considered by some a disadvantage, namely that the rates will more frequently be fractions where the 1,000 unit of population is taken as the basis. For this reason 10,000 and 100,000 population units have often been used. The medical officer of the local government board of England and Wales uses the 1,000 unit in stating morbidity rates. Specific morbidity rates.- — Diseases limited entirely or principally to certain ages or to certain classes of the population should be expressed also in rates of the number of cases per 1,000 persons in the population of that age or class. Diseases limited to childhood should be ex- pressed as rates per 1,000 children; diseases limited to women should be expressed as rates per 1,000 women. Occupational disease rates should be expressed in terms of the number of cases per 1,000 persons employed. 49 Specific morbidity rates showing the incidence of disease by ag& groups, sex, occupation, and economic or social condition -will be possible -with the improved notification methods which are beino- gradually adopted. Fatality rates. — The fatality or case mortality rate of a disease is usually expressed in terms of the number of deaths per 100 cases; that is, as the percentage of cases which terminate fatally. In cal- culating fatality rates it is to be borne in mind that among cases reported during one week, month, or year, all or part of the fatal terminations may occur during a succeeding week, month, or year. Hospital statistics and siclcness insurance records. — In a number of foreign countries much valuable information regarding sickness rates, aside from that of the commonly notifiable diseases, is being secured from the workingmen's sickness insurance records. In some countries hospital statistics are compiled and furnish data of much value. Bolduan ^ has suggested a plan for compiling hospital mor- bidity statistics in this country. The method is especially applica- ble to the hospitals of a large city, but might be used for the hospitals of an entire State and is capable of being made nation wide in scope. The essential feature of the plan is the filling out of ''discharge certi- ficates," analogous to ordinary death certificates, on the discharge of each patient from a hospital. These discharge certificates are then sent to a central filing bureau, preferably the health department, and there classified and analyzed. For a copy of the proposed ''discharge certificate" see appendix, page 75. The fund of valuable information which might be acquired by the use of the statistical method in the study of hospital experience and theproper treatment of hospital statistics has been most ably discussed by Frederick L. Hoffman in his work on "The Statistical Experience Data of the Johns Hopkins Hospital, Baltimore, Md., 1892-1911. "^ It is also especially desirable to have statistics of the insane and mentally defective. New Jersey has recently enacted a law requir- ing the notification of cases of mental deficiency and of epilepsy. Factors Influencing Morbidity Rates. The factors which influence morbidity rates and the prevalence of sickness are the manifold direct and indirect causes of disease. There are certain widely acting indirect factors which increase morbidity by lessening individual resistance. There are other factors which are specific for individual diseases. In malaria the direct cause is infectious anopheline mosquitoes, and the indirect cause swamps 1 Bolduan, Charles F.; Hospital morbidity statistics; New York Medical Journal; Mar., 1913; p. 643. 2 The Johns Hopkins Hospital Reports. Monographs, New Series No. IV. 55256°— 14 4 50 and stagnant water in which the mosquitoes breed. The factors influencing typhoid fever rates are commonly the milk supply, the water supply, the manner of disposal of excreta, presence of flies, the extent to which houses are screened, personal and social habits, etc. In an industrial community the morbidity from occupational diseases and from diseases caused indirectly by the conditions attend- ing certain kinds of labor constitutes a factor the importance of which is beginning to be realized. A discussion of the factors influ- encing morbidity rates would require a treatise on epidemiology and hygiene. Notification of Occupational Diseases. Most civilized nations have during the last hundred years undergone an industrial revolution. It has been within this period that the large factory with its hundreds or thousands of workers has had its devel- opment and that many of our present industries and the majority of our industrial processes have been developed. So great has been this change in the industrial life of the people that there has been developed a new and unportant branch of hygiene and sanitation which is properly termed industrial hygiene. With this industrial development there have evolved new diseases and disabilities due to the nature of the individual's work or to the conditions incident to the work. Not only have new diseases in a sense been evolved, but a number of diseases previously rare have become much more common. Under existmg social conditions a large proportion of the people are engaged in some occupation, and the diseases of occu- pation merit the attention and consideration of the community. Due largely to the activities of the American Association for Labor Legislation the question of the control of occupational dis- eases has during the last few years been receiving much considera- tion. Naturally the first step in the control of the industrial dis- eases was the securing of a means by which the occurrence and prevalence of these diseases might be known to those whose duty it would be to control them. For this purpose, and largely because of the activities of the American Association for Labor Legislation and its secretary, John B.Andrews, a number of States have since 1911 enacted laws requiring the notification of certain occupational dis- eases. Fourteen States have enacted laws on the subject. One State has enacted a law appointing a commission to draft regulations covering the notification and control of occupational diseases, and one State by regulation of the State board of health requires the notification of these diseases. Abstracts of the State requirements will be found in the appendix, pages 76-82. A number of State laws require cases of occupational diseases to be notified to the State health department, and others require the 51 notifications to be made to the State labor office. The results of notifi- cation have not been as j^et satisfactory. This may be due to the newness of the idea to the physician of considering whether a disease is occupational in origin. The medical schools have given httle attention to the subject. It is highly important to the practicing physician that he have a knowledge of the industries of his community and of the diseases and disabilities they are likely to cause. The proper and successful treatment of patients necessarily depends upon a knowledge of the direct or indirect cause of the individual's ailment, and in an industrial community this ^vill depend frequently upon a knowledge of occupational diseases. A number of States have enacted lav/s which should in a way be much more successful in bringing to light the occurrence of these diseases (Illinois, Missouri, Ohio, and Pennsylvania. See appendbc, pages 76, 78, and 79) . The plan referred to is that of requiring certam industries to have their employees examined physically by a competent physician at stated intervals to ascertain whether there exist in the employees any ailments or disabilities due to the nature of their occupation. The physicians making these examinations naturally become in time expert, if they are not so in the beginning, and the examination of the employees in this way will guarantee the finding of a large proportion of the cases of industrial diseases, and that in most instances in their earliest stages. If the occupational diseases are to be controlled, it is necessary that the occurrence of cases be ascertained in some way, for the occurrence of each case shows the existence of conditions which have produced disease in one employee and "wnll in all probabihty produce it in others. Each case notified shows a danger spot. MORTALITY STATISTICS. Mortality statistics are statistics of deaths. They are of interest primarily because of their relation to changes in population. Aside from the factor of emigration, mortalit}^ statistics show the losses in numbers being sustained by the population, just as birth records show the additions. Wliere migration is a factor having an appre- ciable effect upon population it hkewige merits statistical considera- tion, for it, too, represents population gains and losses. Mortality statistics have performed another important service in creating an interest in pubhc health administration and securing support for sanitary measures. They show the extent of the loss by death caused by diseases. In the absence of morbidity records they have also frequently been used as an index of the prevalence of certain infections. It has been possible to use mortality statistics for the latter purpose on the assumption that the fatahty rates of disease 52 are fairly constant, holme lias said: However, we should bear in mind what News- The registration of deatlis gives a very imperfect view of tlie prevalence of disease. * * * It is fallacious to assume any fixed ratio between sickness and mortality. Tlie fatality of a given infectious disease varies greatly in different outbreaks under varying conditions. The highest ratio of sickness is occasionally found associated with a favorable rate of mortality. This absence of fixed fatality rates is shown by the experience in the United States with smallpox, in which the ratio of deaths to cases hag varied from 1:1^000 to 1:3; measles, in which the ratio of deaths to cases has been from 1:800 to 1:5; typhus fever (Brill's disease), in which it hag varied from 1 : 5 to practically no fatahty; and typhoid fever, in which the ratio has varied from 1 : 24 to 1:5. Registration of Deaths in England and the United States. The history of the registration of deaths in England and the United States is coupled with that of marriages and births, and was referred to previously in connection with the registration of births. The accurate registration of deaths in England dates from 1837. In the United States dependable registration was first enforced in Massa- chusetts and New Jersey. Other States have had laws of various types, mostly inadequate. Only recently have any number of States secured anything like complete registration. The bringing about of accurate death registration in the United States is due largely to the efforts made by the Bureau of the Census, and especially to the untiring efforts of Dr. Cressy L. Wilbur, chief statistician. United States Registration Area for Deaths. The registration area for deaths established by the United States Bureau of the Census includes the States and cities in other States which effectively enforce satisfactory registration laws and in the opinion of the Dhector of the Census have at least 90 per cent of all deaths registered. This area was first established in 1880 and at that time included Massachusetts, New Jersey, and certain cities in other States. The States included for 1912 were: ^ California. Colorado. Connecticut. Indiana. Kentucky. Maine. Maryland. Massachusetts. Michigan. Minnesota. Missouri. Montana. New Hampshire. New Jersey. New York. North Carolina (municipal- ities of 1,000 population or over in 1900). Ohio. Pennsylvania. Rhode Island. Utah. Vermont. Washington. Wisconsin. I Virginia v\'as ndded for 1913. 53 The registration cities in nonregistration States were : Alabama: Kansas : South Carolina: Birmingham. Atchison. Charleston. Mobile. Coffeyville. Tennessee: Montgomery. Fort Scott. Knox\dlle. Delaware: Hutchinson. Memphis. Wilmington. Independence. Nashville. Florida: Kansas City. Texas: Jacksonville. Lawrence. El Paso. Key West. Leavenworth. Galveston. Georgia: Parsons. San Antonio Atlanta. Pittsburg. Virginia: Savannah. Topeka. Alexandria. Illinois: Wichita. Danville. Aurora. Louisiana: Lynchburg. Belleville. New Orleans. Norfolk. Chicago. Nebraska: Petersburg. Decatur. Lincoln. Richmond. Evanston. Omaha. Roanoke. Jacksonville. Oregon: West Virginia: Quincy. Portland. Wheeling. Springfield. Source of Data. The origmal information from which mortahty statistics are derived is obtained by the registration of deaths. This is commonly accom- plished by the use of a blank or schedule prepared for the purpose and in this country known as a death certificate. The model law for the registration of births and deaths provides that no body shall be interred or otherwise disposed of or removed or temporarily held pend- ing further disposition "more than 72 hours after death unless a permit for burial, removal, or other disposition thereof shall have been prop- erly issued by the local registrar of the registration district hi which the death occurred or the body was found. And no such burial or removal permit shall be issued by any registrar untU, wherever j^rac- ticable, a complete and satisfactory certificate of death has been filed with him * * *." This msures the making of a death certificate and its registration in each instance of death unless the body is sur- reptitiously and illegally disposed of. It therefore guarantees practi- cally complete registration. In the rural districts of some localities bodies are frequently interred in private burial grounds and on farms in some chosen spot on the premises. Under these conditions bodies would occasionally be buried without registration, due to ignorance of the law. To meet the needs in such case the model law suggests a clause requiring every person or firm selling a casket (at retail) to keep a record showing the name and address of the purchaser, the name of the deceased, and date and place of death, and on the first of each month to report to the State registrar the sales for the pre- 54 ceding month; also to inclose in each casket sold a notice calling attention to the requirements of the law and a blank certificate of death. These provisions do not apply when the person selling the casket is the undertaker in charge of the burial. The Standard Death Certificate. The standard death certificate in use throughout the registration area for deaths calls for the following information: Place of death. Name, sex, color, race, conjugal condition, age, date of birth, occupation, and birth- place of decedent, name and birthplace of father, maiden name and birth place of mother. Signature and address of informant giving preceding information. Date and time of death and a statement as to the duration of medical attendance on the decedent, the cause of death, and its dm-ation, are to be given by the attending physician, if any, last in attendance. When the decedent was a recent resident or died in a hospital or other institution, the length of residence at place of death is to be given and also the former or usual residence and the place where the disease or injury was contracted. The date and intended place of burial and the address of the undertaker are to be given over the undertaker's signature. The date when the certificate is filed is inserted by the registrar with his signature. The responsibility of seeing that a certificate is properly made out and filed with the registrar rests prunarily upon the undertaker, according to the provisions of the model law, which specifies as fol- lows : Sec. 9. That the iindertaker, or person acting as undertaker, shall file the certificate of death with the local registrar of the district in which the death occurred and obtain a burial or removal permit prior to any disposition of the body. He shall obtain the required personal and statistical particulars from the person best qualified to supply them, over the signature and address of liis informant. He shall then present the certificate to the attending physician, if any, or to the health officer or coroner, as directed by the local registrar, for the medical certificate of the cause of death and other particulars necessary to complete the record, as specified in sections 7 and 8. And he shall then state the facts required relative to the date and place of burial or removal, over his signature and with his address, and present the completed certificate to the local registrar in order to obtain a permit for burial, removal, or other disposition of the body. The undertaker shall deliver the burial permit to the person in charge of the place of burial, before intemng or otherwise disposing of the body; or shall attach the removal permit to the box containing the corpse, when shipped by any transportation company; said permit to accompany the corpse to its destination, where, if within the State of , it shall be delivered to the person in charge of the place of burial. Sources of Error. In the use of mortality statistics as well as other statistics erroneous and unwarranted conclusions are sometimes arrived at by attempting to compare incomparable data. Mortality rates secured by lax enforcement or faulty methods of registration can not properly be 55 compared with those based upon complete registration. Nor can the rates of communities with populations of different sex and age composition be compared unless proper allowances are made and the rates expressed in terms of the same population. For example, it is improper to compare the mortality rate of an aggregation of young men picked for physical soundness, such as an army or navy, with the crude or general mortality rate of a civilian popula- tion. The nearest means of making comparison would be to compare the rate of the picked body of men with the rate among men of the same age groups in the civil population. But even this would be faulty, for the one group would consist of men specially picked for physical fitness while the other group would include the fit and the imfit, the strong and the weak. Nor is it possible to compare the mortality rate of any special population group with the rate of the population from which it has been derived by mtentional or other process of selection unless the differences in population com- position are considered. Thus it would give little information of value regarding the effect of locality and environment upon the duration of life to compare the mortality rate of New York City or the registration area of the United States with that of the Canal Zone without taking into account any differences which may have been produced in the age and sex composition of the two populations by the selective process naturally operating in the case of the Canal Zone, For the same reason there is little to be gained by comparuig the mortality rate of any American city or State with that of the civil employees of the Philippine Islaads or any other similar group unless based upon an analysis of age and sex composition of the populations. Another possible source of error in mortality statistics which requires to be considered is the original data contained in the death certificates from which the statistics are compiled. The personal and statistical particulars usually furnished by some member of the family are undoubtedly in most mstances accurate with the exception of the statement of occupation of the decedent, which offers unusual difficulties, due to the indefiniteness of many of the terms commonly used m so far as showing the exact kind of work is concerned. This is due in some measure to the fact that the nomenclature in common use has not progressed apace with the rather rapid development of new industries and industrial processes and methods. Whereas 50 years ago the statement of occupation would have been in most cases comparatively simple and easily understood, to-day with changed industrial conditions the matter requires greater precision if useful statistical information is to result. Perhaps the most common error entermg into death registration, and therefore into mortality statistics, is m connection with the 56 statement of cause of death. Aside from the fact that in the instances in which it has been impossible for the attending physician to feel reasonably certain as to the nature of the terminal illness a cause of death is nevertheless usually stated in the certificate, and also the fact that at times the physician knowing the nature of the illness may, in the belief that he is shielding the family from odium or because of their whim, intentionally state an erroneous cause of death, there stiU remam the many unavoidable errors of mistaken diagnosis. Just how great a factor this last may be it is difficult to estimate. However, the findings of Dr. Richard C. Cabot ^ give at least a hint of its possible importance and the extent to which it may affect that part of mortality statistics relating to causes of death. In a study of 3,000 autopsies with regard to the relation of the actual cause of death as found post mortem to the clinical diagnosis Cabot found that the percentage of correct diagnoses in various diseases was as follows: Percentage of correct diagnosis. Diabetes melitus 95 Typhoid 92 Aortic regurgitation 84 Cancer of colon 74 Lobar pneumonia 74 Chronic glomerulonephritis 74 Cerebral tumor 72. 8 Tuberculous meningitis 72 Gastric cancer 72 Mitral stenosis 69 Brain hemorrhage 67 Septic meningitis 64 ' Aortic stenosis 61 Phthisis, active 59 Miliary tuberculosis 52 Chronic interstitial nephritis 50 Thoracic aneurism 50 Hepatic cirrhosis : 39 Acute endocarditis 39 Peptic ulcer 36 Suppurative nephritis 35 Renal tuberculosis 33. 3 Broncho-pneumonia 33 Vertebral tuberculosis 23 Chronic myocarditis 22 Hepatic abscess 20 Acute pericarditis 20 Acute nephritis 16 1 Cabot, Richard C. Diagnostic pitfalls identified during a study of 3,000 autopsies. — Journal American Medical Association, Dec. 28, 1912, p. 2295. 57 The cases studied were hospital cases under conditions assumed to be favorable to correct diagnosis. It is quite safe to assume that in medical practice at large the percentages of correct diagnosis would be found lower than those found by Cabot. McLaughlin and Andrews ^ carried on an investigation in Manila into the nature of the diseases from which children were dying. They made post-mortem examinations of children in which,certain diseases had been given as the cause of death. The diseases selected were those appearing most frequently in death certificates. The reason for the investigation was to ascertain whether the death certificates showed the real causes of death in children in Manila and if npt what the actual causes of death were. Of 37 supposed cases of acute meningitis in children under 9 years of age the actual causes of death as found post-mortem were: Acute meningitis 2 Pneumonia 2 Empyema 1 Beriberi 10 Cholera. 18 Undetermined (not meningitis) 3 Enterocolitis 1 Total 37 Of 22 supposed cases of enteritis, dysentery, and gastroenteritis in children under 7 years of age the actual causes of death found post-mortem were: Cholera 15 Beriberi 2 Pneumonia 2 Enterocolitis 3 Total 22 Of 40 cases in which the cause of death was given as "infantile convulsions" (all but 2 were infants under 1 year of age), the actual causes of death as found post-mortem were: Beriberi 31 Cholera 4 Pneumonia 1 Enterocolitis 1 Empyema 1 Cerebral hemorrhage 1 Undetermined 1 Total 40 ' McLaughlin, Allan J., and Andrews, Vernon L. Studies on Infant Mortality, Philippine Journal of Science, Vol. V, No. 2, July, 1910, p. 149. 58 In 27 cases in which the causes of death given in the death certifi- cate were acute or chronic bronchitis or bronchopneumonia the actual causes were found to be : Beriberi 14 Pneumonia - 6 Meningitis 2 Nephritis 2 Chronic colitis 1 Acute tonsillitis, pharyngitis, and bronchitis 1 Undetermined 1 Total 27 In 50 cases (all in infants under 1 year of age except 1) certified as dying from ''infantile beriberi" the actual causes of death were found to be: Beriberi 40 Cholera 3 Bronchopneumonia 3 Enterocolitis 1 Undetermined 3 Total 50 A summary of the series was as follows : Assigned causes of death. Meningitis 37 Enteritis 22 Convulsions 40 Beriberi 50 Bronchitis 27 Total 176 Causes of death ascertained hy autopsy. Cholera 40 Beriberi 97 Pneumonia 14 Enterocolitis 7 Meningitis 4 Nephritis 2 Empyema 2 Acute tonsillitis, pharyngitis, and bronchitis 1 Cerebral hemorrhage 1 Undetermined 8 Total 176 In the registration area of the United States very probably the causes given in death certificates of children correspond more nearly to the actual causes of death than they did in Manila. This, how- ever, should be ascertained by careful studies. Mortality statistics can not be more accurate than the death certificates from which they are compiled. For a further discussion of the possible scope of the inaccuracies entering into mortality statistics because of the faulty or incorrect statement of cause of death on death certificates the reader is referred to the Twelfth Annual Report of the Bureau of the Census giving mor- tality statistics for the year 1911, pages 36 to 38. 59 Uses of Death Registration. Death registration serves a number of highly important purposes. Its functions are legal, economic, and social. Death registration is useful in preventing and detecting crime through the restrictions placed upon the disposal of dead bodies. It serves as evidence in the inheritance of property and in the settlement of life insurance con- tracts and policies. It is only proper that the time, place, and cause of death of each indi^ddual should be made a permanent record for both sentimental and legal .reasons. Death registration makes it possible to show by mathematical computations and statistical methods the extent and rate of change in population produced by deaths; the average duration of life; and, to the extent that the certified causes of death have been correctly stated, the relative frequency with which the several causes produce death. Death statistics by comparison with birth statistics give useful information regarding population increase or decrease. Death Rates. Death rates may be expressed as the ratio of the total number of deaths, taken as a unit, to the population. For example: 1 in 60. The usual method, however, is to express these rates in terms of the number of deaths per 1,000 population, or in some instances per 10,000 or even 100,000, or 1,000,000. Crude death rates. — The rate which shows the proportion of all deaths to the total population, and which is usually obtained by dividing the total number of deaths by the total population in thousands, is known as the crude death rate; also as the general or central death rate. To compute the crude death rate the total number of deaths during a year and the mean population for the year (estimated popu- lation as of the middle of the year, for the calendar year as of July 1) are taken. To illustrate: In a city having a total of 900 deaths dur- ing a calendar year, and an estimated population of 60,000 as of July 1 of the year, the crude death rate would be 900 -^ ^ ' „„ =15 and -^ ' 1,000 would be expressed as 15 per 1,000 population. Crude death rates are of value chiefly to show the numerical loss of the population by death. They also serve as a satisfactory basis for the comparison of the death rates of different communities having populations of similar composition as to age and sex. For populations of dissimilar composition they are not suitable as a basis of compari- son, for the death rates of women are usually lower than those of men and the death rates of the several age groups vary within wide limits, and the death rate, therefore, depends to a marked degree upon the relative numbers of males and females and the proportion of the popu- lation included in the various age groups. 60: Death rates for short periods. — Death rates for short periods (for a week, month, or quarter) are expressed, in terms of annual rates; that is, what the annual rate would be provided deaths occurred through- out the year with the same frequency as during the week or month under consideration. Death rates for short periods are likely to have little significance, as quite accidental causes may affect them to a con- siderable degree. Taken for a number of years, however, they give useful information regarding seasonal variations. If in a city there f . '1885 1890 1895 1900 . 1905 1910 1 ^, i 1 36 s^ A / \ ■ s . V ■^ — \ 34 \ \ 32 \ ' - \ 30 -: - - \ \, E8 s ^- % > , . \ J Iw \ .^ ?a- S s ^ \ •> ■v y \ / \ zz \ ' \^ y \ / /■ \ ^o \ / \, \ ^ ""v '" k 18 \ . • \ l{ \ r — % 1 __ 1 ^ ^ « nn- «» J™.™ ..». ^.^ Chaet 12.— Births and deaths (exclusive of stillbirths) per 1,000 population per aimum— German Empire— 1SS6 to 1911. were 20 deaths during a given week and the mean population of the city for the year was 60,000, then the crude death rate for the week would be 17.38. The mortahty for the week would, therefore, be at the rate of 17.38 per 1,000 population per annum. Specific death rates. — Special or specific death rates are the rates .of specified or limited subgroups of the population. These subgroups may be obtained by dividing the population according to sex, age, race, 61 social condition, occupation, and so on. Specific death rates may be stated as the proportion of the number of deaths per annum in the subgroup per 1,000 of the mean annual number of the population in that subgroup. Sometimes specific death rates are given in terms of 10,000, 100,000, Ox- 1,000,000 of the subgi'oup population. Among the most important of the specific rates are those relating to age groups. Their significance is shown by the following statement of rates for the registration States of the United States for the year 1911: Death rate Age group. per 1,000. Under 1 year : 112. 9 1 to 4 years 11. 8 5 to 9 years 3. 1 10 to 14 years : 2. 2 15 to 19 years 3. 6 20 to 24 years 5.2 25 to 34 years 6. 4 35 to 44 years 8. 9 45 to 54 yearc 13. 6 55 to 64 years 26. 2 65 to 74 years 55. 2 75 years and over 138. 9 All ages 13. 9 Specific race group rates are also important. In the registration area for deaths in 1911 the death rate for the wliite population was 13.7 and that of the colored 23.7 per 1,000, while the rate of the two groups taken together was 14.2 per 1,000. The death rate differs also in the two sexes. In the registration area for deaths in 1911 the death rate for males was 14.7 and for females 13 per 1,000. Standardized death rates. — Due to the wide variation in the death rates at different ages it is impossible to satisfactorily compare the crude death rates of populations differing in composition as regards the relative number of individuals in the several age groups. The International Statistical Institute recommended (1895) that to facili- tate the comparison of death rates the population of Sweden as it existed in 1890 be used as a standard population for the statement of rates. Rates expressed in terms of a standard population are known as standardized or corrected rates. The method is as follows: Take the population for which it is deshed to state the standardized death rate and ascertain the specific death rates of its several age groups. Now take the corresponding age groups in 1,000,000 of the standard population and compute the number of deaths that would have occurred in each age group at the specific death rate found to exist in the population for which the standard death rate is being com- puted: add the number of deaths which it is thus found would have occurred in the age groups of the standard population. This gives 62 the standardized rate per 1,000,000. The standardized rate per 1,000 is obtained by moving the decimal point three places to the left. The standardized death rate is the rate which would have occurred in the standard population if the death rates in its several age groups had been the same as those of the corresponding age groups of the population mider consideration. The registrar general of births, marriages, and deaths of England and Wales has for some years taken for a standard the population composition of England and Wales as shown by the 1901 census. The population of Sweden of 1890 was divided without distinction of sex into the five age groups: Under 12 months of age, over 12 1885 1890 1895 1300 1905 1910 te 24 ^ Vh J7£ ,^ zz «^^ \ "'? ^ kX N, / ■^ Z fee ^ S \ / 1 % f^ ""^ r^ < •\ ,20 \ \ / \ ■— "^c ^ ^N / "^« -^^ _^ --- -" ■^ ^f ^18 \ 16 14 ■ Chart 13.— Birtlis and deaths (exclusive of stillbirths) per 1,000 population per aniram— France— 1886 to 1011. months and under 20 years, 20 to 39 years of age inclusive, 40 to 59 years of age inclusive, and 60 years of age and over. The population of England and Wales is classified separately by sexes in quinquennial age groups and furnishes a much more delicate and exact standard for measurement. The use of the Swedish population standardizes for age; the use of the English standardizes for both age and sex. In the United States a standard would be useful which would standard- ize for age, sex, and race (white and colored). Factors Affecting Death Rates. Death rates are affected not only by tbe statistical methods used in their preparation and by the age, sex, and race composition of the population, the social,^ marital, and economic status of the people, the nature and conditions of employment and the adaptability of a people to their environment, but also in limited areas by a number of other factors, such as the location of hospitals and institutions. Nonresidents — Hospitals and institutions. — Frequently a hospital or other mstitution will be located in one community while its pa- tients or inmates will come largely from other places. The extent to which this is true depends upon the nature or reputation of the hos- pital or institutioru The result may be that the local death rate will be affected to an appreciable extent by deaths of nonresidents in such institutions. In England and Wales an attempt has been made dur- ing the last two or tliree years to overcome this diJBEiculty by the allocation of all deaths in so far as possible to the locality of usual 1875 1880 1685 1896 1895 190O 1905 1910 _™ / \ / y \ / ■^ t& f V / \ / -— \, s ^ /n ^ _^ \ ^ / V — — N / 24 s N / \ ^ \, £0 \ 4'^ xi ^s / ^ v, / \ A \ / \ , \ __ ^ S , , / / \ s / \ 16: r"" \ \y -^ / \ ■^ y N 111 c L _ _ -^— __ — Chaet 14.— Births and deaths (exclusive of stillbirths) per 1,000 popailation per annum— Massachusetts— 1871 to 1911. residence. In eompilmg deaths for a registration district or area for the purpose of showing death rates, erroneous i>esults will be obtained if the deaths of nonresidents are excluded and no additions made for the deaths of residents which are contmuaUy occurring and being registered elsewhere. In the absenee of a dependable nie,ans of inclndrng the deaths of residents occurring in other districts it is, nnless under most exceptional circumstances, unsafe to exclnde the deaths of nonresidents. IHgratioQi. — Migration affects death rates by changmg the age, sex, or race composition of the population. Migi-ants are likely to consist more largely of males than of females, of young adults than of the extremes of life. The effect of migration depends upon whether the balance is one of emigration or immigration and the nature of the m.igrants lost or gained. 64 Birth rate. — Ignoring the question of migration, a population increases because of tlie excess of births over deaths, natural in- crease. In a stationary population the birth rate equals the death rate. As aU born must eventualy die the birth rate depends for its excess over the death rate upon the ever-increasing number of child- producing elements in the population and the resulting greater num- bers in the younger age groups. Other things being equal, a com- munity with a high birth rate wiU, because of the greater proportion of the population in the younger age groups, have a lower crude death rate than a community with a low birth rate. Marital condition.— M-Ovidliij in certain countries seems to be more dependent on marital conditions than on sex. This is shown by the following table taken from a paper entitled "Some Researches Con- cerning the Factors of Mortality, " by Lucien March (Journal of the Royal Statistical Society, London, March, 1912): Table 7. — Showing for the period 1886-1895, the number of deaths per 10,000 persons according to their marital status in France, Prussia, and Sweden. Males, aged^ Females, aged— 20-39 40-59 60 and over. 20-39 40-59 60 and over. France: 77 103 2n 71 84 201 53 83 104 153 24(i 293 175 231 346 114 204 190 583 794 1,148 582 806 1,091 453 090 856 80 78 145 79 59 101 66 61 98 121 166 198 128 179 172 96 120 132 456 730 930 Prussia: Married 497 Single 729 805 Sweden: 364 Single . . . . 528 698 Table 8. — Death rates (exclusive of stillbirths) per 1,000 pojoulation in 1886 and 1911.^ certain countries, Country or State. 1886 1911 15.4 29.7 18.1 19.5 22.2 22.5 26.2 31.7 17.8 28.7 21.8 10.5 16.2 26.7 18.9 29.6 29.3 16.6 2 19.8 16.2 18.6 8.9 10.7 21.9 13.6 England and Wales .^ 14.6 16.5 19.6 17.3 25.1 16.5 Ita'y 21.4 14.5 9.3 13.2 25.1 15.1 21.8 23.2 13.8 14.2 15.4 15.3 13.3 1 Taken from the Seventy-fourth Aimual Report of the Registrar General of Births, Deaths, and Marriages in England and Wales, 1911, except the rates for Connecticut, Massachusetts, Michigan, and the United States. » Year 1880. 65 It will be noted in Table 8 that there has been a marked fall in the crude death rates throughout the civilized world. Louis I. Dublin/ statistician of the Metropolitan Life Insurance Co., has discussed the nature of this reduction in the death rate in the United States. He directs attention to the fact that the reduction has been entireh^ in the lower age groups, and that the death rates for the ages above 45 in males and above 55 in females were higher in 1911 than in 1900. The following table illustrating the nature of the changes is taken from Dublin's paper: Table 9. — Comparison of mortality of males and females, by age groups; death rates per 1,000 population. (Dublin.) [Registration States as constituted in 1900.1 Males. Females. Age. 1900 1911 Per cent increase or decrease. 1900 1911 Per cent Increase or decrease. Under 5 54.2 4.7 2.9 4.9 7.0 8.3 10.8 15.8 28.9 59.6 146.1 39.8 3.4 2.4 3.7 5.3 6.7 10.4 16.1 30.9 61.6 147.4 -26.57 -27. 66 -17. 24 -24. 49 -24. 29 -19.28 - 3.70 + 1.90 + 6.92 + 3.36 + .89 45.8 4.6 3.1 4.8 6.7 8.2 9.8 14.2 25.8 53.8 139.5 33.3 3.1 2.1 3.3 4.7 6.0 8.3 12.9 26.0 55.1 139.2 27 29 5-9 32 61 10-14 32 26 15-19 31 25 20-24 29 85 25-34 26 83 35-44 15 31 9 15 55-64 + 78 65-74 + 2.42 — 0.22 75 and over All ages 17.6 15.8 -10.23 16.5 14.0 — 15.15 Similarly instructive is the following taken from a table prepared by Guilfoy^ showing the difference in the mortality rates for the various age groups in 1868 and in 1907 in the city of New York. Table 10. — Death rates per 1,000 persons at different age periods in New Yorlc City, with increase or decrease percentage from, all causes for the years 1868 and 1907. {Guilfoy.) Rates. Per cent, increase 186S 1907 or decrease. Males: Under 5 years 130.6 10.1 5.04 6.14 13.42 16.21 18.01 20. 32 26.36 42.15 103. 71 32.12 57.85 4. .58 2.68 5.24 7.62 9.42 12.50 18.25 31.84 49.87 107.1 21. 13 -56 5-9 -55 10-14 -47 15-19 -15 20-24 -43 25-29 . . .. -42 30-34 -31 35-44 -10 45-54 +21 55-64 + 13 65 and over + 3 All ages -34 1 Dublin, Louis I. "Possibilities of reducing mortality at the higher age gi-oups," Americal Journal of PubUc Health, Dec, 1913. 2 Guilfoy, Wm. H., "At -what age periods and in what measure has the reduction in the mortality rate from tuberculosis manifested itself in the c.^ty of New York during the past forty years?" New York Med, Jour.;Nov. 28, 1908. 55256°— 14 5 66 Table 10. — Death rates per 1,000 persons at different age periods in Neiv Yorlz City, with increase or decrease ■percentage from all causes for the years 1868 and 1907 (Guilfoy) — Continued. Rates. Per cent, increase 1868 1907 or decrease. Femates: 118.9 9.08 3.36 5.74 10.91 12.84 14.24 15.83 17.69 29.37 88.40 26.52 124.8 9. GO 4.19 5.92 12.03 14.42 16.13 18.08 22.10 35.59 94.84 29.24 49.57 3.74 2.75 4.14 5.45 6.82 8.85 12.44 19.67 38.43 97.30 16.53 53.74 4.1G 2.72 4.65 6.43 8.11 10.77 15.54 25.90 44.06 101. 7 18.97 -58 5 9 -59 10 14 -18 15 19 -28 20 24 -.:0 25 29 -47 30 34 -38 35-44 -21 45 64 + 11 55 64 +31 + 10 -38 Both sexes: -57 5 9 -57 10 14 -35 15-19 20 24 -21 -47 25-29 -44 30 34 -33 35 44 -14 + 17 55 Q4 +24 + 7 -35 INFANTILE MORTALITY. Infantile mortality is tlie mortality of infants under 1 year of age. While the specific death rates for other age groups are given as the ratio of the "number of deaths to the number of individuals in the age group as ascertained by census enumeration and estimated for intercensal and post censal years, it is not practicable to do this for the first year of life. There is extreme difficulty in ascertaining by enumeration the infant population. This is due largely to con- fusion of the current year of age with the completed year of life. Many infants less than 12 months old are returned at the census as 1 year of age. This causes an understatement of the infant population and gives an illusory basis for the estimation of infant mortafity rates. The commonly accepted method of stating infant mortality is as the ratio of deaths of children under 1 year of age to living births, and is usually expressed as the proportion of deaths during the calen- dar year to 1,000 living births durmg the same period. To illustrate: If m a city there were during a year 224 deaths of infants under 1 year of age, and if during the same year there were 2,000 births, the infantile mortality rate would be 112 per 1,000 births per annum,. Infantile mortality rates might be based upon the number of births during the preceding year or upon the mean of the number of births of the current year and the precedmg year. However, the number of births of the current year has been accepted as the basis in Great Britain and many other countries. 67 Making the estimation of infantile mortality depend upon birth registration is at present unfortunate in a way for those interested 1892 1895 I9C5 EDO ISO i80 «70 .J60 J50 .130 j20 no 100 90 eo -^ _ "" "" \ / k / \ \ / \ / \ V y \ \ / \ 5^/T ay t'n}///^ 1 \ j N ^ I'v- Z/7 ce f y \ ^, s, . S \ I \ \ 1 \ 1 \ / NJ \ 1 r^ N. 1 <^, j^ / ,>. Ji' k: 's ' ,,' M, 1 ,( f/ \ 4 / •* / \^ k >' / '\\ ,' C^ r j \ r^ f / \ .V- I' 1 \ Vj \ / N V 1 1 \ s < w- s. ^ s V ' »-»■ V i \ ^ M ■^ y \ s \ V, D. •sn, ^J J-A j \ ^ \ — ' \ ^-r \ \ V 1 y \ \ N 1 V \ / \ S 1 \ / ( \ ^"Y \ fN ' t k "H V \ / \ \ N 1 \ / \ -J / ■»>„ Ss .d wt 'd ?n A -^ f \ y V ^ K° i^ \ / \ ^ A en 'A giZ H 1 N / / V V /' \. ~" N A « f \ > / k ^ ^ V \ ■sJ y 1 \^ / \ / — s \ / \, N '^ / \ / / N 1 y-^ / V S, 'N. / ^ / \ ^ y \ \ I--- •^ [N / N X __ _ ba« _ -J _ >s I' v-i r ^ Chaet 15. — Infantile mortality (deaths of infants under 1 year of age per 1,000 liirths per annum, ex- clusive of stillbiiths)— German Empire, France, England and Wales, Denmark, Sweden, and New- Zealand— 1892 to 1911. 170 160 150 140 1845 1850 1855 I860 i865 1870 1875 1880 1885 1890 1895 1900 1905 !9I0 ^ ' 1 1 / .^ — »= y -^ / / ^ •^ k" "^ \ \y ^' \ y N y y N ^ N s ^ y \ ' V \ fJU \ \ 120 \ y 110 100 ■nn _» «„ __ _ u»- __ __ L_ n^ Chaet 16.— Infantile mortality (deatli-s of infants under 1 year of age per 1,000 births per annum, exclusive of stillbii-ths)— England and Wales— 1840 to 1910. The curve shows the mean annual rata for quinquemiial periods. in the subject as it relates to the United States, owing to deficient birth registration in this country and the impossibility therefore of estimating infantile mortality rates, except for certain limited areas. However, there is no other practicable basis for estimation. There are, too, other difficulties to be encountered in the use of incomplete birth registration. In the absence of change in other factors an improving completeness of bJTth registration would give an apparent decreasing infantile niortahty rate and might lead to unwarranted deductions. For a further discussion of the subject the reader is referred to a paper entitled, "Certain phases and fallacies of American mfant mortahty statistics," by Edward Bunnell Phelps,^ in the American Journal of Pubhc Health, Volume III, No. 11, November, 1913. Table 11. — Infantile viortality — Deaths of children under 1 year of age per 1,000 births {exclusive of stillbirths') in certain countries, 1S92 and 1911.^ Country or State. 1892 1911 Australian Commonwealth 106 259 140 148 170 181 68 Austria 207 Denmark 106 England and Wales . . . 130 Finland 114 France 2 111 German Empire 192 Hungary 274 105 184 174 89 105 243 117 196 109 207 Ireland ... . . 94 Italy 2 142 The Netherlands 137 New Zealand 56 Norway 2 67 197 Scotland 2 108 2 138 Sweden 2 75 Connecticut 115 161 119 1 Taken from the seventy-fourth annual report of the registrar general of births, deaths, and mar- riages in England and Wales, 1911, except the rates for Connecticut and Massachusetts, which were taken from State reports. 2 Year 1910. LIFE TABLES. In theory life tables represent the duration of life of individuals born at the same time. Given a group of individuals born in any one year and a life table will show the number in the group that will stiU be alive in each succeeding yeeir as long as any remain. It will also show the number who will have died previous to any given year and the number dying during each year. To observe a group of indi- ..viduals from the cradle to the grave is under most conditions imprac- ticable, and besides yields information the value of which is largely lost before it is obtained, for conditions affecting longevity may change and the life history of one generation may be quite different from that of the next. ^ other papers on the subject by the same author are: "A statistical survey of infant mortality's urgent call for action," Transactions Am. Assn. for study and prevention of infant mortality, 1910. "A statistical study ot infant mortality," Quarterly publications, Am. Statistical Assn., Sept., 1908. "Infant mortality and its relation to woman's employment; A study of Massachusetts statistics," S. Doc. No. 645, 61st Cong., 2d sess., 1912. Much of the value of a life table consists in showing current condi- tions as they affect the longevity of the community or race. For this purpose tables are constructed from the information furnished by an enumeration of the population (census) classified by age and sex and the registration of deaths with the decedents classified also by age and sex. The population age and sex groups give the number and pro- portion remaining alive at each year of age, the deaths show the num- ber dying at each year of age. For the purpose of getting data wiiich show general conditions prevailing durmg the period, and of avoiding the errors which might arise by using the death records of a year during which unusual mortality conditions prevailed, the death records for a number of consecutive years are usually used. Given the above data, the expectancy of life or mean after lifetime at a given age is readily obtained. The following table is one pre- pared under the direction of Dr. William H. GuiKoy, registrar of records of the New York City departm3nt of health and published in the monthly bulletin of the department for May, 1913. It compares the expectation of life based on the mortality experience of the three years 1909, 1910, and 1911, with that found by the late John S. Billings based upon the experience of 1879, 1880, and 1881: Table 12. — Approximate life tables for the city of New York based on mortality returns for the triennials 1879 to 1S81 and' 1909 to 1911. (Guilfoij.) Expectation of life , 1879 to Expectation of life , 1909 to Gain ( + or loss (— ) in years Years of 1881. 1911. of expectancy. mortality. Males. Females. Persons. Males. Females. Persons. Males. Females. Persons. Asjes: — 5 39.7 42.8 41.3 50.1 53.8 51.9 +10.4 + 11.0 +10.6 5 44.9 47.7 46.3 49.4 52.9 51.1 + 4.5 + 5.2 + 4.8 10 42.4 45.3 43.8 45.2 48.7 46.9 + 2.8 + 3.4 + 3.1 15 38.2 41.2 39.7 40.8 44.2 42.5 + 2.6 + 3.0 + 2.8 20 34.4 37.3 35.8 36.6 40.0 38. 3 + 2.2 + 2.7 + 2.5 25 31.2 34.0 32.6 32.7 36.0 34.3 + 1.5 + 2.0 + 1.7 30 28.2 31.0 29.6 28.9 32.1 30.5 + 0.7 + 1.1 + 0.9 35 25.3 28.1 26.7 25.4 28.4 26.9 + 0.1 + 0.3 + 0.2 40 22.5 25.2 23.9 22.1 24.7 23.4 - 0.4 - 0.5 - 0.5 45 19.8 22.4 21.1 18.9 21.1 20.0 - 0.9 - 1.1 - 1.1 50 17.2 19.4 18.3 15.9 17.7 16.8 - 1.3 - 1.7 - 1.5 55 14.5 16.4 15.4 13.2 14.6 13.9 - 1.3 - 1.8 - 1.5 60 12.2 13.8 13.0 10.8 11.8 11.3 - 1.4 - 2.0 - 1.7 65 9.9 11.2 10.5 . 8.8 9.4 9.1 - 1.1 - 1.8 - 1.4 70 8.5 9.3 8.9 6.9 7.5 7.2 - 1.6 - 1.8 - 1.7 75 7.1 7.5 7.3 5.3 5.7 5.5 - 1.8 - l.S - l.S 80 6.2 6.5 6.4 4.1 4.5 4.3 - 2.1 - 2.0 - 2.1 +85 5.4 5.5 5.5 2.0 2.4 2.2 - 3.4 - 3.1 - 3.3 f +24.8 + 2S.7 +26.6 { -15.3 i + 9.5 -17.6 + 11.1 -16.6 + 10.0 ACKNOWLEDGMENTS. It is a pleasure to the author to acknowledge his indebtedness to Drs. Cressy L. Wilbur, WiUiam H. Guilfoy, Jolm S. Fulton, and Charles F. Bolduan for many helpful suggestions. EARLY REGISTRATION IN ENGLAND. ORDER OF THOMAS CROMWELL, VICAR GENERAL UNDER HENRY VIII (l538) REQUIRING THE CLERGY TO RECORD BAPTISMS, MARRIAGES, AND BURIALS. "In the name of God Amen. By the au thorite and commission of the most excel- lent Prince Henry by the Grace of God Kynge of Englande and of France, defensor of the faithe Lorde of Irelande, and in erthe supreme hedd nndre Christ of the Church of Englande, I Thomas lorde Cromwell, lorde privie seall, Vicegerent within this realme, do for the advancement of the trewe honor of almighty God, encrease of vertu and discharge of the kynges majestic, give and exhibite unto you theise injunctions folowing, to be kept observed and fulfilled upon the paynes hereafter declared. "That you and every j^arson vicare or curate within this diocese shall for every churche kepe one boke or registere wherein ye shall w^ite the day and yere of every weddyng christenyng and buryeng made within yor parishe for your tyme, and so every man succeedyng you lykewyse. And shall there insert every persons name that shalbe so weddid christened or buried. And for the sauff kepinge of the same boke the parishe shalbe bonde to provide of these comen charges one sure coffer with twoo lockes and keys whereof the one to remayne with you, and the other with the said W9.rdens, wherein the saide boke shalbe laide upp. Whiche boke ye shall every Sonday take furtlie and in the presence of the said wardens or one of them v/rite and recorde in the same all the weddinges christenynges and buryenges made the hole weke before. And that done to lay upp the boke in the said coffer as afore. And for every tyme that the same shalbe omytted the partie that shalbe in the faulte thereof shall forfett to the saide churche Ills llld to be emploied on the rejjaration of the same churche. . v . "Thomas Crumwell." THE MODEL STATE LAW FOR MORBIDITY REPORTS. ADOPTED BY THE ELEVENTH ANNUAL CONFERENCE OP STATE AND TERRITORIAL HEALTH AUTHORITIES WITH THE UNITED STATES PUBLIC HEALTH SERVICE, MINNEAPOLIS, JUNE IG, 1913. A Bill To provide for the notification of the occurrenee and prevalence of certain diseases. Be it enacted by the Senate and General Assembly of the State of — : Section 1. It shall be, and is hereby, made the duty of the State department of health (or commissioner or board of health) to keep currently informed of the occur- rence, geographic distribution, and prevalence of the preventable diseases throughout the State, and for this purpose there shall be established in the State department of health a bureau (or division) of sanitary reports which shall, under the direction of the State commissioner of health (State health officer or secretary of the State board of health), be in charge of an assistant commissioner of health who shall receive an annual salary of dollars and the necessary expenses incurred in the performance of his duties. The State department of health shall provide such clerical and other assistance as may be necessary for the establishment and maintenance of said bureau. (71) 72 Sec. 2. Tlie following-named diseases and disabilities are hereby made notifiable and the occurrence of oases shall be reported as herein provided: GKOUP I.— INFECTIOUS DISEASES. Actmoinycosis. Anthrax. Chicken-pox. Cholera. Asiatic (also cholera nostras when Asiatic cholera is present or its importation threatened) Continued fever lasting seven days. Dengue. Diphtheria. Dysentery: (a) Amebic. (6) Bacillary. Favus. German measles. Glanders. Hookworm disease. Leprosy. Malaria. Measles. Meningitis: (a) Epidemic cerebrospinal. (6) Tuberculous. Mumps. Oplithalmia neonatorum (conjunctivitis of new- born infants). Paragonimiasis (endemic hemoptysis). Paratyphoid fever. Plague. Pneumonia (acute;. Poliomyelitis (acute infectious). Rabies. Rocky Mountain spotted, or tick, fever. Scarlet fever. Septic sore throat. Smallpox. Provided, That the State department of health (or board of health) may from time to time, in its discretion, declare additional diseases notifiable and subject to the pro- visions of this act. Sec, 3. Each and every physician practicing in the State of who treats or examines any person suffering from or afflicted Avith, or suspected to be suffering from or afflicted with, any one of the notifiable diseases shall immediately report such case of notifiable disease in writing to the local health authority having jurisdiction. Said report shall be forwarded either by mail or by special messenger and shall give the following information : 1. The date when the report is made. 2. The name of the disease or suspected disease. 3. The name, age, sex, color, occupation, address, and school attended or place of employment of patient. 4. Number of adults and of children in the household. 5. Source or probable source of infection or the origin or probable origin of the disease. 6. Name and address of the reporting physician. Provided, That if the disease is, or is suspected to be, smallpox the report shall, in addition, show whether the disease is of the mild or virulent type and whether the patient has ever been successfully vaccinated, and, if the patient has been success- fully vaccinated, the number of times and dates or approximate dates of such vaccina- tion; and if the disease is, or is suspected to be, cholera, diphtheria, plague, scarlet fever, smallpox, or yellow fever, the physician shall, in addition to the written report, Tetanus. Trachoma. Trichinosis. Tuberculosis (all forms, the organ or part afl'ected in each case to be specified). Typhoid fever. Tjfphus fever. Whooping cough. Yellow fever. GROUP n. — OCCUPATIONAL DISEASES AND INJURIES. Arsenic poisoning. Brass poisoning. Carbon monoxide poisoning. Lead poisoning. Mercury poisoning. Natural gas poisoning. Phosphorus poisoning. Wood alcohol poisonmg. Naphtha poisoning. Bisulphide of carbon poisoning. Dinitrobenzine poisoning. Caisson disease (compressed-air iUness). Any other disease or disability contracted as a result of the nature of the person's employment. GROUP m. — VENEREAL DISEASES. Gonococcus infection. Syphilis. GROUP IV.— DISEASES OF UNKNOWN ORIGIN. Pellagra. Cancer. 73 give immediate notice of the case to the local health, authority in the most expeditious manner available; and if the disease is, or is suspecteed to be, typhoid fever, scarlet fever, diphtheria, or septic sore throat the report shall also show whether the patient has been, or any member of the household in which the patient resides is, engaged or employed in the handling of milk for sale or preliminary to sale: And provided further , That in the reports of cases cf the venereal diseases the name and address of the patient need not be given. Sec. 4. The requirements of the preceding section shall be applicable to physicians attending patients ill with any of the notifiable diseases in hospitals, asylums, or other institutions, public or private: Provided, That the superintendent or other person in charge of any such hospital, asylum, or other institution in which the sick are cared for may, with the Written consent of the local health officer (or board of health) having jurisdiction, report in the place of the attending physician or physicians the cases of notifiable diseases and disabilities occurring in or admitted to said hospital, asylum, or other institution in the same manner as that prescribed by physicians. Sec. 5. Whenever a person is known, or is suspected, to be afflicted with a notifiable disease, or whenever the eyes of an infant under two weeks of age become reddened, inflamed, or swollen, or contain an unnatural discharge, and no physician is in attend- ance, an immediate report of the existence of the case shall be made to the local health officer by the midwife, nurse, attendant, or other person in charge of the patient. Sec. 6. Teachers or other persons employed in, or in charge of, public or private schools, including Sunday schools, shall report immediately to the local health officer each and every known or suspected case of a notifiable disease in persons attending or employed in their respective schools. Sec. 7. The written reports of cases of the notifiable disease required by this act of physicians shall be made upon blanks supplied for the purpose, through the local health authorities, by the State department of health. These blanks shall conform . to that adopted and approved by the State and Territorial health authorities in con- ference with the United States Public Health Service. Sec. -8. Local health officers or boards of health shall within seven days after the receipt by them of reports of cases of the notifiable diseases forward by mail to the State department of health the original written reports made by physicians, after first having transcribed the information given in the respective reports in a book or other form of record for the permanent files of the local health office. On each report thus forwarded the local health officer shall state whether the case to which the report pertains was visited or otherwise investigated by a representative of the local health office and whether measures were taken to prevent the sprea,d of the disease or the occurrence of additional cases. Sec. 9. Local health officers or boards of health shall, in addition to the i:)rovisions of section 8, report to the State department of health in such manner and at such times as the State department of health may require by regulation the number of new cases of each of the notifiable diseases reported to said local health officers or boards of health. Sec 10. Whenever there occurs within the jurisdiction of a local health officer or board of health an epidemic of a notifiable disease, the local health officer or board of health shall, within 30 days after the epidemic shall have subsided, make a rejwrt to the State department of health of the number of cases occurring in the epidemic, the number of cases terminating fatally, the origin of the epidemic, and the means by which the disease was spread: Provided, That whenever the State department of health has taken charge of the control and suppression or undertaken the investigation of the epidemic, the local health authority having jurisdiction need not make the report otherwise requhed. Sec. 11. No person shall be appointed to the position of local health officer in any city, town, or county until after the qualifications of said person have been approved by the State department of health. 74 Sec. 12. In localities in which there are no local health officers or boards of health, and in localities in which, although there are health officers or boards of health, adequate provision has not, in the opinion of the State department of health, been made for the proper notification, investigation, and control of notifiable disease, and in localities in which the local health authorities fail to carry out the provisions of this act, the State department of health shall appoint properly qualified sanitary officers to act as local health officers and to prevent the spread of disease in and from such localities and to enforce the provisions of this act: Provided, That salaries and other expenses incuiTed under the provisions of this section shall be paid by the local authorities. Sec. 13. Any physician or other person or pereons who shall fail, neglect, or refuse to comply with, or who shall violate any of the provisions of this act shall be guilty of a misdemeanor, and upon conviction thereof shall be sentenced to pay a fine of not less than dollars nor more than — • dollars or to imprisonment for not less than • days nor more than days for each offense: Provided, That in the case of a physician his license to practice medicine within the State may be revoked in accordance with existing statutory provisions. Sec. 14. No license to practice medicine shail be issued to any person until after the applicant shall have filed with the State licensing board a statement, signed and sworn to before a notary or other officer qualified to administer oaths, that said appli- cant has familiarized himself with the requirements of this act, a copy of which sworn statement shall be forwarded to the State department of health. Sec. 15. Each and every person engaged in the practice of medicine shall display in a pi'ominent place in his or her office a card upon which sections 2, 3, 4, 7, 13, 14, and 15 of this act have been printed with type not smaller than 10-point. A similar card shall be displayed in a prominent place in the office of each and every hospital, asylum, or other public or private institution for the treatment of the sick. These cards shall each be not less than 1 square foot in size and shall be furnished to insti- tutions and licensed physicians without cost by the State department of health. Sec. 16. The sum of dollars is hereby appropriated from any moneyin the State treasury not otherwise appropriated for carrying out the provisions of this act. Sec. 17. This act shall take effect immediately, and all acts or parts of acts incon-- sistent with the provisions of this act are hereby repealed. THE STANDARD MORBIDITY NOTIFICATION BLANK. The following model notification blank was also adopted by the conference of state and territorial health authorities with the United States Public Health Service June 16, 1913, as the standard notification blank referred to in section 7 of the Model Law as the one to be used in the reporting of cases of the notifiable diseases. This blank is intended to be printed on a post card : [Face of card.] ,191... (Date.) Disease or suspected disease Patient's name , age , sex , color Patient's address , occupation School attended or place of emploj'ment Number in household: Adults , children Probable source of infection or origui of disease If disease is smallpox, tjTpe , number of times successfully vaccinated and approximate dates If typhoid fever, scarlet fever, diphtheria, or septic sore throat, vras patient, or is any member of household engaged in the production or handling of mUk Address of reporting physician Signature of physician 75 [Reverse of card.] For use of local health department. P ° s! n- Ei Health Department (City) (State)... HOSPITAL DISCHARGE CERTIFICATE. Suggested by Bolduan for use in connection with hospital morhiditu reporl DISCHARGE CERTIFICATE. Name of hospital Hospital admission No Sex Age How admitted — Ambulance — or O'mi application or (Tabulation transfer from No.) other hospital. White. Colored. Mongolian. Hebrew. Gentile. Place of birth . Patient's address Single or manied or widowed or divorced or un- Borough known. Date admitted Discharged to— Date dischai-ged Home. Days in hospital months ■ Other hospital. daj'S Convalescent retreat. (If over a year, omit the days and give only years and Coroner. months.) Occupation — (a) Trade, profession, or pai'ticular kind of v.^ork. (b) General natm'e of the industry, business, or establishment in wjiich employed (or em- ployer). Diagnosis and Complications If operated upon, state nature of operation Condition on dischaige: Cured. Improved. Unimproved. Died — Autopsy. No autopsy. Signed House Physician— Sm-geou. 76 NOTIFICATION OF OCCUPATIONAL DISEASES, UNITED STATES. Abstracts of the State Laws and Regulations. CALIFORNIA. Medical practitioners are to report all cases among their patients of poisoning by- lead, phosphorus, arsenic, or mercury or their compounds, of anthrax and of com- pressed-air illness, contracted as a result of the nature of tbe patient's employment. These reports are to be made at once to the State board of health and to give the name, address, and place of employment of the patient, and name of the disease from which the patient is supposed to be suffering. Physicians are entitled to a fee of 50 cents for each report forwarded. Willful failure on the part of a physician to report is made a misdemeanor punish- able by a fine of not more than §10. The law is to be enforced by the State board of health, which may call upon local health authorities for assistance. The State board of health upon receipt of reports of occupational diseases as above described is to transmit the data to the commissioner of the bureau of labor statistics. (Chap. 485, Acts of 1911.) CONNECTICUT. Physicians are to report all cases known to them of occupational diseases, that is, diseases contracted as a result of the nature of the patient's employment. The law names specifically poisoning from lead, phosphorus, arsenic, brass, wood alcohol, and mercury and their compounds, anthrax and compressed-air illness. The reports are to be made witliin 48 hours by mail to the commissioner of the bureau of labor statistics and are to show the name, address, and occupation of the patient, the name, address, and business of the patient's employer, the nature of the disease, and such other infor- mation as may be required by the commissioner. Blank forms upon wliich to make these reports are furnished by the bureau of labor statistics. Failure on the part of a physician to report within the time specified is made pun- ishable by a fine of not to exceed $10. (Chap. 14, Act approved Apr. 22, 1913.) In the Illinois law industries in which sugar of lead, white lead, lead chromate, litliarge, red lead, or arsenate of lead are used or handled in any way, and industries engaged in the manufacture of brass or the smelting of lead or zinc are declared to be especially dangerous to the health of the employees. Employers engaged in carrying on these industries are required to cause all employees who come in direct contact with the poisonous agencies or injurious processes to be examined once a month by a physician to ascertain whether there exists in the employees any occupational disease or illness due or incident to the character of their work. The physicians making these examinations are to report immediately to the State board of health. If no occupa- tional disease is found, the report is to so state. If a case of occupational disease is found, the report is to state the name, address, sex, age, and last place of emrjloyment of the employee affected, the name of the employer, and the nature of the disease and its probable extent and duration. Upon the receipt of such a report the secretary of the State board of health is to immediately transmit a copy of it to the Illinois depart- ment of factory inspection. (Act approved May 26, 1911; effective July 1, 1911.) The State Board of Health of Kansas by regulations, adopted December 13, 1913, made the following occupational diseases notifiable to the State health depart- ment through the local health departments in the same manner as the other notifiable 77 diseases: Arsenic poisoning, brass poisoning, carbon monoxide poisoning, lead poison- ing, mercury poisoning, natural gas poisoning, phosphoriis poisoning, wood alcoliol poisoning, naplitha poisoning, bisulpliide of carbon poisoning, dinitrobenzine poison- ing, caisson disease (compressed-air illness). Any otlier disease or disability con- tracted as a result of tlie nature of tlie person's employment. Physicians are to report all cases among their patients of poisoning from lead, phosphorus, arsenic, or mercury, or their compounds, of anthrax, of compressed-air illness, or of any other disease or ailment contracted as a result of the patient's occu- pation or employment. The reports are to be made in writing to the State board of health within 10 days after first seeing the patient, and are to give the name, address, nature of the occupation and place of employment of the patient, the nature of the disease, and such other information as may be required by the State board of health. In like manner physicians are to report all cases of lead poisoning or suspected lead poisoning resulting from the use of water suspected of containing lead. Failure on the part of the physician to make these reports is made a misdemeanor punishable by a fine of not less than $5 nor more than $10. The enforcement of the law is imposed on the State board of health and the county attorneys. (Chap. 82, act approved Mar. 20, 1913.) MARYLAND. Physicians are required to report all cases in which the patients are believed to be suffering from poisoning from lead, phosphorus, arsenic or mercury or their com- pounds, or from anthrax or compressed-air illness, or from any other ailment con- tracted as a result of the nature of the patient's employment. These reports are to be made at once in writing to the State board of health and are to give the name, address, occupation, and place of employment of the patient, the nature of the disease, and Buch other information as may be required by the State board of health. The State board of health is to enforce the act and to transmit the data received in the reports from physicians to the chief of the Maryland bureau of statistics and information . Failure on the part of a physician to make the required reports renders him liable to a fine of not to exceed $5. (Act approved Apr. 8, 1912.) MASSA.CHUSETTS . The State board of labor and the industrial accident board, sitting jointly, are to make regulations for the prevention of occupational diseases and are given the authority to require physicians to report all cases among their patients of diseases contracted as a result of the nature, circumstances, or conditions of the patient's employment, and to fix the information to be furnished and the time within which such reports shall be made. These reports are to be made to the State board of labor and industries. Violations of any regulations made as described above are punishable by a fine of not more than $100 for each offense. (Act approved June 16, 1913.) MICHIGAN. Physicians are to report all cases among their patients of poisoning from lead, phos- phorus, arsenic or mercury or their compounds, of anthrax or of compressed-air illness, contracted as a result of the nature of the patient's employment. These reports are to be made to the State board of health and are to give the name, address, and place and duration of employment of the patient and the nature of the disease from which, in the opinion of the physician, the patient is suffering. The State board of health is to transmit these reports to the commissioner of labor. 78 Failure on the part of a physician, to make these reports is made a misdemeanor punishable by a fine of not more than $5. It is made the duty of the commissioner of labor and the county attorneys to prose- cute violations of the law. (Act approved Apr. 25, 1911.) MINNESOTA . Physicians are to report all cases in which the patient is believed to be suffering from poisoning from lead, phosphorus, arsenic or mercury or their compounds, or from anthrax or compressed-air illness, contracted as a result of the nature of the patient's employment. The reports are to be made at once to the commissioner of labor and are to give the name, address, and place of employment of the patient, the nature of the disease ,_ and such other information as may be required by the commissioner of labor. Enforcement of the law is made the duty of the commissioner of labor, who may call upon the State and local boards of health for assistance. Failure on the part of a physician to make the required reports is made a misde- meanor, punishable by a fine of not more than |10 or by iniprisonment for not exceeding 10 days. (Act approved Feb. 25, 1913 j effective aiter July, 1913.) MISSOURI. Employees engaged in manufacture in which antimony, arsenic, brass, copper, lead, mercury, phosphorus, zinc, their alloys or salts or any poisonous chemicals, minerals, acids, fimies, vapors, gases or other substances are generated, used, or han- dled by employees in harmful quantities, or under harmful conditions, are required at least once a month to cause all employees coming into direct contact with the poisonotis agencies to be examined by a physician to ascertain whether there exists in the employees ajiy disease due or Incident to the character of the work in which the employees are engaged. The physicians making these exajninations are to make within 24 hours a report to the State hosxd of health in triplicate upon blanks f lu-nished by said board. If disease incident to occupation is found, the report is to state the name, address, and business of the employer, the nature of the disease, and its probable extent and duration, the name of the employee and his last place and length of em- ployment. Upon receipt of these reports the secretary of the State board of health is to send one copy to the State factory inspector and one copy to the superintendent of the fac- tory in which the employee is supposed to have contracted Ids ailment. The enforcement of the law is made the duty of the State factory inspector. Failure on the part of a physiciaia. to make the required reports is made a misde- meanor punishable by a fine of not less than $50. (Act approved Mar. 27, 1913; effective June 23, 1913.) NEW HAMPSHIRE. Physicians are to report all cases among their patients believed to be suffering from poisoning from lead, phosphorus, arsenic, brass, wood alcohol, or mercury or their compounds or from anthrax or compressed-air illness or any other ailment contracted as a result of the nature of the patient's employment. These reports are to be made to the State board of health within 48 hoiura and are to give the name, address, and occupation of the patient, the name, address, and business of the employer, the nature of the disease, and such other information as may be required by the State board of health. The State board of health is to prepare and issue blank forms on which the reports are to be made by physicians and is to transmit copies of reports received to the com- missioner of labor. Violations of the law on the part of physicians are made punishable by a fine of |5 for each offense. (Act approved May 7, 1913; effective July 1, 1913.) 79 NEW JERSEY. Physicians are to report all cases in which, the patients are believed to be suffering from poisoning from lead, phosphorus, arsenic, or mercury or their compounds, or from anthrax or compressed-air illness contracted as a result of the patient's employ- ment. The reports are to be made in writing to the State board of health within 30 days after the first visit and are to give the name, address, occupation, and place of employment of the patient, the name of the disease and such other information as may be required by the State board of health. The enforcement of the law is made the duty of the State board of health wliich is to transmit the data received in the reports of physicians to the commissioner of labor. Failure to report renders a physician liable to a fine of |25 for each offense. (Act approved Apr. 1, 1913.) NEW YORK. Medical practitioners are to report all cases in which the patients are believed to be suffering from poisoning from lead, phosphorus, arsenic, brass, wood alcohol, or mer- cury or their compounds, or from antlu'ax or compressed-air illness, contracted aa the result of the nature of the patient's employment. These reports ai-e to be made at once to the commissioner of labor and are to give the name, address, and place of employment of the patient, the name of the disease, and such other information aa may be reo^uired by the commissioner. The enforcement of the law is made the duty of the commissioner of labor who ia authorized to call upon the State and local boards of health for assistance. Failure to report renders a physician liable to a fine of not to exceed $10. (Act approved June 6, 1911; effective Sept. 1, 1911; amended by chap. 145; approved Mar. 28, 1913.) OHIO. The Ohio law enacted April 23, 1913, is the same as that of New Hampshire with the exception that there is no penalty for ^iolations, and the State board of health is to transmit copies of reports received to "the proper officials having charge of factory inspection" instead of to the "commissioner of labor" as in New Hampshire. A law enacted May 6, 1913, and effective October 1, 1913, requires employers to have all employees who are engaged in the manufacture of white lead, red lead, litharge, sugar of lead, arsenate of lead, lead chromate, lead sulphate, lead nitrate, or fluosilicate and are exposed to lead dusts, fumes, or solutions, examined at least once a month by a physician to ascertain whether there exist symptoms of lead poison- ing. If symptoms believed to be due to lead poisoning are found, the examining physician is to make within 48 hours a report in duplicate and send one copy to the State board of health and the other to the State department of factory inspection. The reports are to be upon or in conformity with blanks furnished for the purpose by the State board of health, and are to give the name, occupation, and address of the employee, the name, business, and address of the employer, the nature and probable extent of the disease, and such other information as may be required by the State board of health. The examining physician is also to report his findings within 48 hours to the employer. The law is to be enforced by the State department of factory inspection. PENNSYLVANIA. Employers are to cause all employees who are exposed to lead dusts, fumes, or solutions while engaged in the manufacture of lead, lead chromate, lead sulphate, lead nitrate, or fluosilicate to be examined by a physician at least once a month to 80 ascertain wlietlier symptoms of lead poisoning exist. Physicians making tliese exami- nations are to make a report in duplicate on or in conformity with forms furnished by the State department of health. These reports are to be sent within 48 hours, one copy to. the State department of health and one copy to the State department of labor and industry. The reports are to show the name, occupation, and address of the employee, the name, business, and address of the employer, the nature and probable extent of the disease, and such other information as may be required by the State department of health; the physician is also to report his findings witliin 48 hours to the employer. The enforcement of the law is made the duty of the State department of labor and industry. (Act approved July 26, 1913; effective Oct. 1, 1913.) WISCONSIN. Medical practitioners are to report all cases in wliich the patients are believed to be suffering from poisoning from lead, phosphorus, arsenic, or mercury, or their com- pounds, or from compressed-air illness, contracted as a result of the nature of the patient's employment. The reports are to be made to the secretary of the State board of health and are to give the name, address, and place of employment of the patient and the nature of the disease. The enforcement of the law is made the duty of the commissioner of labor and indus- trial statistics, who is authorized to call upon the State and local boards of health for assistance. Violation of the act on the jjart of physicians is made punishable by a fine of not more than §10. (Act approved June 2, 1911.) In the tables wliich follow an attempt has been made to show briefly in tabular form the essential requirements of the several State lav/s relating to the notification by physicians of cases of occupational and industrial diseases. It has not been possible in all instances to show the requirements accurately in this way. Occupational diseases required by State laws to he reported. Poisoning by- An- thrax. Com- pressed- air ill- ness. AR oc- cupa- tional dis- eases. Lead or its com- pounds. Phos- phorus or its com- poiuids. Arsenic or its com- pounds. Mer- ciu-y or its com- pounds. Brass. Wood alcohol. X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Ohio X X X X X 1 The Kansas requirements are by regulations adopted by the State board of health in December, 1913. 2 Authority is given to the State board of labor and the industrial accident board, sitting jointly, to pro- mulgate regulations requiring the reporting of occupational diseases. These had not been promulgated up to Dec. 1, 1913. 81 Occupational diseases. — Information to be given in reports by physicians. Of patient. Of employer. States. i 1 _o tl ft i o e ■ OS S.2 s p. §1 'S o O CO o .2 S 1 i -a < i .9 And such other infor- mal ion as may be required by— California X X X X X X X X X X X X "x" X X X X X X X X X X X X X X X Bm-eau of labor sta- tistics. Illinois X X X Kansas Maryland Maine. Do Massachusetts Michigan X X X X X X X X X X X X X Minnesota Missouri X X X X X X X bor. New Hampshire. . New Jersey X X X X X X X X X X X X X X X X X X X Do. New York Ohio X X X bor. State board of health. Pennsylvania Wisconsin . . State department of health. 55256°— 14- S ^ 2^ % 1 bJOO a 4) 03 a CO Is ID 2^ 61) S-. O s 3 o o 1 S 1^ o aA m 03 o C3 a c3 03 % ft £; CO o ft 3 0? 03 ft C3 A r^ a ffi "5 a c c 6 c fifl ^•3 § ' ~" S 0^§ 03 O a S^ Fh w y-1 >-ICv,-H CS c^ n — m c^ ooc^ _ ■ococ ^ ^5 o CI CI Cl 03 c 5- C3 oicn 5 C5 0- Ol d c; o~ o "" S -H r-l g3 CCCM 'J3 cc O coir ¥ 1-^ 7- cc X o^ cc cq . ft 03 a fe ^ ftS c3 a-3 CD C ■^ |<^S , O '^ A A^ !>! "3 c: ;'c a ■^ p a "m ^ CD A o T3 ■ i-i ■ a ft a a c "c a P a ■a a a a e2 O C ; o c 1 fta .2-3 >. 03 Q, c i| (3 0, A c:. 1 a 1 03 a^-2 1-1 S C^ : 3 o- P c 1:3 lg-^ m M ;^ K 5 C M u Vh t. -t-3 C o . o o -e o« e« S ft o 'C P c: A c o ^ :^seo «© e? fw ;- c I ;- ? [3 :- t- C3 a o *^5 > > ^ ■ > > S zn cr > > o +^ o c c c •aao >ia. £ c c p o o a >>-2 CD p o c c a. c ; c g^ o c CD a c a o a p p ; p o P a P P a (VJ (—1 fM s S s :S fin s Efi S S 5go C3 t>> c_ ■ c C o =V M S3 ,C3 ti-^ " O o d ; c^ % C3 o ft t^ O O"*^ O 03 ; c 1 ;- +J Sis c3 o d P u O S.2 "c a ■ p o .2 .9 3 3 r. .a '.I 1 .'& o o 1:5 o ti o ^ .^ ftS 5 2 a :£ ; c £ a "^ o 03 +j -fj +j 3+^ 0.3 IH ^ C3 M w O p m a pq O c i~ (- cr s .o > a > a O 1 A 03 c o o; o -S 1 ■a A A'^ -a aa o 00 C3 00 i C c _p _P 'a a P 22 g a c 6'^ « o o ^ i 4-3 1 % Ii ^ ■l , ~7 tH , ^ ■+■3 <-; ^w ^' ^ \a o s \ 2 c ID o ^ p ,Q +^ ^ o ft 1 c3 "3 1< C '.H ^ c3 [o "St; a^ C3 "3 S ,c " ,S ID (D A '■A "o c c 'D ^ X 2 H ^ ^1 o t^ m O o -a 03 o C3 o 3 c8 03 c Id is o3.S 03 6^ '-fe o > _P m 1 "c m 1 (D "i X 03 t. o >< > a o ^ p '3 cr P 3 c ?: & ^ •2 c c c 'S O) CD © 2 a O P M ^ 1^ ss S ii !? S !? O 1^ ^ 83 THE MODEL STATE LAW FOR THE REGISTRATION OF BIRTHS AND DEATHS. A Billi To provide for the registration of all births and deaths in the State of . Note.— After the bill has been prepared for presentation to the legislature of a State, the title should be carefully revised by competent legal authority. Be it enacted by the legislature of the State of Section 1. Tliat the State board of health shall have charge of the registration of births and deaths; shall prepare the necessary instructions, forms, and blanks for obtaini n g and preserAing siich records and shall procure the faithful registration of the same in each primary registration district as constituted in section 3 of this act, and in the central btireau of A-ital statistics at the capital of the State. The said board shall be charged with the uniform and thorough enforcement of the law throughout the State, and shall from time to time recommend any additional legislation ^ that may be necessary for this purpose. Sec. 2. That the secretary of the State board of health shall have general superAdsion over the central bureau of vital statistics, wliich is hereby authorized to be estab- lished by said board, and which shall be under the immediate direction of the State registrar of vital statistics, A^hom the State board of health shall appoint witliin thirty days after the taking effect of this law, and who shall be a medical practitioner of not less than five years' practice in his profession, and a competent vital statistician. The State registrar of vital statistics shall hold ofiice for four years and until his suc- cessor has been appointed and has qualified, unless such ofiice shall sooner become vacant by death, disqualification, operation of law, or other causes. Any vacancy occurring in such office shall be filled for the imexpired term by the State board of health. At least ten days before the expiration of the term of office of the State registrar of vital statistics, his successor shall be appointed by the State board of health. The State registrar of vital statistics shall receive an annual salary at the rate of — — ■ — dollars from the date of his entering upon the discharge of the duties of his ofiice. The State board of health shall provide for such clerical and other assistants as may be necessary for the purposes of this act, who shall serve during the pleasure of the board, and shall fix th-e compensation of persons thus employed within the amount appropriated therefor by the legislature. The custodian of the capitol shall provide for the bureau of idtal statistics in the State capitol at eiu table offices, which shall be properly equipped with fireproof vault and filing cases for the permanent and safe preservation of all official records made and returned under this act. Sec. 3. That for the purposes of this act the State shall be di\^ded into registration districts as follows: Each city, each incorporated town, and each townshij?^ shall constitute a primary registration district: Provided, That the State board of health may combine two or more primary registration districts when necessary to facilitate registration. Sec. 4. That within ninety days after the taking effect of this act, or as soon thereafter as possible, the State board of health shall appoint a local registrar of vital statistics 1 Before introducing this biil in any legislature it should be carefully redrafted by a competent law-yer and submitted to the Bureau of the Census for criticism. 2 The words "and shall promulgate any additional rules or regulations " may be inserted in bills prepared for States in which the State board of health has power to make rules and regxilations having the effect of law. ' Or other primary political unit, as "town," "precinct," "civil district," "hundred," etc. "When there are no such units available , the following substitutes for section 3 may be employed: Section 3. That for the purposes of this act the State shall be divided into registration districts as follows: Each city and each incorporated town shall constitute a primary registration district; and for that portion of each c-ounty outside of the cities and incorporated towns therein the State board of health shall define and designate the boundaries of a sufficient number of rural registration districts, which districts it may change or com- bine from time to time as may be necessary to insure the convenience and completeness of registration. 84 for each registration district in the State. ^ The term of office of each local registrar so appointed shall be four years, and until his successor has been appointed and has quali- fied, unless such office shall sooner become vacant by death, disqualification, opera- tion of law, or other causes: Provided, That in cities where health officei-s or other officials are, in the judgment of the State board of health, conducting effective regis- tration of births and deaths under local ordinances at the time of the taking effect of this act such officials may be appointed as registrars in and for such cities, and shall be subject to the rules and regulations of the State registrar and to all of the provisions of this act. Any vacancy occurring in the office of local registrar of vital statistics shall be filled for the unexphed term by the State board of health. At least ten days before the expiration of the term of office of any such local registrar his successor shall be appointed by the State board of health. Any local registrar who, in the judgment of the State board of health, fails or neg- lects to discharge efr.ciently the duties of his office as set forth in this act, or to make prompt and complete returns of bhths and deaths as requhed thereby, shall be forth- with removed by the State board of health, and such other penalties may be imposed as are provided under section 22 of this act. Each local registrar shall, immediately upon his acceptance of appointment as such, appoint a deputy, whose duty it shall be to act in his stead in case of his absence or disability; and such deputy shall in writing accept such appointment and be sub- ject to all rules and regulations governing local registrars. And when it appears necessary for the convenience of the people in any rural district the local registrar is hereby authorized, -sWth the approval of the State registrar, to appoint one or more suitable persons to act as subregistrars, who shall be authorized to receive certificates and to issue burial or removal permits in and for such portions of the district as may be designated; and each subregistrar shall note on each certificate, over his signature, the date of filing, and shall forv/ard all certificates to the local registrar of the district within ten days, and in all cases before the third day of the following month: Pro- vided, That each subregistrar shall be subject to the supervision and control of the State registrar and may be by him removed for neglect or failure to perform his duty in accordance with the provisions of this act or the rules and regulations of the State registrar, and shall be subject to the same penalties for neglect of duty as the local registrar. Sec. 5. That the body of any person whose death occurs in this State, or which shall be found dead therein, shall not be interred, deposited in a vault or tomb, cremated or otherwise disposed of, or removed from or into any registration district, or be temporarily held pending further disposition more than seventy-two hours after death, unless a permit for burial, removal, or other disposition thereof shall have been properly issued by the local registrar of the registration district in which the death occurred or the body was found. ^ And no such burial or removal permit shall be issued by any registrar until, wherever practicable, a complete and satisfactory certificate of death has been filed with him as hereinafter provided: Provided, That when a dead body is transported from outside the State into a registration district in — • for burial, the transit or removal permit, issued in accordance with the law and health regulations of the place where the death occurred, shall be accepted by the local registrar of the district into which the body has been transported for burial or other disposition, as a basis upon which he may issue a local burial permit; he shall note upon the face of the burial permit the fact that it was a body shipped in for 1 This method of appointment of local registrars by the State board of health— or perhaps by the State registrar or upon his nomination— with a reasonably long term of service and subject to removal for neglect of duty, is the preferable one for efhcient service. Should there be objection, however, to the creation of new offices, the section may be redrafted so that it will provide that township, village, or city clerks, or other suitable officials, shall be the local registrars. 2 A special proviso may be required for sparsely settled portions of a State. 85 interment, and give the actual place of death; and no local registrar shall receive any fee for the issuance of burial or removal permits under this act other than the com- pensation provided in section 20. Sec. 6. That a stillborn child shall be registered as a birth and also as a death, and separate certificates of both the birth and the death shall be filed with the local regis- trar, in the usual form and manner, the certificate of birth to contain in place of the name of the child, the word "stillbirth": Provided, That a certificate of birth and a certificate of death shall not be required for a child that has not advanced to the fifth month of uterogestation. The medical certificate of the cause of death shall be signed by the attending physician, if any, and shall state the cause of death as "stillborn," with the cause of the stillbirth, if known, whether a premature birth, and, if born prematurely, the period of uterogestation, in months, if known; and a burial or removal permit of the prescribed form shall be required. Midwives shall not sign certificates of death for stillborn children; but such cases, and stillbirths occurring without attendance of either physician or midwife, shall be treated as deaths without medical attendance, as provided for in section 8 of this act. Sec. 7. That the certificate of death shall contain the following items, which are hereby declared necessary for the legal, social, and sanitary purposes subserved by registration records: ^ (1) Place of death, including State, county, township, village, or city. If in a city, the ward, street, and house number; if in a hospital or other institution, the name of the same to be given instead of the street and house number. If in an industrial camp, the name of the camp to be given. (2) Full name of decedent. If an unnamed child, the surname preceded by "Unnamed." (3) Sex. (4) Color or race, as white, black, mulatto (or other negro descent), Indian, Chinese, Japanese, or other. (5) Conjugal condition, as single, married, widowed, or divorced. (6) Date of birth, including the year, month, and day. (7) Age, in yea.rs, months, and days. If less than one day, the hours or minutes. (8) Occupation. The occupation to be reported of any person, male or female, who had any remunerative employment, with the statement of (a) trade, profession or particular kind of work; (&) general nature of industry, business^ or establishment in which employed (or employer). (9) Birthplace; atleast State or foreign country, if known. (10) Name of father. (11) Birthplace of father; at least State or foreign countrj^, if known. (12) Maiden name of mother. (13) Birthplace of mother; at least State or foreign country, if known. (14) Signature and address of informant. (15) Official signature of registrar, with the date when certificate was filed, and registered number. (16) Date of death, year, month, and day. (17) Certification as to medical attendance on decedent, fact and time of death, time last seen alive, and the cause of death, with contributory (secondary) cause of compli- cation, if any, and duration of each, and whether attributed to dangerous or insanitary conditions of employment; signature and address of physician or official making the medical certificate. (18) Length of residence (for inmates of hospitals and other institutions; transients or recent residents) at place of death and in the State, together with the place where disease was contracted, if not at place of death, and former or usual residence. 1 The following items are those of the United States standard certificate of death, approved by the Bureau of the Census. 86 (19) Place of burial or removal; date of burial. (20) Signature and address of undertaker or person acting as such. The personal and statistical particulars (items 1 to 13) shall be authenticated by the signature of the informant, who may be any competent person acquainted with the facts. The statement of facts relating to the disposition of the body shall be signed by the undertaker or person acting as such. The medical certificate shall be made and signed by the physician, if any, last in attendance on the deceased, who shall specify the time in attendance, the time he last saw the deceased alive, and the hour of the day at which death occurred. And he shall further state the cause of death, so as to show the course of disease or sequence of causes resulting in the death, giving first the name of the disease causing death (primary cause), and the contributory (secondary) cause, if any, and the duration of each. Indefinite and unsatisfactory terms, denoting only symptoms of disease or conditions resulting from disease, will not be held sufficient for the issuance of a burial or removal permit; and any certificate containing only such terms as defined by the State Kegistrar shall be returned to the physician or person making the medical certificate for correction and more definite statement. Causes of death which may be the result of either disease or violence shall be carefully defined; and if from violence, the means of injury shall be stated and whether (probably) accidental, suicidal, or homicidal.^ And for deaths in hospitals, institutions, or of nonresidents the physician shall supply the information required under this head (item 18), if he is able to do so, and may statd*where, in his opinion, the disease was contracted. Sec. 8. That in case of any death occurring without medical attendance it shall be the duty of the undertaker to notify the local registrar of such death, and when so notified the registrar shall, prior to the issuance of the permit, inform the local health officer and refer the case to him for immediate investigation and certification: Pro- vided, That when the local health officer is not a physician, or when there is no such official, and in such cases only, the registrar is authorized to make the certificate and return from the statement of relatives or other persons having adequate knowledge of the facts: Provided further , That if the registrar has reason to believe that the death may have been due to unlawful act or neglect he shall then refer the case to the coroner or other proper officer for his investigation and certification. And the coroner or other proper officer whose duty it is to hold an inquest on tlie body of any deceased person and to make the certificate of death required for a burial permit shall state in his certificate the name of the disease causing death, or if from external causes, (1) the means of death and (2) whether (probably) accidental, suicidal, or homicidal, and shall in any case furnish such information as may be required by the State Registrar in order properly to classify the death. Sec. 9. That the undertaker or person acting as imdertaker shall file the certificate of death with the local registrar of the district in which the death occurred and obtam a burial or removal permit prior to any disposition of the body. He shall obtain the required personal and statistical particulars from the person best qualified to supply them, over the signatiu-e and address of his informant. He shall then present the certificate to the attending physician, if any, or to the health officer or coroner, as directed by the local registrar, for the medical certificate of the cause of death and other particulars necessary to complete the record, as specified in sections 7 and 8. And he shall then state the facts required relative to the date aud place of burial or removal, over his signature aud with his address, and present the completed certificate to the local registrar in order to obtain a permit for burial, removal, or other disposition of the body. The undertaker shall deliver the burial permit to the person in charge 1 In some States the question whether a death was accidental, suicidal, or homicidal must be determined by the coroner or medical examiner, and the registration law must be framed to hai-mouize. 87 of the place of bui-ial before interring or otherwise disposing of the body, or shall attach the removal permit to the box containing the corpse, when shipped by any transportation company, said permit to accompany the corpse to its destination, where, if within the State of , it shall be deli^^ered to the person in charge of the place of burial. [Every person, fii'm, or corporation selling a casket shall keep a record showing the name of the pmxhaser, j^urchaser's post-office address, name of deceased, date of death, and place of death of deceased, which record shall be open to inspection of the State Registrar at all times. Oa the fii'st day of each month the pei'sou, firm, or corpo- ration selling caskets shall report to the State Registrar each sale for the precediog month, on a blank provided for that piu'pose: Provided, however, That no person, firm, or corporation selling caskets to dealers or undertakers only shall be required to keep such record, nor shall such report be required from undertakers when they have direct charge of the disposition of a dead body. E\ery person, fii-m, or corporation selling a casket at retail, and not having charge of the disposition of the body, shall inclose within the casket a notice furnished by the State Registrar calling attention to the requirements of the law, a blank certificate of death, and the rules and regidations of the State board of health concerning the bmial or other disi>osition of a dead body.]^ Sec. 10. That if the interment or other disposition of the body is to be made within the State, the wording of the burial or removal permit may be limited to a statement by the registrar, and over hie signature, that a satisfactory certificate of death having been filed with him, as required by law, permission is granted to inter, remove, or dispose otherwise of the body, stating the name, age, sex, cause of death, and other necessary details upon the form prescribed by the State registrar. Sec. 11. That no person in charge of any premises on which interments are made shall inter or permit the interment or other disposition of any body unless it is accom- panied by a burial, removal, or transit permit, as herein provided. And such peraon shall indorse upon the permit the date of interment, over his signature, and shall return all permits so indorsed to the local registrar of his district within ten days from the date of interment, or within the time fixed by the local board of health. He shall keep a record of all bodies interred or otherwise disposed of on the premises under his charge, in each case stating the name of each deceased person, place of death, date of burial or disposal, and name and address of the undertaker; which record shall at all times be open to official inspection: Provided, That the undertaker, or per- son acting as such, when burying a body in a cemetery or burial ground having no person in cliarge, shall sign the burial or removal permit, giving the date of bm-ial, and shall write across the face of the permit tire words "No person in charge," and file the burial or removal permit within ten days with the registrar of the district in which the cemetery is located. Sec. 12. That the birth of each and every child born in this State shall be registered as hereinafter provided. Sec 13. That within ten days after the date of each bu-th there shall be filed with the local registrar of the district in which the birth occurred a certificate of such bii'th, which certificate shall be upon the form adopted by the State board of health with a view to procuring a full and accurate report with respect to each item of information enumerated in section 14 of this act.^ In each case where a physician, midwife, or person acting as midwife was in attend- ance upon the birth, it shall be the duty of such physician, midwife, or person acting as midwife to file in accordance herewith the certificate herein contemplated. 1 The provisions in brackets may be useful in States in ^vhich many funerals are conducted without regular undertakers. 2 A proviso may be added that shall require the registration, or notification, at a shorter interval than ten days, of births that occur in cities. m each case v^liere there was no physician, midwife, or person acting as midwife in attendance njDon the birth, it shall be the duty of the father or mother of the child, the householder or owner of the premises where the birth occurred, or the manager or superintendent of the public or private institution where the birth occurred, each in the order named, within ten days after the date of such bhth, to report to the local registrar the fact of such birth. In such case and in case the physician, midwife, or person acting as midwife, in attendance upon the birth is unable, by diligent inquiry, to obtain any item or items of information contemplated in section 14 of this act, it shall then be the duty of the local registrar to secure from the person so reporting, or from any other person having the required knowledge, such information as will enable h-im to prepare the certificate of birth herein contemplated, and it shall be the duty of the person reporting the birth, or who may be interrogated in relation thereto, to answer correctly and to the best of his knowledge all questions put to him by the local registrar which may be calculated to elicit any information needed to make a complete record of the birth as contemplated by said section 14, and it shall be the duty of the informant as to any statement made in accordance herewith to verify such statement by his signature, when requested so to do by the local registrar. Sec. 14. That the certificate of birth shall contain the following items, which are hereby declared necessary for the legal, social, and sanitary purposes subserved by registration records: ^ (1) Place of birth, including State, county, township or town, village, or city. If in a city, the ward, street, and house number; if in a hospital or other institution, the name of the same to be given, instead of the street and house number. (2) Full name of child. If the child dies without a name, before the certificate is filed, enter the words "Died unnamed." If the living child has not yet been named at the date of filing certificate of birth, the space for " Full name of child " is to be left blank, to be filled out subsequently by a supplemental report, as hereinafter provided. (3) Sex of child. (4) Y/hether a twin, triplet, or other plural birth. A separate certificate shall be required for each child in case of plural births. (5) For phu'al bii'ths, number of each child in order of birth. (6) Whether legitimate or ilegitimate.^ (7) Date of birth, including the year, month, and day. (8) Full name of father. (9) Eesidence of father. ' . (10) Color or race of father. (11) Age of father at last birthday, in years. (12) Birthplace of father; at least State or foreign country, if known. (13) Occupation of father. The occupation to be reported if engaged in any remun- erative employment, with the statement of («) trade, profession, or particular kind of work; (b) general nature of industry, business, or establishment in which employed (or employer). (14) Maiden name of mother. (15) Residence of mother. (16) Color or race of mother. (17) Age of mother at last birthday, in years. (18) Birthplace of mother; at least State or foreign country, if known. (19) Occupation of mother. The occupation to be reported if engaged in any remunerative employment, with the statement of (a) trade, profession, or particular kind of work; (b) general nature of industry, business, or establishment in which employed (or employer). 1 The following items are those of the United States standard certificate of birth, approved by the Bureau of the Census. 2 This qu:Etion may be omitted if desired, or provision may be made so that the identity of parents will not be disclosed. 89 (20) Number of children born to this mother, including present birth. (21) Number of children of this mother living. (22) The certification of attending phj^sician or midwife as to attendance at birth, including statement of year, month, day (as given in item 7), and hour of birth, and whether the child was born alive or stillborn. This certification shall be signed by the attending physician or midwife, with date of signature and address; if there is not physician or midwife in attendance, then by the father or mother of the child, house- holder, owner of the premises, or manager or superintendent of public or private institution where the birth occurred, or other competent person, whose duty it shall be to notify the local registrar of such bh'th, as required by section 13 of this act. (23) Exact date of filing in office of local registrar, attested by his official signature, and registered number of birth, as hereinafter provided. Sec. 15. That when any certificate of birth of a living child is presented without the statement of the given name, then the local registrar shall make out and deliver to the parents of the child a special blank for the supplemental report of the given name of the child, which shall be filled out as directed, and returned to the local registrar as soon as the child shall have been named. Sec. 16. That every physician, midwife, and undertaker shall, without delay, register his or her name, address, and occupation with the local registrar of the district in which he or she resides, or may hereafter establish a residence; and shall thereupon be supplied by the local registrar with a copy of this act, together with such rules and regulations as may be prepared by the State registrar relative to its enforcement. Within thirty days after the close of each calendar year each local registrar shall make a return to the State registrar of all physicians, midAvives, or xmdertakers who have been registered in his district during the whole or any part of the preceding calendar year: Provided, That no fee or other compensation shall be charged by local registrars to physicians, midwives, or undertakers for registering their names under this section or making returns thereof to the State registrar. ^ Sec. 17. That all superintendents or managers, or other persons m charge of hospitals, almshouses, lying-in, or other institutions, public or private, to which persons resort for treatment of diseases, confinement, or are committed by process of law, shall make a record of all the personal and statistical jjarticulars relative to the inmates in their institutions at the date of approval of this act, which are requned in the forms of the certificates jsrovided for by this act, as dnected by the State registrar; and thereafter such record shall be, by them, made for all future inmates at the time of their admit- tance. And in case of persons admitted or committed for treatment of disease, the physician in charge shall specify for entry in the record, the nature of the disease, and where, in his opinion, it was contracted. The personal particulars and information required by this section shall be obtained from the individual himself if it is practicable to do so; and when they can not be so obtained, they shall be obtained in as complete a manner as possible from relatives, friends, or other persons acquainted with the facts. Sec. 18. That the State registrar shall prepare, print, and supply to all registrars all blanks and forms Used in registering, recording, and preserving the returns, or in otherwise carrjdng out the purposes of this act; and shall prepare and issue such detailed instructions as may be required to procure the uniform observance of its pro- visions and the maintenance of a perfect system of registration; and no other blanks shall be used than those supplied by the State registrar. He shall carefully examine the certificates received monthly from the local registrars, and if any such are incom- plete or unsatisfactory he shall require such further information to be supplied as may be necessary to make the record complete and satisfactory. And all physicians, mid- wives, informants, or undertakers, and all other persons having knowledge of the facts, are hereby required to supply, upon a form provided by the State registrar or upon 1 This section may be omitted if deemed .expedient and the duty of supplying instructions may be assumed by the State officer. 90 the original certificate, such, information as they may possess regarding any birth or death upon demand of tlie State registrar, in person, by mail, or through the local registrar : Provided, That no certificate of birth or death, after its acceptance for regis- tration by the local registrar, and no other record made in pursuance of this act, shall be altered or changed in any respect otherwise than by amendments properly dated, signed, and witnessed. The State registrar shall further arrange, bind, and perma- nently preserve the certificates in a systematic manner, and shall prepare and maintain a comprehensive and continuous card index of all births and deaths registered ; said index to be arranged alphabetically, in the case of deatlrs, by the names of decedents, and in the case of births, by the names of fathers and mothers. He shall inform all registrars what diseases are to be considered infectious, contagious, or communicable and dangerous to the public health, as decided by the State board of health, in order that when deaths occur from such diseases proper precautions may be taken to prevent their spread. If any cemetery company or association, or any church or historical society or asso- ciation, or any other company, society, or association, or any individual, is in posses- sion of any record of births or deaths which may be of value in establishing the geneal- ogy of any resident of this State, such company, society, association, or individual may file such record or a duly authenticated transcript thereof with the State regis- trar, ajid it shall be the duty of the State registrar to preserve such record or transcript and to make a record and index thereof in such form as to facilitate the finding of any information contained therein. Such record and index shall be open to inspection by the public, subject to such reasonable conditions as the State registrar may pre- scribe. If any person desires a transcript of any record filed in accordance herewith, the State registrar shall fnrnish the same upon application, together with a certificate that it is a true copy of such record, as filed in his office, and for his services in so furnishing such transcript and certificate he shall be entitled to a fee of (ten cents per folio) (fifty cents per hour or fraction of an hour necessarily consumed in making such transcript) and to a fee of twenty -five cents for the certificate, which fees shall be paid by the applicant. Sec. 19. That each local registrar shall supply blank forms of certificates to such persons as requii-e them. Each local registrar shall carefully examine each certificate of birth or death when presented for record in order to ascertain whether or not it has been made out in accordance with the provisions of this act and the instructions of the State registrar; and if any certificate of death is incomplete or unsatisfactory, it shall be his duty to call attention to the defects in the return, and to withhold the burial or removal permit tmtil such defects are corrected. All certificates, either of birth or of death, shall be written legibly, in durable black ink, and no certificate shall be held to be complete and correct that does not supply all of the items of infor- mation called for therein, or satisfactorily account for their omission. If the certificate of death is properly executed and complete, he shall then issue a burial or removal permit to the undertaker; pro-\dded, that in case the death occurred from some disease which is held by the State board of health to be infectious, contagious, or communi- cable and dangerous to the public health, no permit for the removal or other dis- position of the body shall be issued by the registrar, except under such conditions aa may be prescribed by the State board of health. If a certificate of bnth is incomplete, the local registrar shall inmiediately notify the informant and require him to supply the missing items of information if they can be obtained. He shall number consecu- tively the certificates of birth and death, in two separate series, beginning with number 1 for the first bnth a/nd the first death in each calendar year, and sign hia name as registrar in attest of the date of filing in his office. He shall also make a complete and accurate copy of each birth and each death certificate registered by him in a record book supplied by the State registrar, to be preserved permanently in his office as the local record, in such manner as directed by the State registrar. And he shall, on the 91 tenth day of each month, transmit to the State registrar all original certificates regis- tered by him for the preceding month. And if no births or no deaths occurred in any month, he shall, on the tenth day of the following month, report that fact to the State registrar, on a card provided for such purpose. Sec. 20. That each local registrar shall be paid the sum of twenty-five cents for each birth certificate and each death certificate properly and completely made out and registered with him, and correctly recorded and promptly returned by him to the State registrar, as required by this act.^ And in case no births or no deaths were registered dm'ing any month, the local registrar shall be entitled to be paid the sum of twenty-five cents for each report to that effect, but only if such report be made promptly as requhed by this act. All amounts payable to a local registrar under the provisions of this section shall be paid by the treasm'er of the county in which the registration district is located, upon certification by the State registrar. And the State registrar shall annually certify to the treasurers of the several counties the num- ber of births and deaths properly registered, with the names of the local registrars and the amounts due each at the rates fixed herein.^ Sec. 21. That the State registrar shall, upon request, supply to any applicant a certified copy of the record of any birth or death registered under provisions of this act, for the making and certification of which he shall be entitled to a fee of fifty cents, to be paid by the applicant. And any such copy of the record of a bii'th or death, when properly certified by the State registrar, shall be prima facie evidence in all com'ts and places of the facts therein stated. For any search of the files and records when no certified copy is made, the State registrar shall be entitled to a fee of fifty cents for each hour or fractional part of an horn" of time of search, said fee to be paid by the applicant. And the State registrar shall keep a true and correct account of all fees by him received under these provisions, and tm-n the same over to the State treasurer: Provided, That the State registrar shall, upon request of any parent or guardian, supply, without fee, a certificate limited to a statement as to the date of birth of any child when the same shall be necessary for admission to school, or for the puj-pose of seeming employment: And provided further, That the United States Census Bureau may obtain, without expense to the State, transcripts, or certified copies of births and deaths without payment of the fees herein prescribed. Sec. 22. That any person, who for himself or as an officer, agent, or employee of any other person, or of any corporation or partnership (o) shall inter, cremate, or otherwise finally dispose of the dead body of a human being, or permit the same to be done, or shall remove said body from the primary registration district in which the death occurred or the body was found without the authority of a burial or removal permit issued by the local registrar of the district in which the death occurred or in which the body was found; or (h) shall refuse or fail to furnish con-ectly any infonnation in his possession, or shall furnish false information affecting any certificate or record, required by this act; or (c) shall willfully alter, otherwise than is provided by section 18 of this act, or shall falsify any certificate of birth or death, or any record established by this act; or {d) being required by this act to fill out a certificate of birth or death and file the same with the local registrar, or deliver it, upon request, to any person charged with the duty of filling the same, shall fail, neglect, or refuse to perform such duty in the manner required by this act; or (e) being a local registrar, deputy registrar, or subregistrar, shall fail, neglect, or refuse to perform his duty as required by this act and by the instructions and direction of the State registrar thereunder, shall be deemed guilty of a misdemeanor, and upon conviction thereof shall for the first offense be fined not less than five dollars ($5) nor more than fifty dollars ($50), and for each 1 A proviso may be inserted at this point relative to fees of city registrars wiio are already compensated by salary for their services. .See laws of Missouri, Ohio, and Pennsylvania. 2 Provision may be made in this section for the payment of subregistrars and also, if desired, for the payment of physicians and midwives. See Kentucky law. 92 subsequent offense not less than ten dollars ($10) nor more than one hundred dollars ($100), or be imprisoned in the county jail not more than sixty days, or be both fined and imprisoned in the discretion of the court. ^ Sec. 23. That each local registrar is hereby charged with the strict and thorough enforcement of the provisions of this act in his registration district, under the super- vision and direction of the State registrar. And he shall make an immediate report to the State registrar of any violation of this law coming to his knowledge, by observa- tion or upon complaint of any person or otherwise. The State registrar is hereby charged with the thorough and efficient execution of the provisions of this act in every part of the State, and is hereby granted euj^er- visory power over local registrars, deputy local registrars, and subregistrars to the end that all of its requirements shall be uniformly complied v>dth. The State regis- trar, either personally or by an accredited representative, shall have authority to investigate cases of irregularity or violation of law, and all registrars shall aid him, upon request, in such investigations. When he shall deem it necessary he shall report cases of violation of any of the provisions of this act to the prosecuting attorney of the county, with a statement of the facts and cii-cumstances; and when any such case is reported to him by the State registrar the prosecuting attorney shall forthwith initiate and promptly follow up the necessary court proceedings against the person or corporation responsible for the alleged violation of law. And upon request of the State registrar, the attorney general shall assist in the enforcement of the pro- visions of this act. Note. — Other sections should be added giving the date on which th? act is to child in one that m^ithf-r- 7>r&atlt^a nor shovKS I other evidence of life after birth, ) Uiven name added from a supplemental Address- report ,19 (Physician or Midwife) SUPPLEMENTAL REPORT OF BIRTH (STATE) (This retnrn Bboold preferably be taodo by Ihc ptreon Registered Number* Place ofbirfh* .„.,. A'o, -' (Begietration district) SEX OF CHILD" FULL* MAIDEt NAME Number • of birth (Pay) (Y«-ar) i out lUb form -St I HEREBr CERTIFY that the child described herein has been named: (Given nmnc. in full) (tunmmc) (Signature) - - - tPkyaklan ur midwifcj 94 United States Standard Certificate of Death. 2 u B IS Q |« Z u l"*. a a K £ (» *3 ti. s Qt ^^ BgO u R •S > o^d S 3^ (II ■s ^Et: u ^-S !£ a X S ir aSo < X •§«£ 1 PLACE" OF DEATH County — -' — Township -■ Department of commercs STANDARD CERTIFICATE OF DEATH Stale of - - - -- -- 8FIJLL NAME DMRL ano STriTSSTiCAL paRTICOLARS 1 COLOR OR f 'DATE OF BtF If LESS tha particular kind of work (b) General nature of industry, bua'nessi or establishment iti 9 BIRTHPLACE 'IFBCn7£ OF DEATH l OF DEATH , 191. 14 THE ABOVE IS TRUE TO THE I (Informant) (Address)..- Filed . 191 L7 i HEREBY CERTIFY, That i attended deceased from _-, 191 — , to , \9\ — , that Mast saw h alive on , i91..-, and that death occurredi on the date stated above, at —m, The CAUSE OF DEATH* was as follows: _ (Duratlor)., yrj. „_ mo:; dj. Contributory - - «- „ (Duration) _ yrs. mas (ffc (Slsr.ed)- .- — - .H. D. ......191 — . (AddresO- (1) 1 1 C^) V '■SLEHOTH OF RESIDENCE (FOR HOSPITALS, |" OR necE?i7 Resioekts) At placo In tha _d3. State yn. Whore was disease contracted, Ifnotatplaceofdeatfi? 19 PLACE OF BURIAL OR REMOVAL DATE OF BURIAL OUNOERTAKER ADDITIONAL COPIES OF THIS PUBLICATION MAY BE PROCURED FROM THE SUPERINTENDENT OF DOCUMENTS GOVERNMENT PRINTING OFFICE WASHINGTON, D. C. AT 10 CENTS PER COPY