The Registration of Vital 
 Statistics and Good 
 Business 
 
 An Address Delivered before the Annual Conference of 
 Health Officers of the State of Indiana 
 Indianapolis, May 13, 1913 
 
 BY 
 
 LOUIS I. DUBLIN, Ph.D., Statistician 
 
 Metropolitan Life Insurance Company, New York 
 1913 
 
Digitized by the Internet Archive 
 in 2017 with funding from 
 
 University of Illinois Urbana-Champaign Alternates 
 
 https://archive.org/details/registrationofvi00dubl_0 
 
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 THE REGISTRATION OF VITAL STATISTICS 
 AND GOOD BUSINESS.* 
 
 It is a most auspicious occasion that brings together the health 
 officers and representative business and professional men of the 
 State of Indiana to discuss health affairs. The subject of public 
 health is no longer looked upon as exclusively within the province 
 of the medical profession. This is a promising sign of the 
 changing attitude of communities to what concerns them most 
 vitally. Progressive health officers themselves recognize that 
 their work is communal in character and that the success of their 
 endeavors will depend largely upon the co-operation which they 
 receive from the public at large, and, more especially, from the 
 leaders of public opinion who determine the expenditure of public 
 funds. 
 
 The medical men present will pardon my audacity if I still 
 further indicate that the intrusion of lay minds and lay points 
 of view is contributing very essential stimuli to the development 
 of modern medicine. The contributions of the engineer, the 
 educator, the statistician and the statesman to the field of pre¬ 
 ventive medicine have been of the greatest value. They have 
 helped to extend the interest of medical science from the con¬ 
 sideration of individual cases to the solution of broader communal 
 problems. This process has, indeed, been carried to such a point 
 that at a recent discussion by health officers it was seriously 
 urged that much would be gained in the advancement of public 
 health through the appointment of qualified non-medical officers 
 for the enforcement and interpretation of sanitary regulations. 
 This is not a proper occasion for the discussion of this question, 
 but I refer to it only to indicate how appropriate it is for those 
 who represent the other professions and activities in your com¬ 
 munities to get together with the health authorities to-night to 
 consider with them the many matters that vitally concern you. 
 
 *An address delivered at the public meeting of the Annual Conference of Health Officers of 
 the State of Indiana, Indianapolis, May 13. 1913. 
 
 3 
 
The subject which your able State Secretary, Dr. Hurty, has 
 suggested for my paper is “The Registration of Vital Statistics 
 and Good Business.” In the very title there is the implication 
 that this phase of health administration is closely related to busi¬ 
 ness affairs and can be tested by the same standards that are used 
 daily to determine the value or lack of value of other industrial 
 activities. 
 
 Statistics, in brief, is a system of accounting. The executive 
 in industry and finance requires for the efficient administration 
 of his business detailed analyses of the cost of production and 
 distribution. Aside from the assistance which such statistics 
 give him in the determination of a selling price for the product, they 
 furnish him above all with a convenient method for checking 
 the efficiency of his plant management. Cost accounting requires 
 that each unit of raw material shall be traced through the factory 
 in such manner that the value which every process adds to 
 it is recorded. Through these accounts, the executive learns 
 whether it is profitable to substitute machines for hand labor. 
 He is also enabled to detect ill-advised applications of labor 
 and wastefulness in the manipulation of materials. Such evils, 
 unless immediately discovered, lead to inefficiency and the sub¬ 
 sequent disorganization of an otherwise well-conducted enterprise. 
 
 The health officer of the community has a problem similar 
 to that of the business manager in industry. He, too, must test 
 the efficiency of his management. His raw materials are the 
 human beings of his district. He must be able to trace the path 
 of these individuals through life, from the date of their birth, 
 through the years of their childhood to their maturity and marriage, 
 until finally death terminates their record in the community’s 
 book of accounts. He must check up his methods of procedure 
 in combating disease and must be in a position to determine 
 whether the forces which he has applied are productive of results. 
 He also should be immediately apprised of any new perils to the 
 public health which may arise. If his administration is one of 
 mere routine, handling details only, without inspiration and the 
 force of directive ideas, then his community is on the road to 
 civic inefficiency with all the disorganization that this implies. 
 
 It is the function of the vital statistician to provide the neces¬ 
 sary data to the health officer for the settlement of these questions. 
 He must know from year to year the composition and characteris¬ 
 tics of the population. He must also have available an accurate 
 
 4 
 
record of the number of additions to the population by births and 
 immigration, and of the number of deaths, marriages and divorces. 
 Finally, he must know the number, location and intensity of 
 the incidences of transmissible disease. Such, in brief, is the sub¬ 
 ject matter of vital statistics. 
 
 Let us now consider the intimate aspects of each of these 
 subordinate fields of vital statistics. 
 
 Composition and Characteristics of the Population. 
 
 Knowledge of the composition and characteristics of the 
 population is fundamental for the vital statistician. It is to 
 him what an inventory is to the industrial engineer. He must 
 have at his disposal an enumeration by age, sex, race, nationality 
 and marital condition and by such other characteristics as are 
 indicated by the peculiar conditions prevailing in his community. 
 The age distribution, for example, is vital to any intelligent 
 consideration of the death rate. Newer communities where the 
 proportion of infants is small often show a lower death rate than 
 others with better health standards where the distribution of the 
 component parts is more nearly normal. The distribution by 
 sex is indicative of the extent to which a community is settled 
 in its social and moral standards. Recently settled communities 
 show a marked excess of males; it is only when the female element 
 has attained its normal proportion that there come into evi¬ 
 dence those characteristics of social and moral stability which are 
 attributes of modern civilization. The race factor is important in 
 determining the educational program of a community as well as 
 in testing the prevailing mortality conditions. The nationalities 
 composing a community outline the problem confronting social 
 and philanthropic agencies whose work it is to help assimilate the 
 alien and to adjust his condition harmoniously to the rest of the 
 community. Information of this character, renewed every five 
 years, should be of incalculable value in determining conditions of 
 community life, and should serve as an index of progress or 
 retrogression. 
 
 Births. 
 
 Births are the primary items of population income. They 
 are interesting as to their actual number, an excess of births over 
 deaths constituting the natural increment of population. From 
 the number of births we derive birth rates, or the ratio between 
 
 5 
 
 4 
 
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 the number of births and the number of persons living. Nothing 
 reflects better the vitality of a community than its birth rate. 
 The associated factors of legitimacy, nationality and social position 
 of parents throw light on the problem of national fecundity and 
 indicate from which sources our population is being derived. 
 
 No phase of social hygiene has recently received more attention 
 than the conservation of infant life. The movement has received 
 great impetus since the establishment of the Children’s Bureau 
 in Washington under the direction of Miss Julia C. Lathrop. 
 This organization has defined its first problem to be the determina¬ 
 tion of the birth and death rates of infants, but in this work it is 
 hampered by the fact that in only eight States of the country 
 are records kept with sufficient accuracy to justify any conclusions. 
 Thousands of children are born annually in our country and are 
 neither recorded at the time of their birth nor at their death, 
 which in more than one-fifth of the cases occurs during their 
 first year of life. 
 
 Legal considerations of the highest importance enter into 
 the registration of births. Communities are waking up to their 
 obligations to restrict child labor. Without adequate regis¬ 
 tration of births such regulation is hampered and the law often 
 nullified in its effect. In this way, many children are deprived of 
 education and are permitted to waste their limited energies in 
 industrial pursuits, later to become the subjects of community 
 relief. The transactions of life insurance companies frequently 
 call for the legal proof of true age. Since the differences in pre¬ 
 mium charges vary with the age, it will be seen that the factor 
 of age is essential to the determination of the amount of benefit 
 which is to be paid at death. A case in point from the experience 
 of the Metropolitan Life will be of interest. There is now in suit 
 a case where the insured’s age, according to the policy, was fifty 
 years at the time of death; according to the health department 
 register, the true age at death was seventy-two. In this case, 
 if the transcript of the birth certificate could have been secured, 
 it would very quickly have settled the question as to the true 
 age at death. The insured was born in a foreign country, however, 
 which had no better facilities for the registration of births than 
 many States in our Union now have. 
 
 A case nearer home will also be of interest. A boy of thirteen, 
 residing in Indiana, was insured with us in 1904 under one name, 
 and his mother was designated as beneficiary under the policy. In 
 
 6 
 
March, 1913, he advised us that he had been insured under a 
 wrong name, and that the relationship of the beneficiary as given 
 was incorrect. In proof of the contention made we desired a 
 certified copy of the birth record of the boy to establish his 
 identity, but we were informed that no official birth record could 
 be obtained, although the names in the case represented old and 
 well-known families in the county. It would appear, therefore, 
 that in this State the records of births were not kept with any 
 degree of accuracy as recently as the year 1892. Some countries 
 are more fortunate. Great Britain, Germany, France, Italy and 
 Sweden have had a compulsory system of birth registration for 
 many years. From these countries records of birth are obtained 
 with the least expenditure of time and effort. 
 
 The establishment of personal identity often depends upon 
 the validity of a birth record. Litigation in matters of property 
 inheritance, the settlement of estates and the disposition of trusts, 
 can in many instances be avoided when accurate birth records are 
 at hand. Special problems in the morbid aspects of social life, such 
 as the age of consent, the gravity of the offense in criminal cases, 
 etc., depend upon efficient birth registration. Nor can we say 
 just what social readjustments are necessary in dealing with the 
 acute problem of illegitimacy, because we lack utterly information 
 upon w T hich to base an intelligent analysis of the situation. 
 
 Marriages. 
 
 The statistics of marriage are in close connection with birth 
 statistics. Data of this nature are of value to investigators of 
 community welfare. The marriage rate is in the nature of a 
 barometer of a nation’s prosperity. In countries where accurate 
 marriage statistics have been kept the records show that periods 
 of commercial prosperity have been marked with consistently high 
 marriage rates, and those of depression with low rates. The 
 physical and mental condition of the parties to marriages is also 
 of vital importance to the State and should be made a matter 
 of record. Evidences are already at hand that many of our 
 social and even economic problems are caused by the mating of 
 inferior stock. Alcoholics, the shiftless, imbeciles and criminals 
 are permitted, through marriage, to aggravate our social problems 
 by indiscriminate breeding and thereby perpetuate their like to 
 act as even heavier burdens on future generations. In this coun¬ 
 try the students of eugenics have no accurate data to guide 
 
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 * 
 
 them in their endeavors for the improvement of our national 
 race stock. Our neglect to provide intelligible birth and mar¬ 
 riage statistics is a source of grave social loss, and I cannot 
 urge too strongly your active participation in all efforts which 
 will improve our statistics of these social facts. 
 
 The legal aspects of marriage registration are strikingly brought 
 home to us in the life insurance business. Life insurance com¬ 
 panies and other organizations administering trust funds are 
 constantly involved in expensive litigation to establish the validity 
 of claims arising out of defective or non-existent records of mar¬ 
 riage. Questions sometimes arise as to the identity of wives 
 named as beneficiaries in policy contracts. A typical case from 
 our own experience will interest you. An unmarried lady was 
 named in a policy of $10,000 as the beneficiary. After her sub¬ 
 sequent marriage, she requested the Company to change the name 
 entered upon the policy to the one she assumed at marriage. 
 
 As is our uniform practice in such cases, we requested a certified 
 copy of the marriage certificate, in order to protect the interests 
 of all parties to the contract and avoid future litigation. Unfor¬ 
 tunately, no certified record was obtainable, and we were obliged, 
 with reluctance, to accept an affidavit from the parties concerned. 
 
 These are possible sources of litigation. Other instances occur 
 where more than one claimant appears as the beneficiary under 
 the contract, each claiming to be the wife of the deceased. In 
 such cases, a marriage certificate is necessary to establish the 
 truth, in order that the Company may proceed to settle its obli¬ 
 gations. The lack of these fundamental documents in civic 
 accounting leads invariably to confusion and economic loss which, 
 in the last analysis, is borne by the community at large. 
 
 Deaths. 
 
 We can consider as our fourth point of investigation into the 
 subject matter of vital statistics, the significance of death regis¬ 
 tration. A death constitutes a loss to the community especially 
 when young lives, full of promise and potential usefulness, are 
 terminated. It is obvious that in community management the 
 losses should be closely analyzed as to age, cause of death, economic 
 and social condition of the deceased, etc., to indicate the precise 
 lines of endeavor which the health officer and other officials should 
 institute for the prevention of similar losses. This surely would 
 
 8 
 
 4 
 
be the procedure in the conduct of private business, and there is 
 no reason why community losses should not be subject to the 
 same scrutiny. 
 
 The complete registration of deaths makes possible the calcula¬ 
 tion of a death rate. Death rates, however, require a supplementary 
 analysis before community wastes can be traced to their sources. 
 The first step in the analysis is the calculation of the rates by 
 ages, for, as you well know, the age constitution of a population 
 is an important factor in determining its total mortality. With 
 this fuller knowledge, the authorities can make a comparison with 
 the experience of other communities to ascertain whether their 
 losses are abnormal at any particular age. It is a common 
 occurrence for communities with normal general death rates to 
 suffer excessively at certain ages. Such facts can then be 
 brought to the attention of responsible officials and their energies 
 directed to specific remedial measures. 
 
 The utility of accurate mortality statistics by ages has never 
 before been demonstrated with such emphasis as in the movement 
 for the conservation of infant life. Agencies for education and 
 practical social work, such as nursing associations, diet kitchens, 
 milk stations and others, are concentrating their energies upon 
 the solution of this problem which is of such intimate concern 
 to society at large. The work of these institutions for preventing 
 infant mortality is directed at improved sanitation, better housing, 
 and the education of mothers in the care of infants, and their 
 efforts depend wholly upon the prior and exhaustive knowledge 
 which good statistics alone can develop. 
 
 Again, the incidences of sex, nationality and occupation have 
 their effect in coloring death rates of communities. A super¬ 
 abundance of deaths in a certain occupation-group indicates the 
 presence of adverse industrial conditions and points out the 
 need for the enforcement of the labor laws or the necessity for 
 more stringent legislation. The ultimate effect of occupation upon 
 the health of women in industry is, moreover, made evident by 
 a minute study of mortality data from the standpoint of occupation 
 and sex. The tabulation of deaths and death rates by locality 
 is also of use in discovering whether the application of special 
 neighborhood health work is necessary. When one section of a 
 city contributes more than its share of typhoid deaths, it is certain 
 that local sanitary conditions need supervision and correction. 
 By inaugurating proper measures, the causes may often be removed 
 
 9 
 

 l 
 
 and the disease prevented from extending its ravages to other 
 parts of the city. 
 
 You will now readily see the importance of recording full and 
 accurate statements of the essential particulars regarding deaths. 
 Items of name, age, place of death, date of death, marital 
 condition, parentage and an accurate statement of all the morbid 
 conditions which have had any bearing upon the death, should 
 receive the utmost attention from health officers. No part of a 
 death certificate should be admitted to the official files of the 
 health offices until every error of fact is adjusted. Some State 
 laws, fortunately, require registration officials to demand defin¬ 
 ite information from physicians, coroners and midwives who fill out 
 such certificates, whenever data are missing, inaccurate, indefinite 
 or incomplete. In other States, and they are the larger number, 
 the registration laws are of indefinite force-, and the returns reflect 
 this condition. Only a stern and unrelenting criticism of docu¬ 
 ments can make statistics of this character reliable. 
 
 The accurate statement of the cause of death is, of all the items 
 in the death certificate, the most important, and at the same time 
 it involves the greatest difficulty in tabulation. In order that the 
 utmost practical value may be obtained from the returns, it is 
 necessary to adopt a uniform system of classification which will 
 permit the comparison of mortality statistics of different communi¬ 
 ties. The requirement for international comparability is admir¬ 
 ably met by the Bertillon Classification, now in use by the leading 
 registration offices throughout the world. This International 
 List, as you know, comprises 189 standard titles which are grouped 
 under 14 general headings. Each standard title in the list 
 includes under it the names of the diseases or conditions which 
 can properly be classified with it. Thus, under “Typhoid Fever” 
 we find such synonyms as “Continued Fever,” “Enteric Fever,” 
 etc. Registration officials who in their practice meet with these 
 rarer terms on death certificates, therefore, classify such returns 
 uniformly under the “Typhoid Fever” title. It will readily be 
 seen that uniformity of this character is absolutely essential to 
 the comparability of typhoid fever rates, especially since various 
 designations are still extensively employed in different sections 
 of the country to describe the same morbid conditions. Other 
 titles present similar problems of classification which are solved 
 by the use of the International List. To this end, I most earnestly 
 recommend the close study of the Bertillon system of classification 
 
 10 
 
by health officers, and especially of its discussion of the technique 
 of classification for “multiple” causes of death. 
 
 Returns of Cause of Death should include all the morbid con¬ 
 ditions contributing to the death, together with a statement of 
 the duration of the disease and of its complications. It is especially 
 important that the terms employed shall be of the standard 
 nomenclature of the International Classification. The designation 
 of terminal conditions, such as “peritonitis,” “acute nephritis,” 
 “paralysis,” “dropsy” and “meningitis,” and of such vague 
 returns as “marasmus,” “heart failure,” “hemorrhage,” “con¬ 
 vulsions” and “fractures,” are wholly undesirable, and should 
 be sharply questioned by health officers for more definite informa¬ 
 tion which will permit of intelligent tabulation of the data. Nearly 
 eight per cent, of the death certificates which enter the statistical 
 laboratory of the Metropolitan Life Insurance Company present 
 Cause of Death returns which require further information to 
 permit of accurate tabulation. It is our practice to address a letter 
 of inquiry to the physician or coroner signing the certificate in 
 each case for more definite data, and it is gratifying to observe 
 that in the large number of cases, clarifying replies are received in 
 place of the earlier indefinite and unsatisfactory returns. Thus, 
 in twenty-six returns of peritonitis without qualification, inquiry 
 revealed that three deaths were caused by self-induced abortion, 
 two by criminal abortion, two by appendicitis, three by puerperal 
 fever, one by gonococcus infection, and the rest by causes such as 
 alcoholism, tuberculosis, traumatism by falling, typhoid fever 
 and cancer. Not one of the twenty-six cases was ultimately 
 classified as “peritonitis.” 
 
 These facts are reflected in Chart I, which shows the 
 successive annual death rate from such indefinite causes as “peri¬ 
 tonitis” and “dropsy” for the years 1900 to 1911 inclusive. You 
 will see that the number of cases under these two titles have 
 regularly decreased in frequency. This is undoubtedly the result 
 of the more rigid requirements of the Census Bureau, which con¬ 
 sistently returns such an assignment of the cause of death to the 
 certifying physician for a more definite statement of the cause. 
 
 ll 
 
16 
 
 15.1 
 
 Apparent Decreases in “Peritonitis 
 Death Rates—Registration Are 
 
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 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 
 
 CHART I 
 
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 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 
 
 CHART II 
 
K 
 
 The term “poisoning” without further definition is often 
 converted upon inquiry to a statement of “suicide,” as have also 
 numerous instances of so-called ‘ ‘ drowning. ” “ Gunshot wounds ’’ 
 
 turn out to be clear cases of “homicide,” while “fractures,” upon 
 further investigation, are found to be masked cases of railroad, auto¬ 
 mobile and machinery accidents. It is not surprising, therefore, to 
 find, as is shown in Chart II, that the rates for “homicide” and 
 “suicide” have increased regularly during the period since the 
 inauguration of more scientific compiling methods. In the light of 
 this fact, it is difficult to determine whether the indicated increases 
 really represent a greater incidence of homicide and suicide in 
 the Registration Area, or rather the effect of more efficient 
 statistical methods. 
 
 Inquiries into returns of “meningitis” develop the existence 
 of the acute infectious diseases such as “scarlet fever,” “diph¬ 
 theria,” “measles” and “whooping-cough.” The return “pneu¬ 
 monia,” in like manner, is a mask for a whole host of more definite 
 conditions such as “measles,” “scarlet fever,” “traumatisms” 
 and “alcoholism.” In view of the special interest of the com¬ 
 munity in these conditions, it is extremely important that there 
 shall be especially complete registration of the cases in which 
 the communicable diseases are the determining causes. It is 
 reprehensible enough when the substitution of a terminal condition 
 for a primary cause leads to the over-registration of undesirable 
 titles, but what is more serious, is, that in this way, fatal cases of 
 infectious and contagious diseases or of industrial and general 
 violence are left unrecorded. 
 
 Sickness. 
 
 Finally, the statistics of sickness are materials for the vital 
 statistician. The subject is, however, of such vast import that 
 it will be impossible to refer to it in this address beyond the state¬ 
 ment that it is through the analysis of case records of illness 
 that much light is thrown upon the causal phases of disease and 
 also upon clinical treatment. Statistics are, moreover, the 
 chief test at the disposal of the community of its effective control 
 over transmissible disease. To-day, millions of dollars are being 
 expended annually by communities in their campaigns against 
 tuberculosis and other disorders, with the hope that the various 
 activities may check disease at one point or another. It is for a 
 statistical investigation to determine the degree to which these 
 
 14 
 
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 efforts have been productive of results. Thus will be decided the 
 fate of such experiments as visiting nursing, disinfection, isolation, 
 sanatorium treatment for incipient tuberculosis and other ventures 
 still under judgment. 
 
 In concluding this discussion of the business value of regis¬ 
 tration, I hope that I have indicated the extent and character of 
 the losses which result from neglect of thoroughly registering vital 
 phenomena. If communities were to realize that they are called 
 upon ultimately to meet these losses, I think that we would have 
 an awakening of public interest in careful civic accounting of 
 human life. A wide-awake development in this direction would 
 favorably affect the transaction of business along many lines. 
 In life insurance companies alone, fully one-quarter of the disputes 
 would never arise were adequate records at hand. The saving 
 of losses due to present litigation could then be returned as larger 
 benefits to our clients, and would remove many causes for dis¬ 
 satisfaction. We cannot regard these losses as anything more 
 than downright waste. 
 
 The solution of the problems is entirely in your hands. Surely 
 you must see that it is good business for a community to take 
 these necessary precautions to account for its most vital resources. 
 Nothing less than a most efficient system of accounting is now 
 tolerated in any line of modern business, and surely the most 
 important business, that which is concerned with the physical 
 welfare of us all, should not be satisfied with anything less. 
 
 15 
 
 T 
 
t 
 
 STANDARD CERTIFICATES OF BIRTH AND DEATH. 
 
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 1IJ - 
 
 PLACE OF BIRTH 
 
 County of- 
 
 Township of_ 
 
 Village of-_- 
 
 City of- (No. 
 
 FULL NAME OF CHILD ..... 
 
 Brpartmrut uf Cnmmrrrr anil *~*hrw- 
 
 B UREAU OF THE CENSU S 
 
 STANDARD CERTIFICATE OF BIRTH 
 
 Registered 
 
 Twin, trlpM, 
 or other 7 
 
 (To be answered only Ii 
 
 Number In order 
 of birth 
 
 event of plural blithe) 
 
 BIRTHPLACE 
 
 OCCUPATION 
 
 Number of children born t 
 
 i mother, including present b 
 
 FULL 
 
 MAIDEN 
 
 NAME 
 
 BIRTHPLACE 
 
 OCCUPATION 
 
 Number of children of this mother r 
 
 v living . 
 
 I hereby certify that I attended the birth of this child, who 
 on the date above stated. 
 
 [ * When there tea* no attending physician 
 ] or midwife, then the father . householder, 
 j etc., should make this return . A stillborn 
 I child is one that neither breathes nor shows 
 l other evidence of life after birth. 
 
 Given name added from a supplemental Address- 
 report-.,19 
 
 CERTIFICATE OF ATTENDING PHYSICIAN OR MIDWIFE* 
 
 (BorifiHVVorBSUbom) 
 
 (Signature)_ 
 
 (Physician or Midwife) 
 
 REGISTRAR 
 
 A 
 
 Good vital statistics depend upon these certificates. 
 Do you use them in your State ? 
 
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