UC-NRLF HA 38 A22 1907 flb fllS o >- BUREAU OF THE CENSUS v S.RD.NORTH^DIRECTOR Modes of Statement of Cause of Death and Duration of Illness upon Certificates of Death COMPARISON OF FORMS NOW IN USE IN THE UNITED STATES AND CERTAIN OTHER COUNTRIES AND SUGGESTION OF A MODIFICATION OF THE STANDARD CERTIFICATE OF DEATH IN ORDER TO SECURE UNIFORM AND DEFINITE STATE- MENTS OF CAUSES OF DEATH < & & & # CHECK LIST OF REGISTRATION OFFICIALS, REPORTS AND BULLETINS 0f (Eommm? atd ; BUREAU OF THE CENSUS S. N. D. NORTH * DIRECTOR Modes of Statement of Cause of Death and Duration of Illness upon Certificates of Death COMPARISON OF FORMS NOW IN USE IN THE UNITED STATES AND CERTAIN OTHER COUNTRIES AND SUGGESTION OF A MODIFICATION OF THE STANDARD CERTIFICATE OF DEATH IN ORDER TO SECURE UNIFORM AND DEFINITE STATE- MENTS OF CAUSES OF DEATH Jk & j* Jt j* <, CHECK LIST OF REGISTRATION OFFICIALS, REPORTS AND BULLETINS nf fflattuttm? anb CENSUS PUBLICATIONS ON MORTALITY STATISTICS SINCE 1900. TWELFTH CENSUS. Vital Statistics, Part I Analysis and Eatio Tables. Vital Statistics, Part II Statistics of Deaths. Bulletin No. 15. A discussion of the Vital Statistics of the Twelfth Census. [The last of the series of decennial reports. The data are for the census year end- ing May 31, 1HOO, and are based upon enumerators' returns from the nonregistration area and upon transcripts of deaths from the registration records, chiefly, for the registration area. Succeeding reports are for the calendar years and relate to the registration area only.] PERMANENT CKNSl's. Mortality Statistics, 1900 to 1904. Five years in one volume. Mortality Statistics, 1905. Sixth Annual Report. Mortality Statistics, 1906. Seventh Annual Report. In preparation PAMPHLETS. No. 71. (Circular) Registration of Deaths. No. 100. Legislative Requirements for Registration of Vital Statistics. [Out of print. See Nos. 71 and 104.] No. 101. Practical Registration Mb^hot'ls., 1 ;:.:,' ,' No. 102. Relation of Physician? to/Mgrtali^^tjita^Jrics. No. 103. Medical Education, in VitaJ S.tatis^igs. .[O.ut o r f print.] ^ No. 104. Registration o/ ^iiJtl5i*kEfd:i|eath^ : I *\' '; No. 105. Statistical Treatment VA ^auei ofI>eath/ " * * No. 10(3. Extension of the Registration Area for Births and Deaths. No. 107. Modes of Statement of- Cause of Death and Duration of Illness upon Certifi- cates of Death. Manual of International Classification of Causes of Death. NOTE. Any publications now in print may be obtained upon application to the Director of the Census. CONTENTS. Page. Introductory 5-12 Important subjects requiring united action 6 Uniform mode of statement of cause of death indispensable 9 Modification of the standard blank proposed 10 Personnel of American registration service 11 Extension of the registration area 11 Modes of statement of cause of death and duration of illness upon certificates of death 13-39 United States: A. Standard certificate of death 14 B. Modified standard certificate of death _ _ .. . 16 C. Old forms used by Census 19 D. Miscellaneous forms 21 Foreign countries: 1. France 28 2. Germany 30 3. Great Britain and Colonies 31 4. Italy 33 5. Japan 33 6. Sweden 35 7. Switzerland . 35 Terminology and arrangement of terms employed upon certificates of death to denote causes of death 40 Definitions of more important terms 41 Definitions of less important terms 48 Application of terms in certifying causes of death 49 ( 1 ) Deaths from disease 50 (2) Deaths from violence . 58 Duration of illness 61 Conclusions and recommendations 62-67 Appendix A. Circular of announcement of organization of American associa- tion of registrars of vital statistics 69-70 Appendix B. Check list of registration officials, and of reports and bulletins containing vital statistics, in the United States: 1907 71-81 Map showing states in which the standard certificate of death has been adopted (or recommended in nonregistration states') by the state authori- ties: 1907 7 (3) M82445 INTRODUCTORY. This pamphlet has been prepared by the Bureau of the Census for presentation to the registration officials of the United States at the initial session of their national organization, which will be formed as a Section of the American Public Health Association at its meeting to be held at Atlantic City, N. J., from September 30 to October 4, 1907. l The cooperation of the American Public Health Association and the Bureau of the Census has already been fruitful of practical results among them the formulating of the essential requirements of an effect- ive law for the registration of deaths, since carried into successful operation in many states, 2 and the preparation of a standard certificate of death and has received the express approval of the Congress of the United States by a joint resolution approved February 11, 1903, the concluding portion of which is as follows: Whereas the American Public Health Association and the United States Census Office are now cooperating in an effort to extend the benefits of registration and to promote its efficiency by indicating the essential requirements of legislative enact- ments designed to secure the proper registration of all deaths and births and the collection of accurate vital statistics, to be presented to the attention of the legisla- tive authorities in nonregistration states, with the suggestion that such legislation be adopted: Now, therefore, Resolved by the Senate and House of Representatives of the United States of America in Congress assembled, That the Senate and House of Representatives of the United States hereby expresses approval of this movement, and requests the favorable con- sideration and action of the state authorities, to the end that the United States may attain a complete and uniform system of registration. The organization of a special Section of the Association, devoted entirely to vital statistics, and embracing in its membership, as it is hoped, the entire registration service of the United States, should greatly facilitate the continuance of this cooperation, and should enable effective concerted -action to be taken upon many practical questions affecting the collection and presentation of vital statistics, which are now in a chaotic and exceedingly unsatisfactory condition. 1 See Circular of Announcement, Appendix A. 2 See Census circular No. 71 containing paper of the Committee of the American Public Health Association on Demography and Statistics in their Sanitary Relations, entitled ''The Essential Requirements of a Law for the Registration of Deaths and the Collection of Mortality Statistics;" Census pamphlet No. 104, Registration of Births and Deaths Drafts of Laws and Forms of Certifi- cates; and Census pamphlet No. 106, Extension of the Registration Area for Births and Deaths A Practical Example of Cooperative Census Methods as applied to the State of Pennsylvania. These will be sent by the Director of the Census upon request. (6) IMPORTANT SUBJECTS REQUIRING UNITED ACTION. Some of the important subjects requiring agreement and upon which action may well be taken by the representative organisation of American registrars, are as follows: 1. Legislation for the improvement of vital statistics, (a) Federal, (&) state, and (c) municipal. The "Essential Requirements" for the registration of deaths, which have stood the test of actual experience for some six } T ears, should be revised, if any revision be necessary, and reaffirmed. State laws enacted during recent years should be com- pared in connection with the essential requirements, and the condi- tions of their failure or success pointed out. Similar criteria should be framed for the registration of births. No state or city 'has yet been accepted by the Bureau of the Census as having the minimum standard of completeness (only 90 per cent) of birth registration; it is believed that a beginning may be made at an early date and a " regis- tration area for births " be constituted. The drafts of laws recom- mended by the Bureau of the Census should be remodeled, simplified as much as possible, and effective alternative plans suited to special conditions in the West and South be arranged. For cities in the non- registrat^ion states a model city ordinance for the registration of births and deaths should be prepared, so that a beginning of registration can be made without waiting for the sometimes tardy coming of ^general state legislation. The formation of a Section of municipal health officers at the present meeting of the Association should be of impor- tant service in this connection, and a special committee might well be appointed by it to cooperate with the committee of the Section of vital statistics. 2. Administrative methods should be compared, and a higher standard of general efficiency in collecting and handling registration returns be attained. There should be absolute agreement as to what constitutes a birth, a stillbirth, and a death, for registration purposes, in the entire country. 1 At present there is great lack of uniformity in this respect. Some registrars include stillbirths in deaths; some exclude them. Some registrars include stillbirths in births; some exclude them. The term " stillbirth" is undefined, and means one thing in one place and another in another; yet upon its precise definition depends uni- formity in the statement of births and deaths. Sometimes deaths in institutions or deaths of transients or nonresidents are included in total deaths, and sometimes they are excluded; sometimes deaths in institutions located without a city are included in its statistics. When it comes to the classification of causes of death, even when the Inter- national Classification is in use, there is chaos indeed; the same deaths compiled in two or three separate offices, as sometimes happens, may 1 Resolutions containing definitions of these elements of vital statistics will bo presented. show quite different results, largely due to the lack of an accepted uni- form method for the disposition of joint causes and an identical form of statement by physicians and coroners upon their certificates. Imperfect data are not uniformly corrected, and no general system of checks or tests is in operation whereby a registrar may be assured of the substantial completeness of his results. All of these unfortunate conditions can be remedied by the cooperation of the registrars them- selves, if once organized into a coherent body, and there is no other way, under our system of government, by which they can be materially improved. 3. Uniform blanks should be employed for the collection of the fun- damental data upon which the vital statistics are based. In 1900 only two states in the Union employed the same form of certificate of death. States in which the standard certificate of death has been adopted (or recommended in nonregistration states) by tJte stale authorities: 1907. As a result of the movement begun by the Association a standard blank was prepared and recommendjed by the Bureau of the Census for gen- eral adoption. It is now in use in many states and cities, including all of the registration states except a few of the older ones that already possessed forms containing all of the essential items, and which they were reluctant to abandon for the reason that their filing cabinets or methods of clerical work were especially adapted to the old forms in use. Only two states, both included in the nonregistration area, have blanks recommended by their state authorities that do not include all of the information required for the annual reports on Mortality Statisr tics prepared by the Bureau of the Census, and it is hoped that with the adoption of effective laws in those states the standard blank will be introduced. Many cities, however, continue to use very defective 8 forms, and it would be desirable for them, where the matter is entirely under local control, to adopt the standard certificate. Even with the standard blank, however, there is beginning to be a diversity of arrangement and mode of statement of* certain items, so that the condition of actual uniformity may be lost. It would be well for a general agreement to be reached as to the desirability of any modification of it, and then that the standard blank should be adopted and maintained in use in the standard form so far as all of the essen- tial items are concerned. There is, of course, provision for special additional data required by the laws of certain states. The most important items concerning which the form of statement may perhaps be altered with advantage are the following: (a) Occupation. While this item should afford some of the most practically useful information derived from mortality statistics, it does not do so at present. A complete study of the subject by an author- ized committee, and with the aid of all who are interested in statistics of the mortality of occupations, should be made and an improved schedule formulated, if one not too cumbrous can be devised, that will enable a beginning to be made in the collection of satisfactory material. 1 (5) Cause of death. This is even more fundamental than occupation, and this pamphlet has been especially devoted to this subject as the most urgently important of any that can come before the organized association of registration officials, and also one that they are quite able to radically reform. 4. Uniform methods of presentation of data relating to vital statis- tics should be adopted. Registration reports and bulletins of states and cities should be readily comparable with each other and with the annual Mortality Reports of the Bureau of the Census. Each class of report or bulletin has its own field of usefulness and may go into greater or less detail in certain directions, as may be necessary for its own specific purpose, but when the results come together they must harmonize. Otherwise our statistics, as a nation, will become discred- ited and the old gibe that "One can prove anything by statistics" will seem to be true. 5. Standard tables showing the most important results for each year of registration should be prepared for each state and city. The past results of registration in the United States should be made avail- able for convenient reference, no matter how imperfect. The figures should be critically examined, and explanatory notes made of changes of methods of collection or compilation of data, probable degree of completeness of registration, etc. , so that users of statistics may know 1 A form will be submitted merely as a basis of discussion and so that definitive action may be taken in 1908 without waiting another year for the report of the special committee in charge of the subject. It is desirable that all changes in the standard blank be made at the same time. In the meantime it is urged that special attention be given to the subject by statisticians. A symposium on "Occupations" is planned in the American Statistical Association, in which the requirements of the schedule and instructions on occupations may be discussed from the several points of view of population, industrial (manufactures), and vital statistics. 9 just what the sources of information are and the actual value of the published figures. As a basis, the items contained in the international tables published by the French government (Statistique generate de la France, Tome XXXII, 1902) may be taken, namely, population at each census since the beginning of registration and estimated populations for intercensal years, number of marriages, living births, stillbirths, and deaths (exclusive of stillbirths) for each year, with rates per 1,000 enumerated or estimated population. The French tables con- tain data for only five American states, Connecticut (1848-1900), Mas- sachusetts (1849-1900), Maine (1892-1898), Michigan (1868-1899), and Rhode Island (1874-1892). Even in these, however, as also in the standard tables published by certain states, errors occur, so that at present it is necessary to go back to the original annual reports of each state for assurance of correctness; and very possibly in so doing one will be confronted by differing statements of total deaths or other items in various tables of the same report, or perhaps find that the method of treating stillbirths changed from year to year, so that it is absolutely impossible to know in a given instance whether they were or were not included in the total number of births or deaths. Such standard tables are equally necessary for cities, as shown by the valuable series published by Mr. Hoffman 1 and the summaries prepared by Doctor Chapin for the city of Providence. 2 In the latter case it was necessary to go back to the original returns and ascertain the true number of stillbirths (" dead at birth"), so that the figures for total living births and total deaths (exclusive of stillbirths) might be comparable. The method of compiling deaths of children who had lived less than a week after birth as stillbirths had been followed up to 1889, contrary to the present practice of the office. Standard tables for individual causes of death are especially important, but present great difficulties owing to the changes in methods of classification. The work can best be done by those having access to the original returns and familiar with office rules. UNIFORM MODE OF STATEMENT OF CAUSE OF DEATH INDISPENSABLE. Identical schedules are necessary to secure comparable results in statistics. One of the most important statements made upon the certificate of death perhaps the most important for the uses of the data for sanitary purposes is the statement of cause of death. In deaths from disease this statement is usually made by the attending physician, and in deaths of sudden occurrence, under suspicious cir- cumstances, or from violence, by the coroner or medical examiner. In order to obtain a definite and satisfactory statement for statistical purposes, the physician or coroner should clearly understand just 1 The General Death Rate of Large American Cities, 1871-1904, by Frederick L. Hoffman. Publica- tions of the American Statistical Association, March, 1906. 2 Fifty-first Annual Report upon the Births, Marriages, and Deaths in the City of Providence for the year 1905, including Tables for Fifty Years. By Charles V. Chapin, M. D., city registrar. 10 what kind of information is desired, and how the cause or causes of death should be stated so that the mortality statistics can be correctly compiled. If a sequence or certain order of statement of the causes of death, such as "primary," "secondary," etc., be necessary, it should be plainly and unmistakably provided for on the blank, and the exact meaning and relation of the qualifying terms should be understood by all concerned. From the point of view of the Bureau of the Census this is especially important for two reasons: 1. Ail transcripts of deaths received from the states and cities con- stituting the registration area of the United States are made upon blanks of the standard form. When copied from original certificates made out upon other forms of blanks, or perhaps upon materially altered standard blanks, the character of the returns may be consider- ably changed and quite different relations be shown for the causes reported than those originally indicated by the physicians or coroners. 2. It is quite impossible for the Bureau of the Census to cooperate with state and city offices in instructing physicians and coroners as to how they shall return causes of death so as to be most serviceable for the compilation of mortality statistics unless the blanks in use contain a uniform method of statement. MODIFICATION OF THE STANDARD BLANK PROPOSED. While the standard certificate of death has proved very satisfactory in practical use during the time since its adoption, it has not proved to be wholly free from uncertainty, as understood by physicians. It also possesses the fault, in common with every other blank used in this countr} 7 and many of those used abroad, that it does not properly pro- vide for the statement of causes of death due to violence. Primarily prepared for the return of deaths from disease, the form does not suggest the statement of the most essential particular required for the classification of deaths from violent causes, namely, whether the means of death was of an accidental, suicidal, or homicidal character. An explicit statement in this respect is contained in the form proposed, where every physician or coroner can read it while filling out the cer- tificate of death, and if generally adopted a marked improvement should result in the precision of this very important class of statistics. The new form is presented for the criticism of all interested, and with the express request that it be not adopted by any local office, except in a merely experimental way, until it has been thoroughly considered, reported upon through the proper channels, and officially recommended by the organized registration officials of the United States. Upon the possibility of deliberate action upon such a question as this, followed by actual compliance with the decisions made, depends the outlook for improvement in American vital statistics. Unless reg- istration officials can agree upon the adoption of some uniform methods, 11 and then let them stay adopted and in force until regularly and con- sistently modified by general agreement, it is quite impossible to expect a homogeneous bod}^ of national statistics. Without such agreement in practice the form proposed would only add one more to the already too numerous list, and would demonstrate that it is quite impossible to build a uniform and effective statistical administration upon the sand of shifting individual preferences. PERSONNEL OF AMERICAN REGISTRATION SERVICE. Whatever success is reached will be due to the intelligent action of American registrars of vital statistics. Without organization nothing can be accomplished, and the coming together of state and municipal officials for the express purpose of forming a national association de- voted to the improvement of registration methods and results is full of promise for better things. Much is accomplished by personal acquaintance, and by the knowledge that fellow-workers in different parts of the country are watching one's progress. Every health officer who brings the sanitary condition of his city to the attention of the people by means of reports or bulletins containing causes of deaths is helping, or hindering, the progress of American vital statistics. It has seemed desirable to list the state and city registration officials, 1 in- cluding all places having a population of 8,000 or over at the time of the last Federal Census, and also to show, as far as the information is available, some particulars in regard to whether they are acting under state laws or city ordinances, or both, and also as to the issue of reports and bulletins containing vital statistics. EXTENSION OF THE REGISTRATION AREA. The extension of the registration area by the inclusion of new registration states is proceeding apace. There were ten registration states in 1900 Connecticut, Indiana, Maine, Massachusetts, Michigan, New Hampshire, New Jersey, New York, Rhode Island, and Vermont besides the District of Columbia (city of Washington). Of these, two Maine and Michigan were added during the previous decade, while Delaware was dropped. In 1906 five additional states were included California, Colorado, Maryland, Pennsylvania, and South Dakota. Complete laws were enacted in 1907 which should bring Minnesota, Montana, North Dakota, Wisconsin, and perhaps other states, into the list. Earnest efforts will be made by the state authori- ties in Kentucky, Ohio, and Virginia to secure adequate legislation in 1908, and Illinois, Kansas, and other states will endeavor to secure it in 1909. But since 1900 no registration cities in nonregistration states have been added, although it is entirely practicable for many cities in states which are not likely to secure effective state registra- tion for some years to come to pass at once local ordinances for this 1 See Appendix B. 12 purpose, and so execute them as to obtain complete registration of deaths. As soon as this is done and the results tested, the cities can at once be admitted into the registration area. The attention of city authorities whose cities are not included in the list of cities having effective registration 1 is called to this fact, and suitable action is sug- gested, provided that the cities are free to act independently unham- pered by defective state laws. It would be well also if state boards of health in nonregistration states in which the prospect of the* enact- ment of a general state law seems remote would at once use their influence to promote municipal registration under uniform local ordi- nances and by means of the standard blanks containing all of the essential statistical items. It is, indeed, not necessary to wait until the limit of 8,000 population is reached, although this governs the admission of separate registra- tion cities. For local sanitary uses and for legal, historical, and genealogical purposes', registration ma} r yield excellent results in much smaller places. Every American citizen should take pride in having his personal and family history properly recorded, and in future years the official registers of births and deaths will be regarded as an invalu- able possession. As an example, the city of Keene, N. H., not long ago published a volume 2 containing the early records of births (1742- 1877), marriages (1753-1854), and deaths (1742-1881), concerning which it is said: "These records are of invaluable service to historians and genealogists and ought never to be allowed to perish. Once in print the record of these facts will be indestructible. After the publica- tion of the vital statistics it would be comparatively safe to send all the old and badly worn town records to be cleansed, rebound and covered, page by page, with overlays of transparent silk, as is done in such cases, thus permanently preserving the old volumes. 1 ' The first state law for the registration of vital statistics in New Hampshire was enacted in 1849, at which time Keene, although having only about 3,000 inhabitants, had had local registration for over a century. The tender care taken of these old returns shows the estimation placed upon them by the descendants of the men whose vital statistics are there recorded, and reveals the duty to the future owed by the gener- ation of to-daj 7 . In conclusion, thanks are due to American and foreign registrars for samples of blanks and information concerning their use, and sug- gestions and criticisms in regard to the conclusions reached will be warmly welcomed both from registration officials and experts and from physicians and coroners, upon whose statements of causes of death, primarily, is founded the whole edifice of mortality statistics. 1 Appendix B. 2 Vital Statistics of the Town of Keene, N. H., compiled from the Town Records, First Church and Family Records, the Original Fisher Record, and the Newspapers. By Frank H. Whitcomb, City Clerk. Authorized by vote of the City Council, June 1, 1905. MODES OF STATEMENT OF CAUSE OF DEATH AND DURATION OF ILLNESS UPON CERTIFICATES OF DEATH. The wording and arrangement of the form provided on the certifi- cate of death for the statement of cause of death by the attending physician or coroner is one of the most important features of the blank. The information to be thus obtained is very valuable, and the tables of causes of death contain perhaps the most useful and charac- teristic data of mortality statistics. Their value is largely dependent upon a full understanding by those who originally report the causes of death of just what should be properly understood l>y that^terrn what is essential and what is not essential to state concerning the causes of a death. Many of the imperfections of mortality statistics at the present time arise from the fact that complete statements of cause of death in a form best adapted to statistical compilation are not obtained. To some extent this unsatisfactory condition is due to a lack of defi- nite agreement as to just what is wanted from the physician. Physi- cians in active practice can not be expected to take interest in the minutiae of nosological classifications, or to specif} 7 the relations of several causes of death so that the compiler's task will be clear and easy, unless the questions addressed to them are entirely definite and unambiguous. Apparently slight variations in framing the schedules in this respect may be responsible for serious differences in the char- acter of the replies, and even the order of the replies, if order be taken as a basis of classification, may affect the statistical results. Attempts have been made to secure precise information by the use of various qualifying words or expressions in the blanks, or by the use of explanatory notes or instructions. Among the words com- monly found modifying the return of cause of death are the following: 44 Primary," " secondary," u chief," " determining," " consecutive," "contributory," "immediate," ""remote," etc. It is certain that some of these terms are understood in very different senses by various physicians, as well as by the registration officials who compile the cer- tificates of death in which they appear. The statement or omission of the statement of duration of illness is also very important as affecting the compilation of the data. In Eng- land, according to the " Rules as to Classification of Causes of Death," (13) 14 published by a committee of The Incorporated Society of Medical Officers of Health in 1901, of Which committee the distinguished vital statistician : Doctor Arthur: Newsholme was chairman, the element of duration is adopted as the basis of the first and most important general rulf f oi 1 ihe compilation: of joitit causes of death: With the following exceptions, the general rule should be to select from several diseases mentioned in the certificate the disease of the longest duration [italics in origi- nal]. In the event of no duration being specified, the disease standing first in order should be assumed to be the disease of longest duration. On the other hand, general European practice, as shown by the rules published by the Imperial Board of Health of German} T (1905), and by Doctor Bertillon (Paris classification, 1890, 1898; International classification, 1900, 1903), lays little direct stress upon the element of duration in regulating the preference of causes jointly returned, and the certificates of death in use do not usually contain this item of information. In the United States practice is unsettled. So far as the rules for jointly returned causes published in connection with the International classification have been followed it is probable that the duration of illness has been ignored. Many registrars, however, decide as to the "acute" or "chronic" character of certain diseases by the duration stated, or, in the absence of a statement of duration, by the period of medical attendance. In the Mortality Statistics of the Seventh Census of the United States, 1850, may be found tables showing the " Duration of sickness" in connection with the causes of death compiled, but the item was omitted from the mortality sched- ules of subsequent censuses, and was not restored until the adoption of the standard certificate. In the instructions issued for the return of deaths for the calendar year 1906 upon the standard blanks for tran- scripts of certificates of death, it is requested that the duration of illness be given in all cases in which it appears upon the original returns. It is desirable that registrars should endeavor to secure a proper statement of duration of illness for all deaths registered with them. In order to supply a basis for specific recommendations as to these items, it will be of service to examine the forms of statement now in use in this country (samples collected in July, 1906), and to compare them with some forms used abroad. UNITED STATES. A. Standard certificate of death. The standard certificate of death, in the precise form adopted by the United States Bureau of the Cen- sus as a result of cooperation with the American Public Health Asso- ciation, has the following arrangement for the statement of cause of death and duration of illness: 15 [1] U. S. Bureau of the Census; many states and cities. X I. 1 The CAUSE OF DEATH was as follows: (DURATION) __ --DAYS Contributory (DURATION) Following is a list of states and a partial list of cities using the strictly standard form of certificate of death, so far as it relates to the items under consideration: California Iowa Michigan Bellaire, Ohio Buffalo, N. Y. Canton, Ohio Charleston, S. C. Columbus, Ohio Findlay, Ohio Fort Smith, Ark. STATES. Nebraska Oregon Pennsylvania CITIES. Houston, Tex. Lancaster, Ohio Manchester, Va. Memphis, Tenn. Minneapolis, Minn. Nashville, Tenn. Newport, Ky. South Dakota Washington Newport News, Va. Portsmouth, Ohio St. Louis, Mo. Shreveport, La. Toledo, Ohio Wichita, Kans. Yonkers, N. Y. It should be understood that cities in registration states, e. g., Detroit, Mich., Philadelphia, Pa., and San Francisco. Cal., use the standard form prescribed by the state authorities, and that the cities listed above are chiefly registration cities in nonregistration states. Two exceptions are Buffalo, N. Y., and Yonkers, N. Y., which use the exact form of the standard certificate, while the state blank, as shown in the next section (form [7]), contains a slight modification. . : . 1 Indicates that blank is reproduced in same size, approximately, as original; x indicates reduc- tion to about one-half size, etc. In some ca,ses the printer has not uniformly reduced, but merely narrowed the blanks, as in forms [30], [41] fete. In such cases it should be understood that addi- tional blank space exists on the originals. 16 B. Modified standard certificate of death,. Some of the variations that have already developed since the adoption of the standard certifi- cate in 1902 may be seen in the following examples: [2] Colorado; Utah. X 1. The CAUSE OF DEATH was as follows: Chief Cause .,_*- Where Contracted Duration Days Contributory (if any) Where Contracted .__ -Duration- Days The Colorado blank has the same general arrangement as the Utah form shown above, but contains an additional leader line for "Chief Cause" and omits the word "Days" after the word "Duration." The instructions to physicians on the back of the Utah certificate ask them to state the "primary and contributory causes of death, with the duration of each," and, if from peritonitis or septicemia, to "give the contributing cause, especially for females of child-bearing age." [3] Indiana (1906). X 1. . . . the cause of death was as follows : Chief Cause. j Duration Immediate Cause .Duration, Instructions: " Write the name of the disease which caused the death. If the patient had pulmonary tuberculosis and died from hemorrhage of the lungs, write pulmo- nary tuberculosis as th disease causing death and pulmonary hemorrhage as the immediate cause." The above form was in use in July, 1$06, when the general collection of specimens was made. At present a new form is in use: 17 [4] Indiana (1907). X 1. The IMMEDIATE CAUSE OF DEATH ivas as follows: (duration) days Contributory . (duration) days InslJIuctions: "Write the name of the disease which caused the death. If the patient had pulmonary tuberculosis and died from hemorrhage of the lungs, write pulmonary tuberculosis as the disease causing death and pulmonary hemorrhage as the contributory cause." [5] Florida; Middletown, Ohio; Wheeling, W. Va. XL . . . the cause of death was as t ollows : CAUSE OF DEATH. Duration The first appearance of the standard certificate of death in Census Circular No. 71, from which the Middletown, Ohio, blank shown above was derived, was somewhat different from the present familiar form. [6] Massachusetts; Leaven worth, Kans. X 1. ... the CAUSE OF DEATH was as follows: Primary: '. (DURATION) DAYS * Contributory: _.;.,__. .. (DURATION) DAYS 915907 2 18 The regular state form is given above. Boston does not use the standard blank; see form [31]. [7] New York. X 1. the cause of death was as follows: CHIEF CAUSE (DURATION) __. DAYS CONTRIBUTORY (DURATION). __ DAY The form employed by the State Department of Health is shown above. Albany still uses the old New York state blank [29]. Buffalo and Yonkers employ the standard form. So did Greater New York until recently, so far as cause of death and duration are concerned. Lately the matter indicated by brackets in the form below has been stricken out, leaving it entirely without suggestion as to mode of stating the cause of death and with no provision for the statement of duration of illness. [8] New York, N. Y. X J. ... the cause of. death was as follows: ^[(Duration) Yrs.... .. Mos Days.} [Contributory (Duration) Yrs Mos Days.} [9] Vermont. X 1. the cause of death was as follows: CAUSE OF DEATH. [See instructions on back.] Chief _______ Contributing. Duration 19 In this the duration is given for only the "Contributing" cause of death. [10] Baltimore, Md. X 1. CAUSE OF DEATH (Secondary or Immediate). (DURATION) DAYS Contributory (Primary) (DURATION) DAYS This form is of interest because it reverses the usual order of state- ment, placing the secondary or immediate cause first in order, and identifies the primary with the contributory cause. C. Old forms used by Census. In Schedule 3 of the Seventh Census, 1850, the first United States .Census that included the subject of mortality, two of the eleven items related to cause of death: [11] U. S. Census (1850). 10. Disease or cause of death. 11. Number of days ill. The instructions on the latter item are: " In column 11 state the number of days' sickness. If of long duration, insert ' C.' for chronic." The same questions were employed in the census of 1860, but only the first ("Disease or cause of death") in the censuses of 1870, 1880, is'.M), and 1900. The instructions to enumerators of the censuses of 1880, 1890, and 1900 were practically identical: [12.] U. S. Censuses (1880, 1890, 1900). The most important point in this schedule is the question in column 12 [1900] headed "Disease or cause of death." Especial pains must be taken in this column to make the answer full and exact, and' to this end attention is called to the following points: Enter the name of the primary disease in all cases, and where the immediate cause of death has been a complication or consequence of the primary disease, enter that also. For instance, enter all cases of death resulting either immediately or remotely from measles, scarlet fever, typhoid fever, remittent fever, smallpox, etc., under the names of those diseases, but add also dropsy, hemorrhage from the bowels, pneumonia, etc., if these occurred as complications and were the most immediate cause of death. * #'* Distinguish between acute and chronic bronchitis, acute and chronic dysentery or diarrhea, acute and chronic rheumatism. 20 In 1880 and 1890, in addition to the deaths returned upon the regu- lar schedules, an effort was made to collect voluntary returns from physicians, for which purpose they were provided with a special reg- ister of deaths. As shown on page xi, Mortality and Vital Statistics, Part I, Tenth Census (1880), the form was as follows: [13] U. S. Censuses (1880, 1890). Cause or Causes of Death:f Was a post-mortem held ? Name of Physician: fUnder "cause or causes of death" insert remote, immediate, and concur- ring causes. For instance, insert " measles and pneumonia," or "difficult labor, peritonitis, and septicemia," or "scarjet fever, nephritis, dropsy, and coma," in cases representing these phenomena. as=If the true cause of death is not certainly known, insert names of symp- toms with across, thus: "Convulsions and coma x; paralysis of the heart, x," etc. In the introductory remarks of the Report on Vital and Social Sta- tistics of the Eleventh Census (1890), Part I, page 8, may be found a form recommended, after study of the various types at that time in use, in which the sole question is as follows: [14] II. S. Census (1890). Disease, or cause of death, __ Subsequently, in connection with the preparations for the Twelfth Census (1900), the following form was recommended, and may still be found in use to some extent: [15] U. S. Census (1899); Minnesota 1 ; various cities. X 2- 12. Disease or Cause of Death: DURATION. CHIEF CAUSE CONTRIBUTING CAUSE .__ PLACE WHERE DISEASE WAS CONTRACTED, if other than place of death: 1 Under old law; superseded by act of 1907. 21 This blank was in use in 1906 in the following cities: Akron, Ohio Hamilton, Ohio Paducah, Ky. Columbus, Ga. Ironton, Ohio Salem, Ohio Dayton, Ohio Kansas City, Mo. Springfield, Ohio East Liverpool, Ohio Lincoln, Nebr. Tiffin, Ohio Fort Worth, Tex. Louisville, Ky. Youngstown, Ohio Fremont, Ohio Lynchburg, Va. Zanesville, Ohio Greenville, Ohio Marion, Ohio Also, similar in general arrangement, but with different wording, are: [16] Washington, D. C. X . DURATION 13. Cause of Death PRIMARY IMMEDIATE [17] Atlanta, Ga.; Augusta, Ga. X i Duration 12. DISEASE OR CAUSE OF DEATH. Immediate Cause Primary or Contributing Cause ._ D. Miscellaneous forms. Despite the efforts at uniformity shown in the preceding groups of blanks, there is still a considerable variety of forms in use in the United States, most of which are employed only in the states or cities in which they have originated. The following state forms give both a differential statement with reference to cause and a statement of duration: Connecticut, Illinois, Kansas, Maryland, New Hampshire, Texas, and Wisconsin. Alabama and Maine make no dis- tinction on this point and do not provide for duration. The Rhode Island blank suggests a statement of causes of death "in order of occurrence," but offers no prescribed form of statement, while the New Jersey form asks for only a single cause, but requires statement of duration. In Alabama, Illinois, Kansas, Maryland, Texas, and Wis- consin,. all of which states with the exception of Maryland are part of the nonregistration area, the state forms are not used exclusively, but certain cities e. g., Mobile, Ala., Chicago, 111., Topeka, Kans., Balti- more, Md., Galveston, Tex., and Milwaukee, Wis. prepare their own forms. STATES. Following are the state forms of this group: [18] Alabama. X 1. Cause of death . . 22 [19] Connecticut. X 2. Primary cause of death 3. Duration of disease days 4. Secondary or contributory 5. Duration of days [20] Illinois. X |. CAUSE OF DEATH Immediate Cause Contributory Cause or Complication- Duration Years Months Days Hours Instructions: "In the settlement of life insurance and for many other purposes the duration of the immediate proximate or chief and determining cause of death is required to be stated, as also the character and duration of contributory causes or complications." [21] Kansas. X 1. 7. Cause of death 8. Occupation 9. Nationality 10. Place of death ___ 11. Duration of disease 12. Complication 13. Duration of complication __ [22] Maine. X 1. Cause of Death, [23] Maryland. X . CAUSES OF DEATH Primary Immediate How long How long 1 Various sizes are used in different counties. 23 [21] New Hampshire. X 1. Cause of Death, _, Duration, Contributing Cause, Duration, [25] New Jersey. X . the cause of death was_ ..._. _ Length of sickness ___ [26] Rhode Island. X i Please state different causes of death in order of occurrence as FULLY as possible, particularly in DOUBTFUL cases. Date of Death-. -190 Hour M. Name Causes of Death As an addition to the regular form, the blank used in the city of Providence has a line for the ''Duration of Diseases," and also the following special request to the reporting physician: TOTU p DU VQ|P| AM If more than one cause of death is given please ill- l IOIWIAAIN. that which you consider the most important. underline 24 Concerning this request Doctor Chapin writes (August 8, 1907): "I am sorry to say that it is only occasionally that our physicians underline the cause of death which they consider the most important. Sometimes when they do so indicate a cause it is evident that they mistake my intention, for the}^ sometimes indicate the immediate, rather than the most important cause of death; yet in the aggregate during the year there are quite a number of certificates brought in on which this indication by the physician of the proper cause for tabula- tion is of value. I shall probably continue to make the request, as heretofore. " [27] Texas. X \. CAUSE OF DEATH DUR> \TION Immediate Cause YEARS MONTHS DAYS HOURS Contributory Cause 20. Cause of death . Duration of disease [28] Wisconsin. X J. Primary Secondary The standard certificate is required by the new registration law of 190T. CITIES. Among the cities of this group making provision on their certifi- cates for a compound statement of cause and also for duration are: Albany, N. Y. ; Boston, Mass.; Chicago, 111.; Chillicothe, Ohio; Cin- cinnati, Ohio; Cleveland, Ohio; Fredericksburg, Va. ; Galveston, Tex.; Milwaukee, Wis.; and Topeka, Kans. Some give only a simple statement of cause and no statement of duration: Alliance, Ohio; Americus, Ga. ; Bessemer, Ala.; Biloxi, Miss.; Chattanooga, Tenn. ; Greensboro, N. C. ; Jacksonville, Fla. ; Key West, Fla. ; Lexington, Ky. ; Martinsburg, W. Va. ; Newbern, N. C. ; New Orleans, La.; and Parkersburg, W. Va. Others give a single cause, with duration, as Defiance, Ohio; Mobile, Ala.; St. Paul, Minn.; and others give a double statement of cause, with no duration, as Cheyenne, Wyo.; Knoxville, Tenn. ; and St. Joseph, Mo. 25 Some of the forms follow: [29] Albany, N. Y. X *. . . . the Cause of h death was as hereunder written: Chief and 1 Determining J ( Consecutive, and ( 'attributing i Duration of Disease in Years, Months, Days or Hours, f a . ill 8 c a 5 s? s 0.5 S o> bcS a ^ fl . Sanitary observations, __ ThisJs the old and original form of the New York state blank, which is shown on page 111 of the Third Annual Report of the State Board of Health (1883). [30] Boise, Idaho; Covington, Ky.; and other cities. X Remote or Predisposing 18. Cause of death, ( Immediate 19. Duration of last illness _. The following cities employ this form, in some cases without state- ment of duration: Boise, Idaho, Chillicothe, Ohio, Sidney, Ohio, Bucyrus, Ohio, Covington, Ky., Troy, Ohio. Cambridge, Ohio, Elyria, Ohio, Canal Dover, Ohio, Fostoria, Ohio, [31] Boston, Mass. X J. ( Chief cause, Disease \ [ Contributing cause, ( Chief Causey-- Duration < { Contributing cause, 26 [32] Chicago, 111. Xj. CAUSE OR CAUSES OF DEATH. Immediate and Determining -\ DURATION OF CAITSES. Years. Months. Days. Hours. ._____ [ ) Contributing Cause or Complication ^ *... . . \ On the reverse side: "In the settlement of life insurance and for many other pur- poses the duration of the proximate or immediate and determining cause of death is required to be stated, as also the character and duration of contributing cause or com- plication. Albuminuria, emphysema, jaundice, or dropsy the primary cause should be given." [33] Cincinnati, Ohio; Norwalk, Ohio. X$. the cause of death was as hereunder written: Disease Causing Death*- . - Immediate Cause of Death _"_. Contributory Causes or Complications, ifany.__ DURATION OK EACH CAUSE. / Place where Disease causing Death was \ contracted, if other than place of Death. *In case of a Violent Death, state (1) mode of injury, and whether accidental, suicidal or homi- cidal; (2) what was the nature of the injury and the immediate cause. of death; (3) contributory causes or conditions, e. g., septicemia. Also, whether operation was performed, etc. In deaths from tuberculosis, cancer, etc., always specify what organ or part of the body was affected. In septicemia, give cause, especially puerperal. This form is identical with the original Michigan blank (1897), except that it is of greater size. Milwaukee, Wis., also uses the same form of statement as regards cause, except that the item relative to post-mortem is omitted. [34] Cleveland, Ohio. Xi ( Chief __ __. Duration Days, Cause of Death: Contributing., ..Duration __. _.Days. [35] Galveston, Tex. X \. Disease, Injury or other Efficient and Remote Cause of Death Disease, Injury or other Efficient and Immediate Cause of Death 27 [36] Knoxville, Term. X 1. Cause of Death, .. Give immediate cause of Death. Name of Disease,... Give remote cause of Death. If Stillborn, state Supposed Cause of Death, p [37] Macon, Ga. X 1. CAUSE OF DEATH. Immediate Contributing Remote .._ [3gJ Massillon, Ohio. X . f Chief or Primary . Cause of Death : \ I Contributory or Immediate.... [39] Spartanburg, S. C. X . ... the Cause of death was: First (Primary), ... Second (Immediate), __. [40] Topeka, Kans. X 1. Cause of Death, Contributing Cause, Duration. [41] Worcester, Mass. X i Disease p.^ ^ p rimary> Duration of Cause Death. Secondary, . , Duration of 28 FOREIGN COUNTRIES. 1. France. Heretofore individual returns have not been made to the central statistical office of France, numerical statements having been prepared by the communal administrations, these totalized by prefectures for each department, and the department totals transmitted to the office of the Statistique generate de la France. Beginning Jan- uary 1, 1907, however, this system has been changed, and colored slips representing individual living births (rose), deaths (green), stillbirths (chamois), marriages (blue), divorces (yellow), legitimations (orange), transcriptions or corrections (violet), together with a bordereau, or statement slip of transmission (white), giving the first and last reg- istered numbers and the.total number of each class, are sent in on the eighth days of January and July for the preceding half years. The system is much like that employed in many states, and recommended by the Bureau of the Census, for the monthly transmission of returns. As France possesses a deserved reputation for perfection in statistical detail, it will be of interest to present a reduced facsimile of the Bul- letin de Deces (the reference imprint thereon gives exact details of the color, size, and weight of paper), together with a translation of the question concerning cause of death. 29 [42] France. X . DEPARTEMENT REPUBLIQUE FRANCE-USE. ANNEE1<3__ ARRONIMSSKMKNT BULLETIN DE DEGES, X de Pacte: Commune " d'ordre du de*ces: r's xnnrnn le __ du mois d __ 19 a ._ _. heims arie. Xombre d . e nfants survivants __ d'alimen- Au biberon _ ti tation. Age de 1'^poux survivant I Par allaitement mixte '-j. "Z 5. Profession du decede (!).__ -_Patron( 2 ) Employ6( 2 ) Ouvrier ( 2 ).._ 2 Professiondel'6poux survivant I 1 ) Patron ( 2 ) Employe^ 2 ) Ouvrier( 2 ) S 6. Si le decede est un enfant: Profession dupere(') ___._ Patron ( 2 ) Employt>(-') Ouv*er( 2 ) Profession de la mere (') Patronne(-) Employee (-) Ouvriere( 2 ) ^ [niguO* :: 7. Maladie ou accident cause de mort < ( cbronique -jj" 8. Le decesa-t-il ete constate par un medecin? 9 > , I :: , le . 19^. Lf Maire Vu: S 1 Le Declant nl, ou le Preposc de Vetat civil, Le Medecin de I'clat civil, 9 s g , 7 (M Preciser le plus possible la profession. ( 2 ) Oui ou non. [Translation of question 7.] ( acute 7. Disease or accident cause of death I chronic _. 30 2. Germany. The following form is in use in Germany: [43] Germany, x 1. - C. 190 ( Hicrtcljal)r). id) ber Xotgeborenen). ,, J ... ,ft r c i o : (Stabtgemeinbe Sanbgemeinbe ut8bc$irf ._ 1. Glummer im Sterbtrtgifltr: _ 2. s Hor= unb 3inuinic ( bco iscrftorbcncn: | obcr ob rotgcborcn obcr unbcnannt bcrftorbcn ? 3. efd)lcd)t: mannlid) obcr tociblid)? 4. 3eit bco SterbcfaUft? SKonat: . . lafl: ... Stunbc: J. Sonnittagft, 9tad)mittag8. 5. eburtfijaljr unb 5ag bc6 SJcrftorbcnen : .. 6. ^amilienftanb bco iBcrftorbenen : a) bci ^otgcb. u. .Vtinbcrn unter 1 ^al)rc: eyelid) cbcr uncbclid) gcboren? b) bci alien iibrigcn ^icrfoiicn: Icbig, t>crf)ciratct f bcrtpit^ct, gc[d)icbcn? bet SSer^eirateten: Waiter ber biircf) biefen Xobesfafl gefoften @^e: 3a^e. 7. 9lcligionrbcfcnntni0: bci 3:otgcborencn be Satcro: .,., ber SKuttcr: - 8. a) (Stanb, .^aiiptbcruf, O^ciucrbc: bci $crfoncn fiber 15 Satyrc alt bco ^crftorbcncn fclbft:.. ScnifftftcUuiifl (ob felbftanbtg, etytlfe, $rbettcr uftt).) : bei Sotgeborenen nnb nid)t enrcrbtatigen tobcrn nntcr 15 3al)rcn bco $atero: . iDenn baterloS: ber Gutter: .. Senifftellnng bco Sater$ bcjtD. ber SJhtttcr : 9. lobcenrfad)e (bet ^Berungliicfung 5lrt berfefben): __ 10. cmcrfiuigcii, \ 53. : ob anfgcfiuibcnc iinbcfanntc Vcid)c, ob anf bciitfd)cn Sd)iffcn aiif Sec, ober ob in einer ^Inftalt bcrftorbcn? in u>cld)cr [Translation of question 9.] 9. Cause of death (Nature of accident): 31 3. Great Britain and Colonies. The forms supplied by the Regis- trars-General of England and Wales and Ireland are identical in the arrangement and wording of this part of the blank: [44] England and Wales; Ireland. X i the Cause of h death was as hereunder written. Cause of Death. Duration! of Disease in Y ~ ni Calendar \ears. Monthg> Days. Hours. Primarv Enteric Fever 21 Secondary Broncho- Pneumonia 3 fThe duration of each form of Disease or Symptom is reckoned from its commencement until death occurs. The example of primary and secondary causes is that officially given by the Registrar-General of England and Wales in the book of forms .supplied to physicians. [45] Scotland; South Australia. X 5. . . . the Cause of Death and Duration of Disease were as undernoted: Primary Disease Secondary Diseases ( if any} (b) (<*) Cause of Death. Duration of Disease. Years. Months. Days. I : ' [46] New South Wales. X I- the cause of h . . - death was as hereunder written. J Cause of Death. Duration of Disease in Years, Months, Days, or Hours, f (a) Primary (Actual) (b) Secondary _. (Contributing) f-The duration of each form of Disease or Symptom is reckoned from its commencement until death occurs. I N. B. If the Deceased was a State child, boarded out, the Children's Protection Act of 1902 (sec. 10) requires that the medical attendant, in giving the cause of death, should also certify whether such cause was accelerated by neglect or ill-treatment. The addition of neglect 1 ' or " no neglect," under the cause of death, will comply with this requirement. 32 [47] New Zealand. X 1. the cause of h _ death was, _ Time from Cause of Death. attack till Death. - f First Second f Each form of disease, or symptom, is reckoned from its commencement till death. [48] Queensland. X 1. The cause of h death was as specified at foot hereof. Cause of Death. (Disease or Injury.*) Duration of Illness. 1. Primary 2. Secondary 3. Final *In case of a Death resulting from fractures, contusions, wounds of any kind, poison, or drowning, the Registrar-General particularly requests medical men to state specifically THE NATURE OF THE INJURY, and whether the Cause of Death was ACCIDENTAL, SUICIDAL, or HOMICIDAL. [49] Tasmania. X }. Cause of Death 1st 2nd [50] Victoria. X 1. iJn 1 cause of h death was () irst: Second: Cause of Death. Duration of Diseases. 33 Jr. Italy. Individual returns to the central bureau of the government have long been employed in Italy. Unfortunately a copy of the Italian blank is not at hand, but a translation of the reproduction given by Doctor Bertillon (Cows elementaire de statistique administrative, 1895, p. 277), so far as it relates to form of statement of cause of death, with instructions, ma} 7 be given: Natural death [51] Italy. X 1. Primary disease [Maladie primitive']. Complications of the disease or terminal condition [Acci- dent terminal'] [Accidental Violent death 1 ^ Suicide 3 . [Homicide 'If unable to certify whether a death from violence is due to homicide, .suicide or accident, indi- cate the supposed cause. 2 In accidental death state whether caused by fall, crushing, burning, drowning, poisoning, etc. 3 In suicides indicate the means employed firearms, cutting instruments, poisoning, precipitation from height, drowning, hanging, crushing under train, etc. 5. Japan. A reduced facsimile of the certificate of death employed in Japan, and also a translation of the complete instructions issued to physicians in connection with its use, which were kindly supplied by Hon. N. Hanabusa, Director of the Bureau of General Statistics, Imperial Cabinet of Japan, are given below: u [52] Japan. i m . J g s-3 tr j U a IR m JRUM6H m 915907 - 3 34 INSTRUCTIONS TO PHYSICIANS. The certificate of death to be made by a physician should be as follows: CERTIFICATE OF DEATH. 1. Name of the deceased 2. Sex 3. Date of birth 4. Occupation: (a) Occupation of the deceased- -- (b) Occupation of the head of household 5. Whether death by disease, suicide, other violence, or poison- .. 6. Name of disease, means of suicide or kinds of other violence or poison - 7. Date of beginning of disease (if death by suicide, other violence, etc., this clause omitted) -- 8. Date of death 9. Place of death I certify the above mentioned. Dated , Physician. For 1, write the name written on the family register book. When the name is not evident, as in the case of suicide, other violent death, etc., write it as unknown. For 2, when the sex is not distinct on account of a time-worn corpse, write it as unknown. For 3, when the date of birth is not evident on account of suicide, other violent death, etc., write a conjectured age; and if it could not be conjectured, write it as unknown. For 4, when the deceased is the head of household, write the occupation of the deceased only; when the deceased has no definite occupation on account of being young, old, female, etc., write it as "has not," and write the occupa- tion of the head of the household. When the deceased has a definite occupa- tion and is not the head of household, write collaterally the occupations of the deceased and of the head of household. The nomenclature of occupation should not be limited to the use of simple broad terms, as a "merchant" or "manufacturer," but be written in detail as to what [kind of a] merchant, what [kind of a] manufacturer, etc. When the occupation is not certain on account of the case being suicide, other violent death, etc., write it as unknown. For 5, write the distinction of whether the death is by disease, suicide, other violence, or poison. For 6, when the death is by disease, do not write any other matter than the name of disease. When death is caused by two or more diseases, and if one is primary and the others are secondary or after-diseases, write the primary disease only. If each disease is an independent one, write the disease that became chiefly the cause of death. If the distinction is found impossible, write collaterally all the diseases. When the disease as cause of death can not be determined, write it as unknown. As for suicide, write the means of it, as, for instance, by hanging or strangulation, by drowning, or by cutting instruments. As for other violence and poison, write the kinds of them, as, for instance, by accidental drowning, crushing, burns, murder, poison of Fugu (a kind of tetrodon), poison of alcohol, etc. 35 For 7, as for death by disease, write the date of beginning of it; if it is not evi- dent, write conjectural date, and if it is impossible to conjecture, write it as unknown. For 8, no matter whether the death is by disease, suicide, other violence, or poison, write the date of death. If the date of death is not evident, as in the case of suicide or other violence, write conjectural date, prefixing the word "con- jectural." 6. Sweden. Physicians are supplied with a copy of the classifica- tion of causes of death and an alphabetical list of diseases referred to the proper classification number. On the first line of the following form, which is part of the certificate of death, there is to be written the principal cause of death (hufvuddodsorsak) and its classification Dumber, while the following lines are for the contributory causes (bidragande dodsorsaker). [53] Sweden. X 1. Hufvuddodsorsak: Nomenkl. /,.-,' Bidragande dodsorsaker: 7. Switzerland. The methods employed by the Federal Bureau of Statistics of Switzerland deserve special consideration on account of the great pains taken to frame the interrogations as to cause of death, the very explicit instructions, and the provision for a confidential report by the attending physician. A slightly reduced copy of the blank is presented herewith, together with a translation of that part of the blank relating to statement of cause of death and including the sug- gestions to the physician as found upon the reverse side: 36 [54] Switzerland. X . Nom du decede: La notice pour les offlciers de 1'etat civil se trouve au verso. J9&= Le mdecin est pri6 de bien vouloir: 1 repondre le plus tot possible aux questions 8 a 10, en tenant compte des observations iiiscrites au verso, mais seulement apres 1'autopsie, si celle-ci a lieu; 2 controler les reponses donnet-s aux questions 1 a 7 par 1'offieier de 1'etat civil et, cas ch6ant, les computer; 3 apres avoir enlev le present coupon, mettre le bulletin dans 1'enveloppe ci-jointe, fermer cctte derniere et la mettre sans retard a la poste. Masculin. Arrond 4 d'etat civil:... Registre des deces 190... District: 1. Decede" le .' ---a--- ... heures 2. Lieu du deces (Commune): -- (Quart., etc.; hop., 6tabl., etc.) "" Pour les non domicilies au lieu du deces, duree du sjour: 3. Profession du decede: Position dans 1'entreprise: ... Nature de 1'entreprise:-- Si le dfunt a moins de 15 ans, pro- \ fession du pere * ou de la mere *: j 4. Etat civil : celibataire* marie* veuf * d i vorce*. P* les enfants au-dessous de 5 ans: 16git.* illeg.* mis en pension *. 5. Commune d'origine:. 6. Commune de domicile: ... 7. Ne le -* -. 1- 8. Declaration me'dicale de la cause du deces : a. Maladie primitive ou cause primaire. ( En cas de mort violente, indi- (fuer le genre et la cause, date deT accident, du suicide, etc ) b. Maladie consec. et cause immediate de la mort c. Maladies concomit. ou circonst. dignes d'etre mentionnees 9. Autopsie: Oui* Non*.- 10. Observations: (Condit. sanit. de 1'habitation, etc. Voir au verso. ) Le medecin traitant* appele apres la mort*: * Souligner les mots qui se rapportent a la personne. 8. Medical statement of the cause of death. a. Primitive disease or pri-1 inary cause. (In violent d&titu, state kind and I cause, date of accident, of sui-\ dill . iff. * l>. Consecutive disease and | immediate cause of} death. c. Concomitant or circumstan- tial diseases worthy of be- ing mentioned. 9. Autopsy: Yes* No.* 10. Observations: - (Sanitary condition of habita- tion, etc. See other side. ) - The physician attending * called after death * (Signed) ...of jjgp * Underscore the words which apply to the case. DIRECTIONS FOR USE OF SWISS BLANK. According to the directions given on the detachable part above the perforated line, the physician is requested (1) to fill out questions 8 to 10, having regard to the "Observations pour le medecin" or special suggestions printed on the back of the blank, and waiting until after the post-mortem, if any be held, before entering the cause of death; (2) to check the replies to questions 1 to 7, correcting them when necessary; and (3) to detach the coupon and mail the certificate, with statement of cause of death, to the local registrar (Pofficier de 1'etat civil) in a sealed enrelojte especially supplied for this purpose. [This is a " penalty envelope," which goes post free in the mails; it bears the inscription "Statistique de deces" in the upper right-hand corner in lieu of a stamp, and in the left corner above, the words "Controle: No. of the Register of Deaths," with the physician's signature in the corner below. This enables the local registrar to identify the return of cause of death as being made, without opening the envelope, which he is forbidden to do. He sends it intact to the Federal Bureau of Statistics at Berne at the end of each month, where it is used solely for statistical purposes, and thus the confidential statement of the physician as to the cause of death is absolutely guarded.] SUGGESTIONS TO THE PHYSICIAN. Questions. Please distinguish with care the primai^y or causal disease (8a) and the consecutive or secondary disease (8b). Question 8a is important from the viewpoint of hygiene and sanitation, but it is often difficult to answer; sometimes a reply is uncertain or impossible to give. In the latter case indicate by dash after the question 8a, and, if the answer is uncertain, add a question mark. In violent deaths it is necessary to state exactly the nature, the cause, and the date, and to also indicate whether the death was due to suicide (motive: mental disease, alcoholism, etc.), to homicide or to accident. It is generally easier to reply to question 8b, because it most frequently relates to what the physician has been able to observe during life or after death (autopsy? question 9). There should be inserted here the results of accidents, e. g., the nature 38 and the seat of the lesions, fractures, dislocations, cerebral affections, secondary inflammations, etc. Question 8c. Here indicate the pathological processes which accompanied the prin- cipal disease and which have influenced its course and result, as, for example, cur- vature of the spine in diseases of the lungs or heart, alcoholism with the acute diseases, mental diseases, etc. [The remainder of the suggestions relate to sanitary observations, and show how the confidential communication between the physician and the central bureau of public health may be utilized to convey much information of value to the sanitary service of the state not ordinarily obtainable from mortality returns.] NOMENCLATURE OF CAUSES OF DEATH. As an indispensable aid in securing brief and precise statements of cause of death Swiss physicians are supplied with a " Nomenclature of the Causes of Death," similar to those issued by the governments of Sweden, Holland, Germany, and other countries, and to the pamphlet, "Relation of Physicians . to Mortality Statistics," distributed by the United States Bureau of the Census some years ago to every physician in the United States. In this list are indicated by single asterisk (*) diseases frequently secondary, and by double asterisks (**) diseases usually or exclu- sively secondary, so that the Swiss physician has a practical guide to aid him in filling out the form correctly. Here are some examples: Acute bronchitis and broncho-pneumo- Aneurism.** nia.* Meningeal apoplexy.* Bronchial asthma.* Cerebral hemorrhage.* Putrid bronchitis.** Abscess of brain.** Gangrene of lungs.** Convulsions.** Pleurisy.* Acute parenchymatous nephritis.* Empyema.** Acute nephritis of pregnancy. Acute pericarditis: Chronic parenchymatous nephritis.* a. Simple.* Chronic interstitial nephritis.* 6. Purulent.** Suppurative nephritis.** Endocarditis.* Etc. Acquired valvular disease.** CORRECTION OF UNSATISFACTORY STATEMENT OF CAUSE OF DEATH. Not only is there a very precise blank provided for the statement of cause of death by the Swiss physician, together with explicit instructions, a detailed nomenclature showing the relations of individual diseases, and a system of post-free confidential communication assured against violations of secrecy and professional confidence, but the central office also carries out a " follow-up system," which assures that the occa- sional cases of ignorance or neglect of the proper form of statement are promptly corrected. Here is the form: FEDERAL BUREAU OF STATISTICS, Berne, , 190 Dr. DEAR DOCTOR: You have delivered a certificate of death for a person of male female sex, occupation __,born ___, died __ , at _. ., St. _. ..., No. ._ ._., from: ^in^ ff //A,. 39 The disease indicated as a cause of death being regarded as a I will ask you to kindly inform me of the primary cause of the death, wl important to know from the point of view of statistics, as well as from the point of view of public and private hygiene of the sanitary administration. Thanking you in advance, I remain, Very respectfully, The Director, Federal Bureau of Statistics: Dr. GUILLAUME. [On the opposite page are the questions.] What are the sanitary conditions of the habitation? (Question 10 of the card report of the death. ) Hereditary predisposition? Mode of infection? Accident, suicide, homicide? In what way did the accident occur? Probable or certain motive for suicide? ._ TERMINOLOGY AND ARRANGEMENT OF TERMS EMPLOYED UPON CERTIFICATES OF DEATH TO DENOTE CAUSES OF DEATH. Casual examination of the various forms of certificates of death will show that a great variety of expressions has been employed for the purpose of securing a statement of cause of death. These may be brought together for comparison in the following tabular list: First term. Second term. (Subsequent terms, if any.) The CAUSE OF DEATH Chief Chief Immediate ............... Cause of death Primary Chief Cause of death (secondary or immediate) Disease or cause of death Primary 1 rn [1] Immediate True cause of death Contributory. Contributory (if any). Immediate. Contributory. [No second term.] Contributory. Contributing. Contributory (primary). [No second term.] Immediate (when a complication or consequence of the primary). 1 f[2] Immediate. 1 Primary Immediate '. Cause of death Primary Primary Causes of death [in order of occurrence] . Causes of death [in order of occurrence physi- cian is requested to underline that which he considers the most important] . /Immediate and determining \Immediate,proximate,or chief and determining 1 . Chief and determining [1] Disease causing death [1] Mode of injury; accidental, suicidal, or homi- lemote or predisposing ........................... Disease, injury, or other efficient and remote cause of death. f] immediate .................................... Cause of death (immediate) ...................... Chief or primary .................................. First (primary) .................................... First or primary ................................... Primary disease ...... (a) .......................... Primary (actual) First Primary or contributing. Symptoms (when true cause is not certainly knoum). 1 Secondary or contributory. Contributory causes or complications. Complication. Immediate. Secondary. Contributing cause or complication. Contributory causes or complications. 1 Consecutive and contributing. 2] Immediate cause of death. 3] Contributory causes or complications. Post-mortem. f[2J Nature of injury and immediate cause of contributory causes or conditions. 1 4] Post-mortem. mmediate. Disease, injury, or other efficient and immediate cause of death. (b). ). ame of disease (remote). Contributory or immediate. Second (immediate). Secondary. Secondary diseases (if any) Secondary diseases (if any) Secondary diseases (if any) Secondary (contributing). Second. 2 - Secondary 3. Final. Disease or accident causing death ................. {chronic Primary disease ................................... Complications of the disease or terminal condi- tion. Primary disease ................................... Secondary or after disease. Principal cause ............................... ..... Contributory cause. [2] Consecutive disease and immediate cause of death. [3] Concomitant or circumstantial diseases worth y of note. 41 Autopsy: Yes - ; No - . [1] Primitive disease or primary cause. [1] Nature and cause of accident, suicide, etc Results of accidents. iFrom instructions or alternative modification of regular form. (40) 41 What a conglomeration! Are all of these terms and their relations definitely understood by the physicians and registrars who employ them ? It may be well, with the aid of certain authorities available for ref- erence, to analyze them, and to see just what meanings may be attached to the more important ones. Some of the terms are those of ordinary language, so that reference to a general dictionary should be sufficient. Others are used in a more or less technical sense, so that medical dictionaries would seem likely to be more useful. For convenience the more important ones will be listed in alphabetical order, without regard to their usual occurrence as first or second terms, and the definitions given in three dictionaries in common use in the United States will be compared: (a) Dorland: American Illustrated Medical Dictionary; (b) Gould: Illustrated Dic- tionary of Medicine, Biology, and Allied Sciences; and Dictionary of New Medical Terms; (c) Webster's International Dictionary of the English Language. Omission of a reference shows that the word or term is not defined in the work in question. DEFINITIONS OF MORE IMPORTANT TERMS. Chief. (c) 1. Highest in office or rank; principal; head. 2. Principal or most eminent in any quality or action; most distinguished; having most influence; taking the lead; most important. Syn. Principal; head; leading; main; paramount; supreme; prime; vital; especial; great; grand; eminent; master. [Note that pri- mary is not given as a synonym.] Chief cause. [Not specially defined in any medical or general dictionary. This term was probably employed upon certificates of death as an approximate equiva- lent or substitute for primary cause, but without retaining the idea of necessary priority in time of development and causal relation to other causes. Some modes of use upon certificates of death are as follows: First term. Second term. Chief Contributory. Chief Immediate. Chief and determining Consecutive and contributing. Immediate proximate or chief and determining. . Contributory causes or complications. Chief or primary ; Contributory or immediate. The transition of meaning may be seen in these groupings. The term is ambig- uous, meaning either (1) most important (for what?), or (2) primary (original). Thus, in a death from typhoid fever followed by bronchopneumonia (complication), the "chief cause of death" might, in the opinion of the attending physician, be either typhoid fever or bronchopneumonia, in the latter case the secondary disease or condition being regarded as the immediate or determining factor, and hence the most important as directly bringing about the death, which might not have occurred except for such complication.] Complication. (a) 1. A disease or diseases concurrent with another disease. 2. The occurrence of tw r o or more diseases in the same patient. (/)) A disease or process secondary to or more or less dependent upon some primary disease. 42 (c) (Med.) A disease or diseases, or adventitious circumstances or conditions, coexistent with and modifying a primary disease, but not necessarily connected with it. [This term is always used in a subordinate relation: First term. Second term. Primary Immediate Cause of death Immediate and determining. Primary disease Immediate (when a complication or consequence of the primary). Contributory causes or complications. Complication. Contributing cause or complication. Complications of the disease or terminal condi- tions. Complications frequently include mere symptoms, and the term is apt to lead to the statement of inconsequential details upon the certificate of death. Complica- tions are frequently understood to be necessarily secondary in character to the primary disease, but they may equally well include independent intercurrent diseases.] Contributory (or contributing). (c) Contributing to the same stock or purpose; promoting the same end; bringing assistance to the same joint design, or increase to some common stock. Contributory cause (or contributing cause). [This term is not given in medical or general dictionaries, although it is very extensively employed in the United States. It is found upon the standard certificate of death, prepared by the cooperation of the Census and the American Public Health Association, which is used for the tran- scripts of all deaths (over 650,000 yearly) returned to the Bureau of the Census, as well as by many states and cities upon their individual blanks, whether of standard or other form. In the standard certificate, the term is subordinate to the "CAUSE OP DEATH." It is generally secondary in character, if the diseases are related as to cause and effect; if not so related, it may connote any independent disease aiding the principal cause of death. It should not include mere symptoms or trivial complica- tions which do not materially contribute to the fatal result. In modifications of the standard certificate used in different states and cities the term is employed in various connections, and has even been taken as the primary cause, although always coming second in the order of statement. Among the arrangements found are the following: First term. Second term. CAUSE OF DEATH Chief Immediate Primary Cause of death (secondary or immediate). Immediate Primary Immediate and determining Chief and determining Chief or primary Primary (actual ) Contributory. Contributory. Contributory. Contributory. Contributory (primary). Primary or contributing. Secondary or contributory. Contributing cause or complication. Consecutive and contributing. Contributory or immediate. Secondary (contributing). There is evidently great confusion in the practical use of this term, due, perhaps, to the fact that all causes of death aiding to produce the fatal result in any case are "contributory" to the death. The term does not mark with clearness the distinc- tion between primary and secondary or concurrent causes, and for this reason the Bureau of the Census, and it is believed also the various offices using the standard blank, wall welcome any change of form conducive to greater precision of state- ment.] 43 Determining. Determining cause. (6) A cause that precipitates the action of another or other causes. [Only a single definition of "determining cause" is found in the three authorities consulted. For "determining," reference may, of course, be made to the various meanings of the verb determine, as found in any general dictionary; but which precise signification of this word is applicable does not seem certain. The term "determin- ing cause" is extensively used relative to the causation of disease, and considerably, but to a less extent, upon death certificates. Another medical dictionary 1 thus defines it: "A cause that gives efficiency to other causes, precipitating their action." Both of these definitions seem to make determining causes of merely subsidiary impor- tance, as hastening or helping the action of other (efficient) causes. Dr. Lewellys F. Barker 2 , in a passage which may be quoted in full for the purpose of showing the relation of various other terms, makes it equivalent to the efficient, proximate, immediate, or direct cause. "All pathologists are now agreed that by far the majority of pathologic conditions are the result of external causes; i. e., are due to inimical environmental influences. These are divisible into (1) efficient causes and (2) predisposing and accessory causes of disease. "The efficient causes of disease (causx proxlmse sire determinantes) are the immediate or direct causes. Thus the cholera-spirillum is the efficient cause of cholera, the micrococcus lanceolatus is the efficient cause of acute lobar pneumonia, the heat of the sun's rays of insolation, lead-poisoning of wrist-drop. " The predisposing and accessory causes of disease (causse predisponantes sire remotss) include those which render the body more susceptible to the efficient cause. Thus, external agents which render the contents of the stomach alkaline are believed to predispose to infection with the comma-bacillus of cholera; exposure to cold and wet predispose to lobar pneumonia; alcoholism predisposes to insolation; and certain occupations make lead-poisoning possible, and in a sense may therefore be regarded as remote causes of lead paralysis. That an efficient cause of one disease may be a predisposing cause of another disease, and vice versa, is obvious." Stengel 3 says, "The causes of disease may be classified as predisposing and deter- mining. The former prepare the system or part by rendering it weaker and less resistant; the latter are the immediate or specific causes of disease," and, under "Determining causes," he says: "Among the immediate or determining causes of disease are those which originate outside the body and those which are generated within the body. Among the former are included traumatism, heat, cold, and living organisms, including bacteria and various animal parasites." As the deter- mining (= efficient = proximate = immediate = direct) cause of a disease, e. g., typhoid fever, is the bacillus typhosus, so the disease itself (the pathologic entity called typhoid fever, with all its complications and sequelae) is sometimes taken as the determining (= efficient = proximate = immediate = direct) cause of death. As found upon death certificates, the term occurs always in combination, and in the first place: First term. Second term. Immediate and determining . . Contributing cause or complication Immediate proximate or chief and determining.. Chief and determining Contributory causes or complications. Consecutive and contributing 1 Foster: An Encyclopedic Medical Dictionary. 2 Introduction, American Textbook of Pathology, s. A Text Book of Pathology, third edition, page 18. 44 However useful the word may be in connection with causes of disease, its employ- ment in connection with causes of death is vague and indefinite.] Immediate. (a) Direct; with nothing intervening. (6) Direct; withou t anything intervening. (c) 1. Not separated with respect to place by anything intervening; proximate; close. 2. Not deferred by an interval of time; present; instant. 3. Acting with nothing interposed or between, or without the intervention of another object as a cause, means, or agency; acting, perceived, or produced, directly; as an immediate cause. Immediate cause. (a) An exciting cause that is not remote or secondary; any cause 'which is operative at the beginning of an attack. (6) See C., Proximate; and, making the reference, we find that primary and proximate causes are thus defined: "C., Primary, C., Proximate, that one of several causes which takes effect last and acts with rapidity." [Another medical dictionary (Dunglison) refers the term to " essential or proxi- mate cause," an essential cause being defined as "one that produces the effect with- out regard to other causes." See identity with efficient, proximate, determining, and direct causes of disease, as used by writers on pathology, under "Determining cause," supra. The term is very frequently and most confusingly employed upon certificates of death in this country : First term. Second term. Chief Immediate Immediate. Contributory. Cause of death (secondary or immediate) ........ I Contributory (primary). Primary ........................................... ! Immediate (complication or consequence of the primary). m RpmotP 7L 2 J Immediate. [1] Remote ........................................ UhJ Concurring . Immediate ........................................ | Primary or contributing. Immediate ........................................ i Contributory causes or complications. Primary ........................................... ! Immediate. Immediate and determining ...................... Contributing cause or complication. m nispncp r>anino-riPflth /I 2 ] Immediate cause of death. Disease causing death ......................... ^ 3 j Contributory causes or complications. Remote or predisposing ........................... ; Immediate. PI Primitive disease or primary cause of death ...... i Consecutive disease and immediate cause of death. In its practical use upon certificates of death it has at least three distinct meanings: (1) As a term subordinate to the principal term ("Chief cause," "Primary cause," " Remote cause," "Disease causing death," etc. ), and indicating the special patholog- ical process, condition, or complication through which the disease itself, or primary cause, brings about the fatal result. Thus, in a case of typhoid fever the on mediate cause of death might be a secondary pneumonia, perforation of the intestine, peri- tonitis, or hemorrhage of the bowels, all consequences and properly a part of the original disease. In the only foreign blank in which this term occurs, that of Switz- erland, it appears to bb used in this way. (2) In a very different manner, the term is employed to indicate the principal or even primary cause of death, being followed by subordinate terms, such as "Contributory cause," "Primary or contributing cause," " Contributory causes or complications," etc. (3) In common with the synonymous term, proximate cause, it is frequently understood by physicians as merely indicating the mode of death, e. g., asphyxia, "heart failure" or syncope, coma, etc. Thus Quain's Dictionary of Medicine, under "Death, modes of," says, "The proximate causes of death, whether resulting from natural decay, disease, or violence, may be reduced in ultimate analysis to two, namely, first, cessation of the circulation; and, second, cessation of respiration." "Shock," "debility," "exhaus- tion," and also terms representing terminal conditions, such as "hypostatic pneumo- 45 nia," "uremic convulsions," and the like, are frequently reported as the immediate causes of death.] Primary. (a) First in order; principal. (6) First in time or in importance. (c) 1. First in order of time or development or intention; primitive; fundamental; original. 2. First in order as being preparatory to something higher. 3. First in dignity or importance, as chief, principal. [There are other significations of the word ''primary" as employed to qualify names of diseases or causes of death, as indicated by the definition in the New Sydenham Society's Lexicon: "Primary. (L. primarius, of the first rank.) A term used in a variety of senses in medicine; e. g., to denote the original site of a disease (primary seat of a new growth), or its earliest manifestations (primary syphilis); often used in opposition to secondary, in cases in which the morbid condition so indicated is viewed as the main disease, and not as a secondary effect, e. g., primary lateral sclerosis = idiopathic lateral sclerosis."] Primary cause. (a) The principal or original cause of an attack. (b] C., Proximate, that one of several causes which takes effect last and acts with rapidity. [See also another medical dictionary (Foster): "Primary cause, proximate cause. That one of two or more causes that comes into play last and produces its effect with comparative rapidity." The last two definitions seem at variance with the first, and explain how, the immediate (proximate) and primary causes of disease being con- sidered the same, 1 so likewise the immediate and primary causes of death come to be treated as identical. In England, at least in its official use for registration pur- poses, the term has been uniformly employed to show precedence in time or causal relation. In the First Annual Report of the Registrar-General (1837), Doctor Farr stated: "When after hooping cough it was stated that the patient died of pneu- monia, the case has been referred to the primary disease; and the same principle has been adhered to in similar instances." And in the Thirteenth Annual Report: "It has been the general rule, in the classification, to refer the secondary affections that supervene in the course of measles, scarlatina, phthisis, and other diseases, to the primary diseases by which they are caused or modified, and the diseases that are the direct result of external causes to those causes." The certificates of death supplied to physicians as early as 1845 provided for the statement of primary and secondary causes, as do those in use at the present time in Great Britain and many of the British colonies. Up to a recent date the "Suggestions to Medical Practi- tioners respecting Certificates of the Cause of Death" 2 contained the following para- graph: "Write the causes of death, when there are more than one, under each other, in the order of their appearance, and not in the presumed order of their importance." The accepted English arrangement (primary, secondary) is of very infrequent occur- rence in this country, the term primary cause being usually opposed by some other term, as contributory cause, immediate cause, etc., as shown by the following comparison: First term. Second term. Primary Contributory Cause of death (secondary or immediate) Contributory (primary). Primary Immediate Immediate Primary or contributing. Primary Secondary or contributory. Primary Secondary. Chief or primary Contributory or immediate. First (primary) Second (immediate). !Cf. Barton-Wells, Thesaurus of Medical Words and Phrases: "Immediate cause of disease Essen- tial, proximate, or primary cause," and "Predisposing cause of disease Antecedent, procatarctic remote, or secondary cause." 2 See Newsholme's Vital Statistics, third edition, page 72. 46 Even in England, after over sixty years of continuous use of the terms "primary" and "secondary" upon the official blanks, there is confusion as to their proper significance in the minds of many medical practitioners. Following are the conclu- sions of the Select Committee on Death Certification of the House of Commons (1893) on this subject, together with the testimony upon which they were based: Hicks, 1325. (C.) It appears that there is some confusion in the minds of medical Tatham, 2010. men as to the meaning to be attached to the words "primary" and Vallance, 2267. "secondary," in the space provided in the form for setting foVth the Grimshaw, 775. cause of death. The words are interpreted by some as meaning the Sykes, 450. "primary cause chronologically, and by others as the primary cause phj-sically of death." The forms are filled up in accordance with these different interpretations. Sykes, 450. The result of this is that in many instances the certificate does not Wells, 691. give correct information as to the cause of death, and it is difficult for a person from mere inspection of the certificate, and without having seen the patient, to say what was the immediate cause of death. Your committee are of opinion that it is desirable that the words "primary" and "secondary" should either be omitted from the form as leading to confusion in stating the cause of death, or that they should be defined in a footnote as meaning the order of the develop- ment of the diseases as they occurred. In the event of the entire omission of the words, some other terms should be substituted so as to secure the declaration in all cases of associated diseases or associated traumatic conditions. [Testimony.] 450. [Mr. J. F. J. Sykes, M. B.] ^yill you tell the committee now, as briefly as you can, the directions in which you think the present system of certification is defective as regards the'causes of death? The difficulty arises when those who have to extract these causes of death and classify them, find either a number of terms not used in the ordi- nary form of classification, or else a multitude of terms without any guide as to which of the several terms the death should be classified under, and it is extremely difficult for persons seeing only the certifi- cate, and not the patient, "to know the real cause, the true cause from which the patient died, and under which the death should be classi- fied. The certificate of the Registrar-General contains under the "Cause of death," the words "primary" and "secondary." In my opinion those are more misleading than useful, for this reason: that they are interpreted by some as being the primary cause chronolog- ically, and by others as the primary cause physically of death; so that the two interpretations that they are open to do not coincide. And as far as chronological order is concerned, they are unnecessary, inas- much as at the other end of the line under the "cause of death" there is a space for stating the duration of each cause in years, months, days, or hours. I would suggest that the words "primary" and "second- ary" should be omitted altogether from the certificate, and that it should be made compulsory to state the duration of the complaint or the approximate duration, so as to form some sort of guide as near as possible. 451. You think those terms lead to confusion? I think those terms lead to confusion. 691. [Sir Spencer Wells, M. D., F. R. C. S.] And in what way; would you give us an illustration of that insufficiency? That the registered cause of death was not sufficiently precise; that one could not tell from the terms exactly what weia the alleged causes of death; that they were inaccurate and insufficient; that you want full informa- tion as to the cause of death. 692. And you believe that fuller and more detailed information of the cause of death would lead to a greater value being given to the sta- tistics of the Registrar-General, and secondarily (and this is a most important point) to an improvement in the national health? Distinctly. 775. [Thomas W. Grimshaw, M. D., Registrar-General for Ireland.] With regard to that we have had evidence given here that the division of the causes of death into primary and secondary is undesirable. What is your opinion upon that subject? It would not be undesirable if 47 properly used, but there is a great deal of confusion in the minds of medical men as to what is primary and what is secondary. 776. Would you suggest the omission of those words or the substi- tution of others? I do not know really any way in which we could amend the certificate so as to get rid of that ambiguity, because it is in the mind of the man who certifies, it is not in the form of the certifi- cate. If we could get a specific cause mentioned and then get the med- ical man to add a descriptive note as to how this state of things was arrived at which caused the man to die, it might be of very great value; but I do not think we could succeed in doing that. If we were to ask him to voluntarily give us any other information that threw light upon the case, he might do so, but he might become a very great nuisance; some would write a great deal too much. 1325. [Mr. A. B. Hicks, coroner, London.] Do you want the words "primary" and "secondary" altered? I wish to put in the primary cause with the duration of the illness, and the secondary cause also, and then, if there is one, the immediate cause of death. 1326. Then you would still retain the words "primary" and "sec- ondary"? They are somewhat misleading, I think. I do not say I would insist myself upon them, but at any rate there should be some words which may really lead to the cause of the decease, if the doctor knows it, and how it runs its course, with the symptoms; that it is essential to get, and then the immediate cause of death, if he knows it. Then I should suggest a note at the bottom of the certificate, which he should fill up, if he can: "Facts which may be known to the medical man w r hich may bear upon the cause of death, and which he considers desirable to state." 2010. [Mr. John Tatham, M. A., M. D., then medical officer of health for Manchester, now statistical superintendent of the department of the Registrar-General of England and Wales.] If you would kindly make such remarks as you think fit. I think in the first place that the space left for the cause of death should be. enlarged. I think it should also be explained what is the real meaning of the terms "primary" and "secondary " whether they refer to time or to the relative importance of the causes of death. That is a point upon which certificates are fre- quently indefinite. As I have said before, I think the certificates should be delivered to the registrar direct, and I attach very great importance to that. 2267. [Mr. William Vallance, superintendent registrar, Whitechapel district.] You say that you have reason to believe that there is a good deal of lax certification both as regards the mode of filling up the cause of death and the circumstances under which the certificate is given. Will you illustrate that point? I consider that the words "During the last illness" require some explanation as to what is to constitute the attendance during the last illness, and, therefore, appended to the cer- tificate it appears to me there needs to be an instruction to the medical practitioner. And next, with regard to the cause of death, the words "primary" and "secondary" are somewhat misleading, or, at all events, they are differently interpreted; so that if statistical results are recorded from one or the other they may be fallacious in their results. I would much prefer myself I think it would be much more simple if the actual disease which is the immediate cause of death were recorded in the column headed "Cause of death," with the dura- tion of the disease, and an observation column appended, not for reg- istration but for transmission to the statistical authority. The committee did not, however, suggest the "other terms" which should satis- factorily replace those in use. Secondary. (a) Second or inferior in order of time, place, or importance. (6) Following, succeeding to a first. Subordinate in order of time or develop- ment. (c) Succeeding next in order to the first; of second place, origin, rank, etc.; sub- ordinate; not of the first order or rate; not primary. (Med.} a. Dependent or con- sequent upon another disease; as, Bright' s disease is often secondary to scarlet fever. 6. Occurring in the second stage of a disease; as, the secondary symptoms of syphilis. 48 Secondary cause. (a.) One which helps to bring on an attack of disease. [Another dictionary (Dunglison) refers "remote or secondary cause" to "predisponent cause; one which renders the body liable to disease." It is evident that these definitions relate to the secondary cause of disease and that they are quite the opposite, in time relation, to the sense in which the term is used as applying to causes of death. Although the proper associate of primary cause (q. v.), the term is quite rarely used in this country upon certificates of death, and when used is probably frequently understood in the sense of minor rather than according to the original statistical usage of consecutive and resulting from the primary cause. Some examples of use are as follows] : First term. Second term. Primary \ Secondary or contributory. Primary | Secondary. Secondary (contributing). Primary (actual ) Cause of death (secondary or immediate). Contributory (primary). Only the more important terms that actually occur upon certificates of death are considered in the preceding examination of definitions. These are: "Chief cause," "complication," "contributory (or con- tributing) cause," "determining cause," "immediate cause," "pri- mary cause," and " secondary cause." Other terms occurring less fre- quently, or used chiefly in instructions, are : " Concurrent (or concur- ring) cause," "consecutive cause," "consequence," "efficient cause," "final cause," "predisposing (predisponent) cause," "remote cause," "sequela," "symptom," and "terminal cause." Among these the fol- lowing are defined : DEFINITIONS OF LESS IMPORTANT TERMS. Concurrent (c) 1. Acting in conjunction; agreeing in the same act or opinion; contributing to the same event or effect; cooperating. 2. Conjoined* associate; con- comitant; existing or happening at the same time. ["Concurrent cause" or "concurrent disease" is not found in the authorities cited, but " intercurrent disease" appears as follows: (a) "A disease occurring during the course of another disease with which it has no connection." (6) "A disease occurring during the progress of another of which it is independent," and also, else- where, "A term loosely applied to diseases occurring sporadically during a period of prevailing endemic or epidemic diseases. Also applied to a disease arising or pro- gressing during the existence of another disease in the same person."] Efficient cause. (c) The agent or force that produces a change or result. Final cause. (c) The end, design, or object for which anything is done. [Not used in this sense upon certificates where it means a terminal cause, i. e., symptoms or conditions attending the fatal termination of the disease.] Predisposing (or predisponent} cause. (a) Anything which renders a person liable to an attack of disease without actually producing it. (b] That which tends to the development of a condition. (c) (Med.) Causes which render the body liable to disease. Proximate cause. (a) That which immediately precedes and produces a disease. (6) The immediate cause of any change. (c) A cause which immediately precedes and produces the effect, as distinguished from the remote, mediate, or predisposing causes. 49 [Usually equivalent to immediate cause. The new Sydenham Society's Lexicon thus defines it: "The term is used by some in the sense of the disease itself; by others as meaning those morbid processes which the exciting cause induces; by others as denoting the morbific cause itself." The same causes may be either " proximate " or " ultimate," according to the previous direction of thought: (Quain's Dictionary of Medicine; "Death, modes of.") "The proximate causes of death, whether resulting from natural decay, disease, or violence, may be reduced in ulti- mate analysis to two, namely, first, cessation of the circulation; and, second, cessa- tion of respiration," (Flint's Encyclopedia of Medicine and Surgery; Death, modes of.) "Failure of the heart or of the respiratory mechanism is always the ultimate cause of death."] Remote cause. (a) Any cause which is not immediate in its effect; a predisposing, secondary, or ultimate cause. Sequela. (a) Any lesion or affection following and caused by an attack of disease. (b) The consequence or abnormal condition following an injury or the abatement of a disease; any diseased or abnormal condition that folio ws an attack of disease or an injury. (c) ( Med. ) A morbid phenomenon left as the result of a disease; a disease resulting from another. Symptom. (a) Any evidence of disease or of a patient's condition; a change in a patient's condition indicative of some bodily or mental state. (b) That change or phase which occurs synchronously with a disease and serves to point out its nature and location. (c) Any affection which accompanies disease; a perceptible change in the body or its functions, which indicates disease, or the kind or phases of disease. Terminal cause. [Not defined. But see "Final cause" above.] Ultimate cause. (a) One which may be considered the original cause in point of time; the most remote cause. (6) One which eventually comes into play aided by a proximate cause. To these definitions might be added two others which are frequently to be considered in vital statistics, although not expressly stated: Hidden cause. An undiscoverable cause. Obscure cause. (L. obscurus, dark.) A cause not definitely known. APPLICATION OF TERMS IN CERTIFYING CAUSES OF DEATH. It is evident in comparing the definitions of various causes as found in medical and general dictionaries and works of reference, and which the physician would ordinarily consult in attempting to understand the requirements of the official blanks, that they relate almost exclusively to causes of disease and do not apply to causes of death except by impli- cation or transference of meaning. It is not surprising, therefore, that their use in the latter connection is not well defined. Thus, the Bacillus typhosus is the efficient, proximate, immediate, determining, or direct cause of the disease known as typhoid fever; it has also been termed the primary cause, in which case all antecedent causes would be termed secondary. Typhoid fever itself, the disease resulting from an invasion of the typhoid bacillus, is the primary cause of death in a fatal case of typhoid fever; it may also be reported as the immediate, determining, or direct cause of death. The disease-entity known as 915907 4 50 typhoid fever properly includes all of the secondary pathological con- ditions and processes resulting from the development of the specific infection, such as ulceration of the intestinal Lymph-follicles, perfora- tion of the intestine and resulting peritonitis, intestinal hemorrhage, bronchopneumonia or lobar pneumonia clue to the typhoid bacillus (but not independent intercurrent pneumonia due to Pneumococcus), terminal phenomena such as hypostatic pneumonia from impairment of circulation, and modes of dying " heart failure," exhaustion, debility, coma, and the like. Any of the secondary affections, or even terminal conditions and modes of d}ang, is likely to be entered upon the certifi- cate of death as the proximate, immediate, direct, or determining cause of death; or even, when the form of the blank facilitates it, as the primary or chief cause of death, leaving the disease itself in the position of a secondary, contributory, or remote cause, if reported at all. In considering the application of various terms to the certification of deaths, the broad and fundamental distinction necessary in vital statistics must be borne in mind. All deaths are divided into two great classes, namely, (1) deaths from disease, and (2) deaths from vio- lence. A third subdivision, due solely to imperfections in the returns or impossibility of securing exact information to make the distinction, would include deaths the causes of which are absolutely "unknown." It should not include deaths from ill-defined diseases or from violence whose exact character is not certain. Such deaths should at least be distinguished as due to diseases of unknown or unspecified nature, or as due to traumatism or some unknown form of violence. It may be mentioned that the term ""violence" is an entirel3 r general one and includes all deaths not due to disease; poisons (not autointoxications proper), effects of weather agencies, as sunstroke, etc., are included as well as the usual forms of violence due to accident or negligence, suicide, homicide, war, and execution. (1) Deaths from disease. As an illustration of the complexity of the relations involved and of the necessity for a precise understanding of the terminology to be employed in reporting causes of death, a not unusually complicated fatal case of typhoid fever may be selected. 51 Causation, course, and fatal termination of case of typhoid fever. Phenomena. A. CAUSATION OF DISEASE. (1) A previous case (2) Dejecta containing typhoid bacilli, not disinfected. t :' i A young man, Cause of disease. (4) whose "vital resistance" ("opsonic index"?) maybe low- ered by insanitary conditions, e. g., tilth, crowding, bad air, adulterated or insufficient food, <5) drinks infected water or milk which con tains - (6) Bacillus typhosus (the "ty- phoid germ"). Ultimate; remote; anteced- ent. Remote; antecedent Age and sex are predispos- ing causes. Accessory; predisposing; re- mote; contributory.- Accidental; occasional; re- mote. Specific; efficient; proximate; determining; immediate; direct. [Also called pri- mary, in which case all antecedent causes become secondary.] [Causation of disease ends.] Cause of death. [All causes of disease are, of course, more or less remote causes of resulting deaths. They do not enter into the formal statement of cause of death.] B. COURSE OF DISEASE. j Disease processes or conditions. (7) After the usual period of incu- ' The disease itself. [Also bation the disease TYPHOID called the proximate FEVER is recognized, a general cause.] infection. (8) It is characterized by ulcera- tion of the lymph-follicles of the intestines. (9) Perforation of bowel may re- sult. (10) Peritonitis may follow (11) A pneumonic process may exist from the start (primary " pneumo-typhus") or develop in the course of the disease (sec- ondary), due to invasion of ty- phoid bacilli. (12) An independent (primary) acute lobar pneumonia may oc- cur, clue to Pneumococcus infec- tion. Pathologic process Complication Complication Complication; pneumonic type of disease. Complicating disease; com- plication; concurrent or intercurrent disease. [Causation of death begins.] Disease causing death; cause of death; primary, first, chief, actual, principal, or original cause of death or disease. [Also reported as immediate, proxi- mate, determining, remote, pre- disposing, and contributory causes of death.] Sometimes reported as cause of death. Secondary; contributory; imme- diate. Secondary: contributory; imme- diate. Secondary; contributory; imme- diate. Contributory; immediate; second- ary (in time); concurrent; in- tercurrent. C. PROCESS OF DYING. (13) Hypostatic pneumonia may result from failure of circula- tion. Terminal condition; compli- cation. (14) Death finally results (Bichat) Terminal symptoms; from interference with the func- of death or, rather, tions of the brain (coma), heart of dying, ("heart failure," syncope), or lungs (apnea, asphyxia); or from asthenia, collapse, debility, ex- haustion, etc. modes modes [Frequently returned as second- ary, contributory, or immediate cause of death. Not a proper cau-e of death.] [Modes of death should not be returned as causes of death when the latter can be ascertained.] D. POST-MORTEM APPEARAM KS. (15) The disease itself, or its com- plications, may cause certain lesions evident on post-mortem examination, as typhoid ulcers, necrosis and perforation of the bowel, etc. Pathologic findings; lesions. [Post-mortem findings, as such, should not be given as the cause of death, but the disease should be named from whiph they result.] In such an instance, what should the attending physician report upon the certificate as the cause of death ? -52 The question may be simplified by first considering what he should not report, namely, any of the items coming under the subdivisions (A) Causation of disease, (C) Process of dying, and (D) Post-mortem appearances. All of the information desired pertains to (B) Course of disease. It should be understood that this limitation pertains to the formal statement of cause of death upon certificates of death as at present generally employed. The causation of disease is antecedent to the actual existence of the disease in the given case. Much of the information under this head is of a very important practical character, but relates rather to mor- bidity than to mortality reports. A special place might be given for such data, as upon the back of the Swiss return, but many of the replies would be merely conjectural, and it has usually been necessary to limit the statements to what should be definite facts concerning the cause of death, not the cause of disease leading to the death. Various important predisposing causes of disease- can also be obtained from other parts of the certificate, as, for example, age, sex, nativity, occu- pation, residence, etc. The process of dying need not be described upon a certificate of death. Terms descriptive of mere terminal conditions or symptoms and of the modes of death should uniformly be omitted, provided, a state- ment of the disease leading to the final appearance of such conditions or symptoms and ultimate death can be given. The inclusion of such terms upon certificates of death is responsible, to a very considerable degree, for the indefinite and unsatisfactory character of the returns. Deaths from asthenia, collapse, coma, debility, exhaustion, " heart failure," etc., are compiled under ill-defined causes, unless they are reported in connection with some definite cause of death, in which case the terminal conditions are neglected, and the death compiled under the proper cause. But a death from hypostatic pneumonia, for example, occurring as a terminal state of chronic Bright's disease, is quite likely to be reported as " pneumonia," leading to possible inclu- sion with deaths from lobar pneumonia, and thus invalidating the mortality statistics. A complete schedule of post-mortem findings is not necessary. or desirable upon a certificate of death. What is wanted is the exact statement of the disease causing death. (The relation of the post- mortem examination to deaths from violence will be considered a little later.) An autopsy may be indispensable for ascertaining the nature of this disease, and the agreement of the pathologic find- ings with the clinical diagnosis may be of the highest importance, e. g.,'in a death reported from }^ellow fever at the beginning of an epidemic, as giving assurance that the true cause of death has been registered. Negative findings may be of value, as making it cer- tain that the disease reported as a cause, of death was not confounded with some other having definite pathological lesions. A certificate 53 of death should, preferably, provide a space for a brief statement of the results of the post-mortem examination (see form [33]), or at least, as in the Swiss blank [54], should state whether an autopsy was held or not; and if an autopsy was held, then the statement of the disease causing death should be based upon the results of the autopsy and the clinical diagnosis, and not solely upon the clinical diagnosis. It has happened, and undoubtedly is constantly happening at the present time, that certificates of death are filed with local registrars containing the clinical diagnoses of diseases causing death; permits are duly issued, and the certificates accepted as the basis of the mortality statistics of the city, state, and United States Bureau of the Census the last on the authority of transcripts of the original certificates of death returned by the "state or city authorities. But after the filing of the original certificates, or even before, post-mortem examinations may be held which reveal entirely different causes of death. The results of such examinations and the .pathological diagnoses are not used to correct the erroneous certificates. It is desirable that such discrepancies should be prevented, and the use of a special blank for this purpose, as required for deaths in hospitals and other institutions in Greater New York, may be heartily commended. [55] New York, N. Y. (Institutions), X \. UH-1KK STATE OF NEW YORK. No. of Certificate. CERTIFICATE AND RECORD OF DEATH IH P | .Tn. . Hem. ._ _Dyi Character of premises, whether etc. 1?hoic!! r hop.tal or other ir- tat* fall title ovred'or divorced apatlon Father's 2 5 111 Birthplace S . I I : *g5. i _____ **%&* i ijggj- jjj / hereby certify that deceased was admitted to this institution on. that I last sawh alive on the day of.. 190 ., that be died on the. jiayof. J90. , about. .....o'clock A. AT., or P. M., and that P / am unable to state definitely the cause of death ; the diagnosis during h last illness was : K __ _ _ ;.__ o _ , Z Q Witness my hand this , day o/_ J.90 SPECIAL INFORMATION. Former Residence. . How long Resident at Place of Death. .. o = I hUOy certify that 1 have this day of,. J90_.. performed an autopsy upon the body of taid deceased, and that the cause of h. death was as follows: _ M.D. Pathologist .-. Oospitft 54 On such a blank considerable pathological detail ma\- be expected, but it should not be allowed to obscure the statement of the disease causing death and primarily responsible for the lesions shown, pro- vided the evidence is sufficient to warrant a definite statement. Otherwise the return may be of very little service for statistical com- pilation, although the case may excite the wonder of the general public as in an instance quoted from a newspaper dispatch: Had Ten Diseases; Fate of One Man; Physicians at Hospital Call for Help to Per- form the Post-Mortem. Physicians of the Hospital reported to the coroner's office to-day that had died and that they were unable to determine the cause of his death. Coroner instructed the physician, Dr. - , to perform an autopsy and the hospital physicians watched Dr. with interest when he found that had died of a complication of diseases, which were: Abscess of the pan- creas, laceration of the brain, hemorrhage of the brain, dilatation of the heart, pericarditis, chronic diffuse nephritis, pleurisy with intense adhesion of both lungs, gastritis, dilatation of stomach and alcoholism. And then he issued a death certifi- cate. The transcript of this death certificate that reached the Bureau- of the Census contained simply this statement: "The cause of death was as follows: Abscess of pancreas, pericarditis.'" This may suggest that sometimes the statement of unnecessary details may lead to the omis- sion of essential facts. On this subject, the relation of the pathological findings to the statement of cause of death, and with special reference to the death from typhoid fever under consideration, Delafield and Prudden 1 may be quoted. Great care is necessary in endeavoring to ascertain the cause of death when the clinical history is imperfect or unknown. Mechanical injuries, which destroy life by abolishing the function of one of the important viscera, are relatively infrequent. Most of the lesions found after death are rather the marks of disease than the cause of death. We do not know, for example, how great a degree of meningitis, or of pneumonia, or of endocarditis, or of cirrhosis, or of nephritis necessarily leads to death. On the contrary, one patient may recover with an extent of lesion which is sufficient to destroy the life of another. So with accidents; there is often no evi- dent reason why fracture of the skull or of the pelvis should destroy life, yet they usually do. In some, of the infectious diseases, such as typhoid fever, the visible lesions can not be called the cause of death. Sudden deaths of persons apparently in good health are often particularly obscure. In many of them we have to acknowledge that we can find no sufficient cause for the death. This is of course due to our imperfect knowledge, but it is much better in such cases to avow ignorance than to attribute the death to some trifling lesion. The brain and the heart are the organs which are especially capable of giving symptoms during life without corresponding lesions after death. Very well marked cardiac or cerebral symptoms may continue for days or months, and apparently destroy life, and yet after death we find no corresponding anatomical changes. Coming finally to the items which should be included in a statement of cause of death, and which are all embraced in group B, Course of disease, as given in the tabular arrangement on page 51, it may be 1 Pathological Anatomy, Cth edition, page 3. 55 said that it is not necessary or desirable to include all symptoms or complications attending the course of the disease. In fact, it is not necessary to name any of them if only the name of the disease causing death and responsible for the secondary affections be stated. Mere symptoms should not be stated at all; ordinary minor complications are of no consequence; and other diseases, unless they play a distinct part in the causation of the death, should not be mentioned. A case-history of the decedent's last illness or previous illness is not wanted. Such a return as the following, which was received at the Bureau of the Cen- sus during the present year (1907) and which is easily first in multi- plicity of terms among the several millions of transcripts received upon the standard blank, is merely ridiculous: The CAUSE OF DEATH was as follows: Diphtheria, Antitoxin, Septicaemia, Erythema, Urticaria, Dermatitis, Lymphangitis, Multiple dermal ulcer, Abscesses, Rheumatic Fever, Hepatitis, Jaundice, Duodenitis (DURATION) 4\ MOS. Contributory Nephritis, Pneumonia, Erysipelas, La Grippe, Cerebro Spinal Meningitis, Peritonitis, Convulsions, Death (DURATION) 96 Hrs. In the assumed case of a death from typhoid fever, with the various complications indicated, the certificate of death might be filled out, according to some of the various forms in use, as follows: CAUSE OF DEATH ............... ...................... ] Disease causing death ................................ | Primary cause of death ............................... j- Typhoid fever. Chief cause of death ................................. | Chief and determining cause of death ................. J The additional statement, of entirely subsidiary importance, may be given: Secondary cause of death Consecutive and contributing cause of death . . It may be of very considerable medical interest to know just what complications are the most frequent immediate causes of death from typhoid fever. Doctor Osier estimates 1 that of the 35,379 deaths compiled from typhoid fever by the United States Census as occur- ring in the United States during the census year 1899-1900 between 9,000 and 12,000 were due to intestinal perforation. The returns are not sufficiently complete, however, to show the true relations of secondary affections to primary causes, and it is more important 1 Principles and Practice of Medicine, sixth edition, page 81. 56 that all of the primary causes should be reported and that no deaths be erroneously classified through failure to report the principal disease. This is especially liable to occur where blanks require the immediate cause to be stated first and the true cause of death (primary disease) is given as the remote or contributory cause, if at all. The most complete form of statement employed in this county, which is quite comparable in this respect with the Swiss form the most complete among the European samples is that originally employed in Michigan 1 and now in use in the cities of Cincinnati, Ohio, and Norwalk, Ohio [33]. It was originally suggested by Dr. Henry B. Baker, former secretary of the State Board of Health of Michigan, and is incorporated in the Michigan law of 1897, whose first draft (1895) provided chiefly for the statement of "immediate cause." A death registered in this form might show: DISEASE CAUSING DEATH.. Immediate cause of death ._. .. _ Per f oraii 9 n ^ hemorrhage of intestine. Contributory causes or complications, if any Bronchoprieumonia. Post-mortem confirmed statements above. In this blank the immediate cause has its proper subordinate place, and also serves to catch statements of modes of death, such as "heart failure," coma, etc., which might otherwise be reported as the main cause of death. Also a careful physician is less likely to report "old age" as the disease causing death than he is to report it simply as u cause of death," especially when a place is provided for its insertion as a contributory cause. The whole subject of mortality statistics, as does medicine in gen- eral, labors under the disadvantage of lack of precision and definiteness in the terips employed. No definition can be found for the much used term cause of death. As emploj^ed in vital statistics, this term may be held to signify either (1) a disease, or (2) a form of violence from which, either wholly or partly, the death of an individual results. But the word disease is equally ill defined: DISEASE: (a) Any departure from a state of health; an illness; more frequently the genus or kind of disturbance of health to which any particular case of sickness may be assigned. (6) A condition of the body marked by inharmonious ac f ion of one or more of the various organs, owing to abnormal condition or structural change. The latter part of the first definition more closely represents the conception of diseases as returned and tabulated as causes of death; 1 See facsimile in Reference Handbook of the Medical Sciences, article by the late Doctor Samuel W. Abbott on "Certification of Deaths; " also reproduced by Doctor Chapin in his work on Municipal Sanitation in the United States, page 855. 57 , but it is difficult to give explicit directions for the proper statement of diseases when almost any condition of " departure from a state of health" may be included in the categoiy. Of the conditions included under section B, page 51, only typhoid fever and the intercurrent acute lobar pneumonia are entitled to the designation of diseases; the others are secondary affections which should not be returned or classified as individual causes of death. "Dropsy " is certainly a " condition of the body marked by inharmonious action of one or more of the various organs;" nevertheless it should not be reported as a disease causing death, but the disease of the heart, liver, kidneys, etc., which caused it should be named. That this fact is already recognized, even among the laity, is shown by the following quotation: 1 "Dropsy is not a disease in itself, but is a symptom associated with a number of different dis- eases, chiefly of the heart and kidneys." What names of diseases shall be employed by the physician in reporting causes of death ? The practical compilation of returns of deaths is greatly embarrassed by the large number of more or less synonymous expressions employed to designate the same disease. 2 The commonly accepted English name of the disease should be inva- riably used, as, in the United States, typhoid fever for the disease taken as an example. (The accepted term in England is enteric fever; this is one of the few cases in which the usage of the two countries differs.) Unfortunately we have in the United States no generally accepted standard of nomenclature for the naming of diseases. In England the "Nomenclature of Diseases drawn up by a Joint Com- mittee appointed by the Royal College of Physicians of London," of which the third revision has recentty been published (1906), furnishes an authoritative guide of the greatest service to physicians in report- ing causes of death. At the last meeting of the American Medical Association, held at Atlantic City, N. J., it was voted, on June 4, 1907, that the president of the -association appoint a committee of five on nomenclature and classification of diseases, as a result of whose labors this need of the medical profession of the United States may be met. In the meantime, and in the absence of an} r other guide, it would be well if the Nomenclature of the Royal College of Physicians could be followed in this country and physicians employ only the terms author- ized therein. It should be remembered that a nomenclature of diseases is not a statistical classification, and this recommendation does not affect in any way the adherence to the International Classification of Causes of Death, which is the accepted standard in the United States. It rather aids its usefulness, because a satisfactory nomenclature of diseases is a fundamental requisite for an effective statistical classifica- tion of causes of death. 1 Youth's Companion, August 1, 1907. 2 See Manual of International Classification of Causes of Death, published by the. Bureau of the Census in 1902, and containing terms actually employed upon certificates of death. 58 (2) D eat Jis from violence. The facts required on a certificate of death from violence are of quite a different character from those required on a certificate of death from disease, and a complete statement can not well be expected unless special provision is made in the arrangement of the blank or special instructions be given to the physician, health officer, or coroner making the report. The transcripts received by the Bureau of the Census are especially unsatisfactory in this respect, 1 and although efforts have been made to secure more complete statements by corre- spondence with the local registrars sending indefinite returns the improvement is comparatively slight. Success can not be obtained in this way, but only by seeing that the certificates contain all of the data required when originally filed with the local registrar. The kind of facts desired may be seen from the general classification of violent deaths, whether from (1) accident and negligence, (2) suicide, (3) murder, or (tt) manslaughter, as employed by the Registrar-General of England and Wales: Cause or character of accident; method of suicide, murder, or manslaughter. 1. Mines, quarries, etc. 2. Vehicles and horses. 3. Ships, boats, docks, etc. (excluding drowning). 4. Building operations. 5. Machinery. 6. Weapons and implements. 7. Conflagrations, burns, scalds, explosions (not in mines, ships, etc.). 8. Poisons and poisonous vapors. 9. Drowning. 10. Suffocation. 11. Falls. 12. Weather agencies. 13. Otherwise or not stated. And, more minutely, under 2 (a), for example, Injuries on railways, there is an exact specification of the mode in which the injury occurred, as, "run over on line," "collision," "locomotive machinery," "strik- ing against bridge," etc. The kinds of mines are specified and always the special means of injury or agent by which the casualty occurred. i See Mortality Statistics, 1900 to 1904, page lv: " In the statistical treatment of this class of deaths they naturally fall into four primary groups (1) suicide, (2) homicide, (3) accidental violence, (4) other external causes; but the information upon which the classification must be made is too incomplete to permit the accurate separation of the deaths even by these general groups, and all general statistics of deaths from suicide, homicide, and various special forms of accident, derived from registration records, are incorrect and absolutely misleading. It would seem that in this class of deaths more than any other there should be no difficulty whatever in securing a proper classifi- cation, to the extent specified at least, since it is the only class in which there are practically uni- versal provisions for an official inquiry into the circumstances attending each death, by a coroner, medical examiner, or other official, for the precise purpose of determining whether the death was due to homicide or suicide or to purely accidental causes; but instead of this being true the returns in this class of cases are the most unsatisfactory." 59 The International Classification of Causes of Death does not make clear-cut distinctions in this respect, but admits such a title as u Frac- tures," a term merely expressive of the nature of the injury (lesion) and not of the nature of the violence, and one which the Registrar- General considers indefinite and places, in the absence of other infor- mation, under " 13. Otherwise or not stated." As an example of the factors to be considered in violent deaths, the following- illustrative cases may be presented: Class of fact. Case!. Cas.-'j. CaseS. 1 CHARACTER OF VIOLENCE H Accidental Suicidal Homicidal. 2 MEANS OF VIOLENCE Toy pistol River Revolver 3. Nature of injury (lesion); imme- diate cause of death. 4 Secondary effects of injurv, includ- Wound of hand... Tetanus Drowning (as- phyxia). Wound of abdomen, perforation of intes- tine. Peritonitis. ing infection of wound (sepsis, tetanus) . 5 Contributory disease or condition Acute mania Alcoholism In the above cases, and, in fact, in all deaths from violent causes, there are two items that are absolutely essential for statistical pur- poses; these are, (1) the character of the violence, and (2) the means of violence. The character of the violence, as accidental, suicidal, homicidal, 1 forms the primary basis of classification. A place should be provided for its statement on every certificate of death, and no case of violent death should be left unqualified in this respect. "Probably accidental " may be written in a doubtful case, or "Unknown" if absolutely impossible to determine; but in many cases the character is left unstated when it is perfectly eas} 7 to give it. In case of a railway collision it is not necessary to await the verdict of the coroner's jury before reporting any death resulting therefrom as accidental; a verdict to the effect that the collision resulted from criminal negligence would not change the statistical character of the death return, however it might alter its legal aspect. No fine distinctions as to murder, man^ slaughter, or justifiable homicide appty to a statement of homicidal violence; it is sufficient that one person kills another and not by accident. . The second essential feature of a return of a death from violence is the means or agency causing the death. A specific statement should be made of the special cause of the injuiy, as by fall of elevator, struck by trolley car, fell from building,' carbolic acid (names of poisons should always be stated), etc. Frequently a satisfactor}^ statement of both items 1 and 2 can be given in a single expression; as, lightning, sunstroke, boiler explosion, 1 Legal execution, war, and catastrophes such as earthquakes, volcanic eruptions, tidal waves, etc.; should be made special subdivisions when necessary, the latter group because it includes various modes of violent death, as ordinarily classified, but all due to one common cause. 60 collision on railway, etc. .But if there be any shadow of doubt as to the event being entirely free from possibility of interpretation as suicidal or homicidal, its accidental character should be stated. The remaining items, 3 to 5, are not essential for statistical pur- poses, but may be very important otherwise, and should be specified as completely as possible. Tetanus resulting from a wound should always be mentioned. It may be noted that while the injury itself that is, the lesion resulting from the violence, as a fractured skull, a wound inflicted by a firearm, or the burn resulting from a conflagra- tion may be considered the primary cause of death in the same sense that the disease itself (e. g., typhoid fever) is considered the primary cause of death in a death from disease, in the first case the statement of the primary cause is not necessary and in the second case it is neces- sary for statistical purposes. Fractures, wounds, and burns are indefi- nite terms, and we desire to know, for the purposes of statistical classi- fication, what caused the fracture, whether the wound was caused by a firearm, or the burn by a conflagration. In other words, we wish to know the proximate cause of the injury, corresponding to the Bacillus typhosus as a cause of typhoid fever, together with the directive influence determining that cause (suicide, homicide), or a statement that there was no directive or purposive element (accident, negligence, effect of weather agencies). The element of purpose is entirely absent, as a rule, from deaths from disease. 1 The dissimilar character of the information required in deaths from disease and in deaths from violence is chiefly responsible for the imperfect returns of the latter and for the absence of proper forms of statement on nearly all of the forms employed for certificates of death. 1 A case of self-infection by typhoid fever with suicidal intent, cited by Schultze in his article on "Autopsies," Reference Handbook of the Medical Sciences, might be considered suicide by disease, and wilful persistence in providing a contaminated water supply verges on homicide, but prac- tically all deaths from disease are considered "accidental " in the sense of absence of purpose in their incidence. DURATION OF ILLNESS. The blanks used in the United States provide, as a rule, for a fairly satisfactory statement of duration of illness. The standard blank is not as excellent in this respect as the English form, with its columns for "Years," " Calendar months," "Days," and "Hours." Not in- frequently transcripts are received showing* duration of a few days from such diseases as chrtmic Bright's disease. This may mean either that the terminal symptoms are referred to only, or that the physician or transcriber forgot to crosscut the word "Days "and write "Months" or "Years" as the case might be. It is difficult to suggest a remedy with the present form of the blank, although it would possibly be better not to have any word on the form that is not always applicable; let the physician write "3 inos.," "3 days," etc. Another objection is that by specifying "days," the physician may state no duration if it is less than one day; this is especially objectionable in the case of children dying soon after birth, who may thus come to be included among still- births. "Acute" and "chronic," employed upon the French blanks, are serviceable for precision under certain titles of the International Classi- fication (acute and chronic bronchitis, rheumatism, nephritis), but are very indefinite terms, and should be considered in connection with a correct statement of duration. The physician and registrar should always note the relative duration of related terms; the primary cause or disease causing death can not have a less duration than one of its secondaiy affections or consequences. (61) CONCLUSIONS AND RECOMMENDATIONS. / As a result of the examination o^ present conditions, it seems proper tOJsubmit to the registrars of the United States, soon to be organized as a national body and constituting a Section of the American Public Health Association, some propositions looking to the improvement of the registration of causes of death, and especially to the adoption of more uniform methods for the United States as a whole. Whatever is done must depend upon harmonious individual action of the regis- tration states and cities. The Census has no authority except to sug- gest the desirability of certain measures, ,but its work is for the benefit of all, and if there should be a general agreement as to the expediency- of action in any direction, it is hoped that mere individual preference, however well founded, will yield for the greater good to the whole United States that can come only from concerted action. Such action should be well considered before it is taken. The recom- mendations, together with any others affecting statistical practice, should be laid before the annual meeting, referred to the proper com- mittee for report at the succeeding one, printed in the proceedings and distributed to every registrar of vital statistics in the United States for his consideration. 1 If necessary a referendum should be taken to tte individual offices. The report of the committee and the expressions of the state and city offices should be thoroughly digested, and when a final decision has been made, by a majority or two-thirds ballot, that action should stand as the action of all of the registrars of the United States and should be carried out by them faithfully in accordance with the general desire. There can be no real prog- ress in the upbuilding of a National System of Vital Statistics something in which this country is at present behind all of the civilized nations of the world until some definite basis of agreement can be reached and maintained relative to the collection of the basic material. It is worse than useless to attempt a local change or improve- ment here and there, which has no chance of general adoption, and which only serves to cause still greater confusion and complication of methods. By the plan proposed anr^)le notice will be given of any change, so that no loss of blanks already printed will result the form proposed would not become effective at the earliest before January 1, 1909 and the satisfaction of feeling that each office, large or small, 1 This pamphlet has been sent to the registration officials of all states and places of 8,000 inhabitants or more (Census of 1900). (62) 63 is employing standard methods and contributing fully comparable data to the vital statistics of the United States should amply compensate for the slight trouble of making any change. It is therefore recommended, subject to the consideration and ap- proval of the American Association of Registrars of Vital Statistics l organized as a Section of the American Public Health Association, that certain resolutions be adopted: Proposed Resolution No. 1. That a uniform mode of statement of causes of death upon certificates of death shall ~be adopted by all regis- tration offices in the United States which shall provide, First, in the case of a death from disease, for the name of the disease causing death 9 and in the case of a death from violence, for the means of ffcttth, and whether accidental, suicidal, or homicidal; together with such subsidiary information, if any, as may he necessary, under the head of "resulting in" or "aided by" As an example of how such data might be provided for with but slight modification of the standard blank, the following form is sub- mitted : [56] Proposed form of statement. MEDICAL CERTIFICATE OF DEATH DATE OF DEATH ..19.... (Month) (Day) (Year) I attended deceased from 19 to__ .. 19 , I last saw h alive on __19 , and I HEREBY CERTIFY that death occurred on the date above at... __M. The DISEASE r MEANS OF DEATH *^ Duration in CAIKim DEATH [> ( g_j_ _ ] -. V.,,s, Mo h! , Hours. Resulting in: or Aided by: L ___" (Signed) M.I). ..10_.._ __ (Address) {Accidental? Suicidal? Homicidal? 1 Or whatever name the Section may adopt. 64 The proposed form will concentrate the attention of the certifying physician or coroner upon the fact that it is necessary to name the disease that caused the death, or the means from which a violent death resulted, with complete absence of the very uncertain meanings some- times embraced under the term " cause of death.' 1 It will be compar- atively easy to give definite instructions as to just what is, and just what is not, a "disease" for the purposes of registration; and to explain the use of the word "means" so that precisely the class of information necessary for classifying violent deaths can be obtained. The expression "cause of death" is an ill-defined or undefined term, of complex significance even when employed in the strict sense under- stood in vital statistics, and also includes other conceptions, such as terminal condition, mode of dying, and cause of disease, that serve only to perplex reporting physicians and to vitiate the mortality statistics. Its entire disuse upon certificates of death, at least in the most important position, is therefore advised; its use in registration reports and bulletins, as a convenient general term, is quite another matter, as it is seldom improperly employed therein. The term "disease causing death" may be criticised upon the ground that, at the time of the making out of the certificate, the dis- ease is no longer a continuing cause, and that it would be better to speak of the "disease that caused death." Either term will serve, but it is an objection to the latter that a disease that very remotely caused death may not be actually present at the time of death, and hence, under the accepted method of classification, should not be entered as the cause of death. A child may have rheumatic fever with endocarditis and recover from the rheumatic fever. Years afterward the individual may die from valvular heart disease remotely due to the rheumatic infection. Under the International Classification, and probably in practical agreement with most methods in use, it is expressly provided that deaths from rheumatic fever shall not include deaths from organic diseases of rheumatic origin; the organic heart affection is taken as the primary cause of death. This rule may be subject to criticism, but while it is practically accepted, only a disease actually present at time of death should be reported as the disease causing death. The word "means," as used only in connection with the statement of deaths from violence, is fairly definite, in the sense of "instru- ment" and "necessary condition or coagent." When the instrument is a deadly weapon, its use is implied by the mere name, and the statement of the character of the act as accidental, suicidal, or homi- cidal. When the instrument is not a deadly weapon, the statement of means may properly incjude the necessar}^ condition of action, although even here the mere naming of the instrument is usually sufficient for the main purpose of classification; thus, "elevator," "horse," or 65 "bicycle," would be sufficient, although a little more detail, as "fall of elevator," "kicked by horse," "fell from bicycle," would usually be given. Properly understood, the exclusive use of this term would prevent the mere statement of the lesion, such as "fracture of skull," "hemorrhage," etc., without giving, in the first place, the instrumen- tality or means by which it was caused, and which is primarily necessary for statistical compilation. The subsidiary information is less important, providing we can assure a correct statement of the disease causing death, or the means of death in accidents, suicides, and homicides. Possibly some of the old terms could be chosen, such as "secondary," "immediate," "concurrent," and after settling upon their exact definitions and educating all con- cerned in their definite use, the purpose would be answered, which is chiefly that the true cause of death be picked up in the subsidiary statement when the physician or coroner does not properly enter it in the principal one. The mam relations of importance would be clearly shown by the arrangement suggested, which has the advantage of breaking away from the hackneyed terms employed for this purpose, the most definite of them being widely misunderstood. It is possible for the physician to indicate, by crossing out the term that does not particularly apply, just how he wishes the minor cause to be under- stood. "Resulting in" would always mark a secondary affection, while "Aided by," alone, would show that it was an independent dis- ease or injury. The plan of stating duration is merely suggested; the present form [1] can be retained if desired. / roposed Resolution No. 6 2. That a continuous and systematic effort be made, through the conjoined action of the local, state, and Govern- ment authorities, to secure the cooperation of physicians and coroners in the more definite and satisfactory statement of causes of death; and that for this purpose each certificate of death hear a certain minimum amount of suggestions in regard to the statement of cause of death, which shall he uniform throughout the United States, in addition to any special instructions or regulations required for local use. As a basis for discussion in regard to what this minimum amount shall be, the following draft of suggestions, which can readily be inserted upon the reverse side of any certificate or printed on the inside of the cover of the booklet of blanks supplied to physicians and coroners, has been prepared: (DRAFT OF) SUGGESTIONS TO PHYSICIANS AND CORONERS RELATIVE TO THE STATEMENT OF CAUSE OF DEATH. (Adopted by the American Public Health Association and recommended by the United States Bureau of the Census for the purpose of securing uniformity in returns of deaths throughout the United States. 1 Please read carefully.} 1 Provided, of course, that any definite instructions can be generally agreed upon. 915907 5 66 A. Deaths from disease. 1. Name, first, the DISEASE CAUSING DEATH. What is wanted is the name of the disease (or malformation) itself responsible for the death; not a mere secondary, con- secutive, contributory, or immediate cause, complication, symptom, terminal condi- tion, or mode of death. Never report a death from such ''causes" as asphyxia, asthenia, collapse, coma, convulsions, debility, dropsy, exhaustion, heart failure, hypostatic pneumonia, inanition, marasmus, old age, shock, syncope, or weakness, if a definite disease causing the condition can be named. WAS IT PUERPERAL? Always qualify, as puerperal convulsions, puerperal peritonitis, puerperal septicemia, etc., all deaths resulting from childbirth or miscarriage. 2. Important secondary affections or independent (concurrent) diseases actually contributing to the death may be named. Example: Measles (disease causing death); bronchopneumonia (secondary affection). B. Deaths from violence. 1. Name, first, the MEANS OF DEATH, and whether ACCIDENTAL, SUICIDAL, or HOMI- CIDAL; as, accidental drowning.; suicide carbolic acid; railroad collision. NOTE. In the last example, it is not necessary to write "Accidental," because such cases are plainly of that character. A judicial determination of "man- slaughter" on account of negligence does not affect the statistical character of the return, and a coroner should not delay the filing of the certificate of death on that account. 2. Nature of injury (lesion) or immediate cause of death may be given if not implied under (1). 3. Important secondary affections (e. g., erysipelas, septicemiaj tetanus) and contributory diseases (e. g., insanity, alcoholism) should always be stated. Duration. Enter duration, in years, months, days or hours, after each separate cause of death. Duration of a disease is from its commencement until death occurs; do not merely give time of final illness in chronic diseases. Duration in deaths from violence is from the time of injury or appearance of complication until death. This draft is merely suggestive. Some cities already have more stringent directions and, by the direct communication possible in a city between the reporting physician and the registrar, have elimi- nated some undesirable classes of returns. For the country as a whole, however, strict compliance with the instructions given above would work a vast improvement in the returns, and it would be especially beneficial if such a guide could appear on all state blanks. If it be possible to agree upon certain explicit instructions as sug- gested above, and similar in their purpose to those disseminated by the Registrar-General of England to the physicians of that country, then the Bureau of the Census can cooperate in a very practical man- ner with the state and local offices by bringing home to the individual attention of every physician in this country, at occasional intervals, the importance of precise and definite statements of causes of death. This may be done by means of a pocket leaflet or small pamphlet of a size such as can readily be carried in a vest pocket or visiting list, and 67 perhaps containing the scheme of statistical classification (Inter- national), with indication of indefinite terms and secondary affections, as in the booklet distributed to physicians in Switzerland. Moreover, with exact directions available for reference, the instruction of newly appointed local registrars would be greatly facilitated, and a uniform method of obtaining corrections of imperfect data would be more readily installed. I*Ost8CTipt, In this pamphlet the bearing of the correct and orderly statement of causes of death upon the statistical compilation of such causes, especially when two or more causes are returned for the same death, has only ~been casually touched upo^ The subject of ''''joint causes' 1 ' 1 has heen a perplexing one from the very beginning of vital statistics, and irregularities and discrepancies, some of great impor- tance, may he found in 'mortality reports because no adequate plan has yet been accepted for their treatment. Several plans have been devised, and it is intended to compare them, together with the principles that hare been formulated by various authorities for this purpose, in a revised edition of the Manual of International Classification of Causes of Death, which it is hoped to have ready next year in preparation for the approaching Decennial Revision. But it is probable that the true solution of this question will not be reached until physicians and coroners are educated in the proper reporting of causes of death so that their order of statement can be depended upon; and until registration officials shall at once detect any inconsistency or anomaly of statement, and secure prompt correction or interpretation thereof, so that a simple rule of dependence upon the disease causing death as reported by the attending physician and accepted by the local registrar can be followed. APPENDIX A. CIRCULAR OF ANNOUNCEMENT OF ORGANIZATION OF AMERICAN ASSOCIATION OF REGISTRARS OF VITAL STATISTICS. Ammratt iJttbltr ijfaltij A00ortattnn Sty? Utttteb >iat?0 nf Ammra inmuwm of (Eattaim Sty? ffiepuhltr of fepubUr of Olitha 19flfi-r President DR. DOMINGO ORVANANOS, Mexico City, Mexico First Vice-President, DR. QUITMAN KOHNKE, Covington, Louisiana Second Vice-President, DR. ROBERT W. SIMPSON, Winnipeg, Manitoba Third Vice-President, DR. GARDNER T. SWARTS, Providence, Rhode Island Secretary, DR. CHARLES O. PROBST, Columbus, Ohio Treasurer, DR. FRANK W. WRIGHT, New Haven, Connecticut in Atlantic Qlttg, &*pi. 30-rt. 4, 190T ORGANIZATION OF SECTION OF VITAL STATISTICS. At the last meeting of the American Public Health Association, in accordance with the request of many registration officials, the following resolution was adopted: Resolved, That a committee of five be appointed by the president of the American Public Health Association to report on the organization of a Section of Vital Statis- tics at the next meeting of the association, and that it be authorized to notify regis- tration officials in the countries represented in the association, particularly inviting their attendance at the next meeting, and to prepare a constitution for approval by the association and adoption by the section at that time. The committee on organization appointed to carry out the purpose of this resolu- tion met at Washington in May, and formulated a draft of a constitution, the first two sections of which are as follows: PURPOSE OF THE ORGANIZATION. 1. The purpose of this organization is to bring about a closer official and personal association of the registration officials of the several countries composing the Ameri- can Public Health Association; to promote the introduction of effective systems of registering vital statistics; to aid the adoption of uniform methods of collecting, pre- serving, correcting, and compiling registration records and of publishing the statis- tical-data derived therefrom in the most useful form, especially for sanitary purposes; to conduct the active cooperation of the American Public Health Association with the Government agencies of each country and with other organizations interested in (69) 70 the improvement and use of vital statistics; to report on the actual condition of the International Classification of Causes of Death as employed in vital statistics reports and bulletins, and to formulate recommendations for its decennial revision; to help in the better reporting and classification of the mortality of occupations; to present and discuss papers relating to vital statistics both in the section meetings and in the general sessions of the American Public, Health Association; and in general to pro- mote a proper appreciation of the necessity and importance of vital statistics as an absolutely essential basis of modern public health work, and to improve the charac- ter and status of registration service. MEMBERSHIP. 2. Registration officials and other workers in vital statistics who are members of the American Public Health Association shall be eligible to membership in the Vital Statistics Section. The above extract, which is subject to approval by the association and section, shows the general scope of the movement as understood by the committee on organi- zation. Your attendance is earnestly requested at the jirxt inet-thtg of the section, which will be held in connection with the Thirty-fifth Annual Meeting of the American Public Health Association at Atlantic City, N. J., beginning on Sep- tember 30 and ending October 4, 1907. A circular will be sent by the secretary of the association giving full information in regard to reduced railway fares, accommo- dations, etc. It is expected that the first section meeting will be held on Monday, September 30, when the preliminary organization will be effected. In addition to organizing, it is planned to begin the active work of the section at this meeting, and papers, questions, and suggestions on various phases of vital statis- tics, and especially relating to the practical side of registration work and the sanitary uses of mortality statistics, are requested. They may be sent to Dr. Cressy L. Wilbur, Bureau of the Census, Washington, D. C., who will provisionally act as secretary of the committee. There is a large field of usefulness for this section, and it should have the enthu- siastic support of all registration officials and users of vital statistics. If you can not be personally present at this first meeting, or send a paper or suggestions, please let us know that you are interested in the movement and will, at least, be with us in spirit. Sincerely, J. X. HURTY, Chairman, CRESSY L. WILBUR, JOHN S. FULTON, Jcsrs E. MON.TARAS, CHARLES A. HODGETTS, Committee, APPENDIX B. CHECK LIST OF REGISTRATION OFFICIALS, AND OF REPORTS AND BULJ.ETINS CONTAINING VITAL STATISTICS, IN THE UNITED STATES. EXPLANATORY NOTE. This list of state registrars and local registrars is a pro- visional one of all places (cities, towns, and boroughs) in the United States whose population was 8,000 or over in 1900. It is based chiefly upon a circular request for information issued July 24, 1907, and asking the following questions in regard to each local office: 1. Are deaths registered? 2. Under state law or city ordinance? 3. Do you publish city reports containing mortality statistics? 4. Annual or biennial? Latest? 5. Do you publish city bulletins showing mortality? 6. Weekly, monthly, quarterly? 7. Name of city registrar? 8. Official title? Replies were promptly received, as a rule, and the statements as to publications and nature of legislation under which deaths are registered have been accepted on the authority of the local registrars given in the last column of the table. Com- parison has been made with reports and bulletins on file, and where no reply was received the probable condition with respect to state or municipal legislation has been entered, subject to future correction. Thus it is known that all places in Massachusetts, Michigan, New York, and Pennsylvania are under state law 7 , sup- plemented, perhaps, in a few instances, by local regulations. A registration city in a nonregistration state which has no general state law, e. g., Atlanta, Ga., must necessarily have a city ordinance for the registration of deaths. But in nonregistra- tion states with general state laws for the registration of deaths, but which are not usually effective, registration may be conducted under local ordinances, as in Kansas, Ohio, and Texas. In such cases, in the absence of direct statement, "State law" is inserted, but not to the exclusion of possible local ordinances. The circulars w T ere uniformly addressed "City Registrar of Vital Statistics," and in some instances there is no such official, returns being made under the county system. Publications are indicated as follows: a = annual report; b = biennial report; w = weekly bulletin; m = monthly bulletin; q = quarterly bulletin. The Bureau of tJie Census desires to preserve complete files of all official publications containing vital statistics in the United States. It is requested that registration officials noting omission of their publications urill kindly correct this list and regularly transmit copies of all reports and bulletins to the Library of the Census; penalty labels will be provided for this purpose upon request. Registration states, and registration cities in nonregistration states, which make returns of deatlis directly to this Bureau, are designated by asterisks (*) before each name. Registration cities in registration states, whose returns are received through their respective state offices, are indicated by daggers (f). (71) STATES AND CITIES. (Reports and bulletins see explanatory note, p. 71.) Estimated population, 1906. State law or city ordinance. Name and official title of registrar. ( Remarks. ) ALABAMA (a) 1 Anniston 2,017,877 10,919' 45,869 8,110 42,903 40,808 12,047 1,421,574 State law W. H. Sanders, M. D., State Health Offi- cer, Montgomery. " Unclaimed." D. T. Rogers, Secretary Board of Health. I. C. Skinner. M. D., Registrar. D. B. Sparks, City Clerk. F. M. Oliver, Citv Clerk. State law Birmingham State law. Huntsyille State law ^Mobile City ordinance. State law Montgomery Selma (m) Both ARKANSAS Fort Smith 23, 505 11,157 39, 959 13,038 Both Hot Springs Little Rock (am) 2 City ordinance. Pine Bluffs None. N. K. Foster, M. D., Secretary State Board of Health and Registrar of Vital Statis- tics, Sacramento. L. W. Stidham, M. D., Citv Physician. .1. J. Benton, M. D., Health Officer. T. M. Hayden, M. D., Health Officer. L. M. Powers, M. D.. Health Officer. E. W. Ewer, M. D.. Health Officer S. P. Black, M. D., Health Officer. H. L. Nichols, M. D., Health Officer. F. H. Mead, M. D., Health Officer. J. T. Watkins, M. D., Health Officer. J. C. Corcoran. Assistant Secretary Board of Health. H. L. Taylor, M. D., Secretary State Board of Health, Denver. W. H. Sharpley, M. D., Health Commis- sioner. J. H. Townsend, M. D., Secretary State Board of Health, Hartford. A. P. Kirkham, City Clerk. J. N. Booth, Town Clerk. Town Clerk. C. P. Botsford, M. D., Registrar of Vital Statistics. S. M. Benton, Town Clerk. H. Hess, City Clerk. W. C. Howard/Town Clerk. H. Heanes, Town Clerk. L. D. Penfield, Town Clerk. J. J. Carr, Registrar of Vital Statistics. F. L. Kenvon, Town Clerk. C. S. Holbrook, Town Clerk. W. F. Waterburv, Town Clerk. W. W. Bierce, Town Clerk. F. P. Brett, Registrar of Vital Statistics. F. P. Fenton, Town Clerk. A. Lowber, M. D., Secretary State Board of Health, Wilmington. J. Wigglesworth. Registrar of Vital Sta- W. C. Woodward, M. D., Health Officer, Washington. J. Y. Porter, State Health Officer, Jack- sonville. C. D. Taylor, Clerk Board of Health. L. G. Avmard, Clerk Board of Health. J. A. Borns. M. D.. Citv Physician. CALIFORNIA (bm) (Alameda (a) 1,648,049 19, 644 19,700 13, 460 ( 4 ) 73, 812 14,378 31,022 19, 140 ( 4 ) 23, 564 19,354 615, 570 29,338 10,147 151,920 13, 697 30, 824 1,005,716 14,085 84, 274 16, 537 95, 822 12,029 25,880 9,937 13, 133 33,722 121,227 19,822 19,759 17,599 10,808 61,903 9,111 194, 479 85, 140 307, 716 629, 341 36, 675 21, 174 22,256 24,220 State law State law (Berkeley State law State law State law (Fresno ("Los Angeles (am) (Oakland (am) State law State law 5 State law State law State law ( Pasadena . (Sacramento (m) San Diego (m) 'San Francisco (am) San Jose State law State law (Stockton *COLORADO (b in) State law State la\v State lav. (Colorado Springs (m) 'Cripple Creek town (Denver (a) Both State law (Leadville ( Pueblo (m) State law State law CONNECTICUT (am)... (Ansonia State law (Bridgeport (m) 7 State law Danbury State law . (Hartford (am).. .. State law Manchester town (m) (Meriden (a) .. State law State law fMiddletown town State law State law fNaugatuck borough [New Britain State law State law fNew Haven (am) [New London State law [Norwich State law* State law ^Stamford [Torrington town State law [Waterburv State law State law State law [Will iman tic DELAWARE (b) "Wilmington (a) City ordinance . ( 9 ) State law *DlSTRICT OF COLUM- BIA 8 (aw). FLORIDA (am) "Jacksonville (m ) City ordinance . City ordinance . City ordinance . City ordinance . 'Key West Pensacola Tampa .. 1 None issued since 1894. 2 Reports made by city physician. 3 No record is kept of deaths. Burials (in city cemeteries) are recorded, showing cause of death, etc. * No estimate. 5 City ordinance also, but simply supplemental. 6 And city charter. 7 Published by Board of Health, E. A. McLellan, M. D., Health Officer. 8 Coextensive with city of Washington. 9 Registration is effected under an ordinance of the late board of health, duly legalized by Congress. 73 STATES AND CITIES. Estimated Stfttelaworpltv (Reports and bulletins-see Population. SiES! explanatory note, p. 71. ) Name and official title of registrar. (Remarks.) GEORGIA 2,443,719 11,211 L. Thornton, Clerk Board of Health. E. C. Goodrich, M. D., Secretary Health Department. J. A. Butts, M. D., Health Officer. M. M. Moore, Secretary Board of Health. T. L. Massenburg, Secretary Board of Health. J. A. Egan, M. D., Secretary State Board of Health, Springfield. G. Gray, City Clerk. C. W. Geyer, M. D., Health Officer. G. H. Beineke, Citv Clerk. H. E. Rhoads, City Clerk. None. M. 0. Heckard, M. D., Registrar of Vital Statistics. " Name not found in Directory." A. Leach, City Clerk. W. F. Sylla, City Clerk. None. G. E. Baxter, M. D., Health Officer. M. Beescheid, City Clerk. B. B. Cole, City Clerk. A. H. Arp, M. D., Health Commissioner. F. Mendel, Citv Clerk. F. C. Gale, M. D., Health Officer. J. F. Wolf, Registrar of Vital Statistics. P. W. Reardon, Health Officer. J. E. Smith, City Clerk. W. L. Smith, M.D., President Board of Health. J. N. Hurtv, M. D., Secretary State Board Athens * Atlanta (a) 104, 984 43, 125 9,453 17,800 32, 692 68,5% 5, 418, 670 16, 562 26, 823 18,756 25,506 13, 910 11,054 2,049,185 21, 794 24, 727 40, 958 25,199 22, 949 15, 100 20,611 16, 362 32, 185 16, 337 10,668 10,800 10, 891 11,301 20, 478 11,188 9, 662 66, 365 39,108 23,009 36, 051 38,933 15,771 12, 132 2, 710, 898 25,842 8,976 17,501 19, 232 63, 957 50,947 15,956 11,047 219, 154 10,840 12, 019 19,238 IT, 932 24,030 17,292 27, 293 20, 628 11,648 19,602 44,605 52, 805 11, 393 9,944 10.045 City ordinance . City ordinance . City ordinance . City ordinance . City ordinance . City ordinance . State law Augusta (a) Brunswick (a). finlilTnb'ls (am) Macon (m) Savannah ILLINOIS (am) Alton (m) State law. ... * Aurora (a) State law "Belleville City ordinance . State law Bloomington (a m) Cairo State law Champaign State law 'Chicago (a w) Both Danville State law *Decatur State law East St. Louis State law . . . Both Elgin Evanston State law . State law Freeport Galesburg State law Jacksonville (m) .. City ordinance . State law Joliet Kankakee - State law .... Kewanee State law Lasalle State law Lincoln . .... State law Mattoon <'itv ordinance. State law State law Moline Ottawa Pekin Both State law Pporin. (a. m) "Quincy (a) City ordinance . State law Rock Island. Rock ford (m) State law State law "Springfield (am) Streator (a) State law State law Waukegan *!NDIANA (a m) State law [Anderson State law State law of Health, Indianapolis. T. G. Wilkinson, City Clerk. J. J. Casey, Chief Sanitary Officer. H. O. Brueggeman, M. D., "Secretary Board of Public Health. J. T. Clark, M. D., Secretary Board of Health. None. E. Buehler, M. D., Health Officer. W. H. Sheets, M. D., Secretary Board of Health. J. D. Hillis, M. D., Secretary Board of Health. O. W. McQuown, M. D., Secretary Board of Health. V. V. Bacon, M. D., Secretary Board of Health. H. R. Spickerman, M. D., Health Officer. C. C. Funk, M. D., Health Officer. C. S. Bond, M. D , Secretary Board of [Columbus (Elkhart State law Elwood State law Evansville (a m) State law [Fort Wayne (a) State law State law [Hammond (a) |-Huntington State law State law [Indianapolis (a) [Jeffersonville State law (Kokomo State law [Lafayette (a m) .. .. State law [Logansport State law [Marion (a) State law ^Michigan City State law State law [Muncie (a) [New Albanv... State law [Peru. State law Both ^Richmond (aq) [South Bend (a) State law State law Health. D. W. McNamara, M. D., Health Officer. P. H. Caney, M. D., Secretary Depart- ment of Public Health. N. H. Thompson, M. D., Health Officer. "Returned." [Terre Haute [Vincennes (a) Both State law fWabash .. [Washington... State law . . . 74 STATES AND CITIES. (Reports and bulletins see explanatory note, p. 71. ) Estimated population, 1906. State law or city ordinance. Name and official title of registrar. (Remarks.) IOWA (b m) 2,205,690 9,596 25, 741 29,380 22,768 25,117 40, 706 78, 323 43,070 14,810 8,665 14, 597 12,100 15,290 10,288 20,548 42, 520 18, 849 1,612,471 18, 871 9,413 12, 633 13,024 77, 912 12, 123 22,167 15,964 41,886 35,541 2,320,298 8,428 46,436 10, 447 15, 201 29, 249 226. 129 30, 329 14, 461 22, 464 1,539,449 11,743 314, 146 17, 831 714,494 13,971 12, 379 23,500 11, 527 17, 165 24, 997 55, 167 8,150 10,899 1,275,434 9,077 553, 669 19,768 9,956 15.673 State law L. A. Thomas, M. D., Secretary State Board of Health, Des Moines. J. P. Harrell, M. D., Health Officer. None. N. J. Rice, M. D., Health Officer. None. Boone State law Burlington (am) State law State law Cedar Rapids Clinton State law Both St^te law Council Bluffs (am) Davenport Des Moines (a) . State law E. A. Linehan, City Recorder. H. T. Moore, Clerk of Council. J. D. Fulliam, M. D., Health Officer. J. A. Hull, M. D., Physician to Board of Health. G. J. Ross, M. D., City Health Officer. S. J. Crumbine, M. D., Secretary State Board of Health, Topeka. None. J. O. Brown, City Clerk. None. E. J. Lutz, M. D., Secretary Board of Health. F. D. Brooks, Secretary and Treasurer of Cemeteries. J. F. Wallace, M. D., Secretary Board of Health. M. R. Mitchell, M. D., City Physician. R. M. Dorr, City Clerk. W. H. Philips, City Clerk. B. L. Powell, Citv Clerk. J. E. Cassidy, City Clerk. G. A. Schneider, Registrar, (i. \V Brown M D Health Officer Dubuque (m) 1 City ordinance . State law State law Fort Dodge Fort Madison Keokuk (m) State law State law . Marshalltown Muscatine (a) Both Oskaloosa State law Ottumwa (m) .. (-) State law Sioux City Waterloo State law . KANSAS (b m) State law Atchison State law . Emporia State law Fort Scott 3 City ordinance . State law City ordinance . City ordinance . Both Hutchinson Kansas Citv (a) Lawrence *T/eHVfTi worth (am) Pittsburg State law . Topeka City ordinance . Both *Wichita KENTUCKY Bowling Green (a) City ordinance . City ordinance . *Covington (a) Frankfort Heriderson (a) . Both Lexington (a) City ordinance . City ordinance . City ordinance *Louisville (a) *Newport (aw) Owensboro None None. N. F. Graves, M. D., Health Officer *Paducah (a) City ordinance . State law LOUISIANA (b) W. S. Ingram, M. D., Secretary State Board of Health. L. J. Granary, City Auditor. W. F. O'Reiflv, M. D., Chairman Board of Health. L. H. Pirkle, M. D., Secretary Board of Health. A. G. Young, M. D., Secretary State Board of Health and Registrar of" Vital Statis- tics. G. W. Bumpus, City Clerk. E E Newbert City Clerk Baton Rouge Both *New Orleans (b m ^ : State law . Shreveport (a w m) State law State law *MAINE (a m) State law fAugusta State law fBangor (a) State law V. Brett, City Clerk. A. J. Grassy, City Clerk. A. O. Marcille, City Clerk. F. F. Driscoll, Citv Clerk. A. L. Orne, City Clerk. F. W. Clan, City Clerk. M. L. Price, M. D., Secretary State Board of Health, Baltimore. W. S. Welch, M. D., Health Officer. J.Bosley, M. D., Commissioner of -Health and Registrar of Vital Statistics. C. H. Brace, M. D., Secretary Board of Health. I. J. McCurdv, M. D., Health Officer. L. Petermau.Citv Clerk. fBath (a) State law fBiddeford State law fLewiston State law t Portland (am) State law State law fRockland (a) fWaterville State law *MARYLAND (a) State law fAnnapolis (m) State law *Baltimore (am) Both (Cumberland State law Both fFrederick (m) tHagerstown . . . State law . . . 1 Published by Board of Health, Charles Palew, M. D., Physician to Board. 2 Resolution of Board of Health. 3 "Ordinance requires doctors and undertakers to make reports of deaths, but it is almost ignored. Births the same." 75 STATES AND CITIES. (Reports and bulletins seo explanatory note, p. 71.) EstiniMted population, 1906. State law or city ordinance. Name and official title of registrar. (Remarks.) *MASSACHUSETTS (a) . . . Adams town 3, 043, 346 12,756 S, 713 9,881 12, 975 15, 491 602, 278 49. 340 24, 136 98,544 37, 932 State law State law State law Hon. W. M. Olin, Secretary of State, Bos- ton. F. H. B. Memton, Town Clerk. N. E. Collins, Town Clerk. T. J. Robinson, Town Clerk. F. I. Babcock, Town Clerk. L. S. Herrick, Citv Clerk. E. W. McGlenen, City Registrar. D. C. Packard, City Clerk. E. W. Baker, Town Clerk. E. J. Brandon, Citv Clerk. C.H. Reed, Citv Clerk. J. C. Bucklev, City Clerk. J. H. Carr, Town Clerk. J. Peale.Town Clerk. J.H.Cannell, Citv Clerk. A. B. Brayton, City Clerk. W. A. Davis, City Clerk. F. E. Hemen way, Town Clerk. J.J. Somes, City Clerk. \V. W. Roberts, City Clerk. J. F. Sheehan, City Clerk. C. J. Corcoran, City Clerk. R. L. Carter, Citv Clerk. <;. P. Dadman.Citv Clerk. .l.W.Att well, Citv Clerk. J P Litch Clerk Board of Health. \rlington x town (a) State law Attleboro town State law State la \v State law State law Beverly (a) .... Boston (a m) J Brookline town (a). State law State law State law Cambridge (a) Chicopee (a) 20, 396 13,217 9,167 30,066 105, 942 33, 319 11,597 12, 252 25, 989 37, 961 50, 778 14, 763 71.548 14. 678 95, 173 78, 748 38, 912 14,106 19,974 14, 562 12, 251 9,633 76, 746 14,714 37, 475 21, 740 20, 222 13,413 25, 648 11,424 28, 911 13,112 37,961 70, 798 11, 195 75, 836 30, 953 10, 464 26, 842 8,660 11,568 10, 261 13,871 11,637 14,432 130, 078 2, 584, 533 11,194 12,715 14, 645 24,039 40, 587 353, 535 11,872 State law State law State law State law Clinton town (a) 'Danvers town (a) . 'Everett (a) Fall River State law Fitchburg State law State law Framingham town (a) 'Gardner town State law State law 'Gloucester (a) 'Haverhill (a) State law Holyoke (am) State law 'Hvde Park town State law 'Lawrence (m^ s State law State law 'Leomin^ter town (a) 'Lowell (a) ... State law State law 'Lynn (a) Marlboro (a) State law P. B. Murphv, City Clerk. A. P. Joyce, City Clerk. W. D. Jones, City Clerk. J. McManus, Town Clerk. D. B. Leonard, City Clerk. J O W Little City Clerk Medford State law 'Mel rose (a) State law State law State law State law State law Milford town - 'Natick town (a) New Bedford 'Newton (a) 4 State law I. F. Kingsbury, Citv Clerk. C. S. Brooker, City Clerk. C. D. Chase, Citv Clerk. E. M. Poor, Town Clerk. W. R. N. Barker, City Clerk. E. Le Brugen, Town Clerk. H. A. Keith, Citv Clerk. 'North Adams (a) State law Northampton (a) State law State law State law State law State law .... Peabody town Pittslield (a) Plymouth town (a) Quincy (a) . . Revere town (a) State law State law A. J. Brown, Town Clerk. J C Entwisle Agent Board of Health. "Salem Somerville (a) State law F. W. Cook, City Clerk. W. W. Buckley, Town Clerk. E. A. Newell, City Clerk. E. A. Tetlow, City Clerk. C. F. Hartshorne," Town Clerk. L. N. Hall, City Clerk. A. F. Richardson, Town Clerk. F. E. Critchett, Town Clerk. L J Upham Town Clerk Southbridge town State law Springfield (a) State law Taunton (a) State law Wakefield town (ai j-Waltham (a) State law State law State law State law rWare town (a) fWatertown town (a) fWebster town State law fWestfield town State law J. A. Raymond, Town Clerk. J. H. Finn, Citv Clerk. E. H. Towne, City Clerk. Hon. G. A. Prescott, Secretary of State, Lansing. J. Mawdsley, City Clerk. R. Granger, Citv Clerk. T. Thome, City Recorder. H. T. Renshaw, Registrar. T. J. Burke, Citv Clerk. {Weymouth town (a) State law rWoburn (a) r Worcester (am)* State law . State law *MICHIGAX (a m) State law State law . tAdrian 'Alpena State law Ann Arbor ( m ) State law State law State law State law fBattle Creek tBavCitv [Detroit (a) Escanaba. . . State law... 1 Monthly bulletin published by Health Department, Samuel H. Durgin, M. D., chairman: and werkly and monthly mortality from reports of the Board of Health in Monthly Bulletin of the Sta- tistics Department, published quarterly, by Edward M. Hartwell, Secretary. 2 Monthly bulletin by Board of Health, J". H. Lawrence, M.D., Health Officer. 3 By Board of Health. * Monthly bulletin by Board of Health. 76 STATES AND CITIES. ^Reports and bulletins see explanatory note, p. 71.) Estimated population, 1906. State law or city ordinance. Name and official title of registrar. (Remarks.) *MICHIGAN Cont'd. (Flint 15, 574 State law D. E. Newcombe City Clerk Grand Rapids (a m). . 99, 794 State law . J Schriver Secretary Board of Health Iron Mountain^ 8 257 State law J B Calis Citv Clerk Ironwood 10, 177 State law W. D. Snyder Citv Clerk 'Ishpeming . . . 10, 807 State law J. D West Citv Recorder Jackson 25 360 State law Kalaniazoo (a) 32, 472 State law J. J. Lew Health Officer Lansing 22, 172 State law M F Gray City Clerk (Manistee 11, 932 State law C. A. Gnewuch, Citv Clerk [Marquette (m) .. 10, 969 State law. H. Siegel Citv Recorder Menominee 10,234 State law B T Phillips M D Health Officer (Muskegon 20, 937 State law P. P. Misner, Citv Recorder ("Owosso 9,369 State law A. H. Dumond Citv Clerk Pontiac 11 942 State law G H Drake M D Health Officer [Port Huron (m) 20, 464 State law . 'Saginaw 48, 742 State law D C Bell Citv Clerk Sault Ste. Marie 11,894 State law Traverse Citv. 12, 153 State law . T. H. Gillis City Clerk MINNESOTA (am) "Duluth (am) 2, 025, 615 67,337 State law 1 State law . . . H. M. Bracken, M. D., Secretary State Board of Health, St. Paul. D. D. Murray, M.D., Health Commissioner "Mankato (a) ''Minneapolis (am) 11,075 273, 825 Both State law A. O. Bjelland, M. D., Health Officer. A M Kriedt Registrar of Vital Statistic-- St Cloud 9 574 State law J B Dunn M D City Health Officer "St. Paul (am) 203, 815 State law G.A. Renz M D Commissioner of Health- Still water 12, 458 State law W. H. Pratt, M. D., City Physician. "Winona (a m) 20,458 State law D. B. Pritchard, M, D., Health Officer MISSISSIPPI 1 708 272 Meridian 20 503 Natchez (b m) 2 13, 476 City ordinance . G. T. Eiseli, City Clerk. Vicksburg 15, 710 MISSOURI 3, 363, 153 Carthage 10 280 None None Hannibal 12, 780 Citv ordinance A. S. Lilleman, City Clerk. Jefferson 11 416 State law None Joplin 35,671 "Kansas City 182 376 City ordinance H. L. Ebert, Secretary Board of Health. Moberlv 8,012 None None. "St. Joseph (a) 118, 004 City ordinance W. H. Hartigan, Secretary Health Depart- "St. Louis (aw) 649, 320 Both ment. P. J. Regan, Citv Register. Sedalia 15 927 C. E. Baker, City Clerk. Springfield 24 119 Webb City. 11,897 None None. MONTANA (b m) .. 303, 575 State law l T. D. Tuttle, M.D., Secretary State Board Anaconda (a) 12 267 Both of Health, Helena. II W Stephens, M. D., Health Officer. Butte (a) 43, 624 State law C. T. Pigot, M. D., Health Officer. Great Falls 21 500 State law . Helena 16 770 State law J S. Tooker, Secretary Board of Health. NEBRASKA 1 068 484 State law G. H. Brash, M. D., Secretary State Board "Lincoln (m) 48, 232 Both of Health, Beatrice. W. C. Rohde, Health Officer. "Omaha (a) 124 167 City ordinance J. Barker, Registrar. South Omaha 36, 765 Both -J.J.Gellev, Citv Clerk. *NEW HAMPSHIRE (a) 432 624 State law I. A. Watson, M. D.. Secretary State Board [Berlin (a) 11 982 State law of Health and Registrar of Vital Statis- tics, Concord. P. J. Smvth City Clerk. [Concord (a m) 21 210 State law H E Chamberlain Registrar of Vital [Dover (a) 13 459 Both Statistics. F E Quimby Citv Clerk. [-Keene (a) 10, 197 State law F. H. Whitcomb, Citv Clerk. KLaconia (a) 8 042 State law J.F.Frank, Citv Clerk. (Manchester (m) 3 64 703 State law E C Smith Citv Clerk. [Nashua (a) . 26, 652 State law A.L. Cvr, Citv Clerk. ["Portsmouth 11 123 State law L Hilton, Citv Clerk. [Rochester (a)... 9.108 State law . . . H. L. Worcester, Citv Clerk. i New law in effect, 1907. -Semimonthly. Published by Board of Health. 77 STATES AND CITIES. (Reports and bulletins see explanatory note, p. 71.) Estimated population, 1906. State law or city ordinance. Name and official title of registrar. (Remarks.) *NEW JERSEY (a) 2 1% 237 State law H Mitchell M D Secretary State Board [Atlantic City (a) 39 544 State law . . of Health, Trenton. A.T.Glenn, Registrar of Vital Statistic^ rBayonne 44, 170 State law PBloomfield town 12 068 State law W. L. Johnson, Registrar of Vital Sta- [Bridgeton 13, 682 State law tistics. F. L. Hewitt, City Recorder. r Camden 84 849 State law . I. V. Bradley, City Clerk. ^ East Orange (a) 25,909 State law L. E. Rowley, City Clerk. rEli/abeth 62 185 State law J.F.Kenah, City Clerl$. 11 429 State law W. P. Ellery Assessor ^Harrison town (am) 13,268 State law and C. J.Roonev, Clerk Board of Health and fHoboken (a) < 66 689 county ordi- nance. State law . Vital Statistics of Hudson County. See Jersey City. J. Tucker, Registrar of Vital Statistics. [Jersev City (am) 237, 952 State law and C.J.Rooney, Clerk Board of Health and [Kearnv town (m) 14, 142 county ordi- nance. State law Vital Statistics of Hudson County. C. Schiller, Registrar of Vital Statistics. [Long Branch 12 525 State law E.B.Blaisdell, Secretary Board of Health Millville 12, 144 State law and Registrar. L. H. Hogate, City Recorder. Montclair town (a) 16 851 Both C. H. Wells, Health Officer Morristown town (a ) New Brunswick 12, 322 23 758 City ordinance . Both D. H. Wilday, Registrar of Vital Statistics. J. A. Morrison Citv Clerk. Newark (aw) ... .1 289, 634 State law J. F. Connelly, Citv Clerk. Orange 26 493 State law W. B. Gano, City Clerk. Passaic (a) 39, 799 Both G. F. Grear, Registrar of Vital Statistics. Paterson (am) 112 801 State law C. S. Gall, Registrar of Vital Statistics. Perth Ambo v 27,534 State law C. M. MacWilliam, Citv Clerk. Phillipsburg town 13, 712 State law Plainneld (a) 19 088 State law Miss H. O. Mattison Registrar of Vital j-Trenton (a) 86,355 State law Statistics. T. B. Holmes c/o Board of Health Office. f Union town 17,369 State law and See Jersey City. [West Hoboken town 30,280 county ordi- nance. State law *NEW YORK (am) * Albany (a) 8, 226, 990 98, 537 State law City ordinance . E. H. Porter, M. D., Secretary State Board of Health, Albany. W. G. Van Zandt, Registrar of Vital Sta- f Amsterdam 24 172 State law tistics. S W Brumlev Registrar of Vital Sta- ! Auburn (a m) 32 963 State law tistics. A. H. Brown M. D., Health Officer. Batavia village 10,400 State law E. J. Hogan, Registrar of Vital Statistics. Binghamton (a) . 43, 785 State law . J. T. Lamm, Secretary Board of Health. "Buffalo (a) 381 819 Both F C Gram M D Registrar of Vital Sta- [Cohoes . 24 093 State law tistics. Ktorning 13, 913 Both E. W. Byran, M. D., Health Officer. Portland (a) 11,530 State law E. S Dalton City Clerk. fDunkirk (am) 15, 913 Both L. N. Murrav, Registrar of Vital Sta- f-Elmira 35 734 State law tistics. S. A Warner Registrar of Vital Sta- f Geneva 12 506 State law tistics. J M O'Malley, Citv Clerk. [Glens Falls village 15, 057 State law . . . D. I. Howe, Registrar of Vital Statistics. [Gloversville 18, 624 State law [Hornellsville (m) 13 390 State law B R Hollands Registrar of Vital Sta- ^Hudson 10 531 State law tistics. L Van Hoesen M. D. Registrar of Vital [Ithaca 14 768 State law Statistics. W O Kerr Secretary Board of Health Jamestown 26 628 State law C B Jones Registrar of Vital Statistics. f Johnstown 9, 692 State law . F. Bogaskie, Citv Clerk. f Kingston (m) 25 585 State law W. B Scott Secretary Board of Health. Little Falls 11 169 State law J G Hazlett Registrar of Vital Statistics. J-Lockport 17 597 State law J. R. Compton, Registrar. f-Middletown (am) 15,914 State law J. G. Grav, Registrar of Vital Statistics. [Mt. Vernon 25 670 State law A. T. Banning M. D., Health Officer. New Rochelle 21 520 State law W B Croft Clerk Board of Health. *New York (a w q) 4, 113, 043 Both W. H. Guilfov. M. D., Registrar of Records, Manhattan borough 2, 153, 495 Both Department of Health. C. J. Burke, M. D , Assistant Registrar of Bronx borough 285 809 Both Records. A.J O'Learv M D Assistant Registrar of Brooklyn borough... . 1,392,811 Both Records. S.J. Byrne, M. D., Assistant Registrar of Queens borough 206,806 Both Records. R.Campbell, M, D., Assistant Registrar of Richmond borough . . 74,122 Both Records. J W Wood M D., Assistant Registrar of Records. 78 STATKS AND CITIES. (Rejorts and bulletins see explanatory note, p. 71.) Kstimated population 1906. State law or city ordinance. Name and official title . J. Crichton, jr., City Clerk. T. B. Loughlen, M. D.. Registrar of Vital Statistics. E. A. Cooke, Clerk Board of Health. A. Barger, jr., Registrar of Vital Statis- tics. T.F.Mannix. Citv Clerk. J. F. Clearv, Citv Clerk. E. Burgess City Chamberlain. \V. F. Hitchcock, Registrar of Vital Sta- tistics. A. T.Huggins, Registrar of Vital Statistics. C. I. Leggett. Registrar of Vital Statistics. D. E. Hart, Citv Clerk. J.Metz. Registrar of Vital Statistics. E.Bolton, Registrar of Vital Statistics. T. W. Fogartv, Registrar. F. W. Streeter, City Clerk. F. E. Holahan, City Clerk. J.J. Hanrahan, Secretary Board of Health. R. H. Lewis, Secretary State Board of Health, Raleigh. A. G. Halvburton, Citv Clerk. F. O. Hawlev, M. D., Superintendent of Health. E. Harrison, M. D., Superintendent of Health. F. M. Hahn, Citv Clerk. T. P. Sale, Clerk Board of Health. C.T. Harper. M. D.,CitySuperintendehtof Health. Superintendent of Health. J. Grassick, M. D., State Superintendent of Health, Grand Forks Hon. C. A. Thompson, Secretary of State, Columbus C. O. Probst. M. D.. Secretary State Board of Health, Columbus. A. A. Kohler, M. D.. Health Officer. None. None. W. T. Ramsey. M. D.. Health Officer. A V Smi'h M D Health Officer fNiagara Falls (a) State law fNorth Tonawanda State law fOgdensburg (a) State law. tOlean (a) . State law j-Oswego (a) State law. . j-Peekskill village State law (Tlattsburg... State law.. [Port Jervis State law rPoughkeepsie (a i {Rochester (a m) State -law... Both . Rome (m) Both Saratoga Springs village Schenectadv (a) 13,117 61,919 118,880 76, 513 65, 096 25,992 14, 513 64,110 2, 059, 326 18,414 22, 009 14,067 9,840 14,225 21,528 11,202 463, 784 13,097 4, 448, 677 50,738 9,796 15, 415 9,912 10,569 38,440 13,990 345, 230 460, 327 145, 414 State law State law Syracuse (am) State law Troy (m) . State law Utica (a) State law State law State law VVatertown (m) Watervliet ''Yonkers (am).. Both NORTH CAROLINA (bm) \sheville State law Stair law Charlotte (m) Both jTeensboro (a) City ordinance . City ordinance . City ordinance . City ordinance . Both Newbern . "Raleigh (a m^ 'Wilmington.. Winston (m) NORTH DAKOTA (b) ... Fargo State law % State law OHIO (a) J 2 (State law [State law State law Akron (m) .. Alliance State law. Ashtabula... . State law State law Bellaire (a) Cambridge (a) 3 State law. City ordinance State law Canton (a) Chillicothe E. F. Waddle. Health Officer. H. M. Millar. Registrar of Vital Statistics F. Combes, Secretary Public Health ]><- partment. E. G. Horton, M. D., Health Officer. C.E.Adams, Clerk Department of Health. None. A. W. Overmver, Secretary Board of Health. M. Millikin, M. D., Health Officer. A. L. Jones, M. D., Health Officer. E. V. Hutf. M. D.. Health Officer. J. M. Bums, M. D., City Health Officer. None. F. C. Miller, Health Officer. G. I). Lummis. M. I).. Health Officer. C. B. Hatch. M. !>.. Health Officer. Health Officer. J. W. Bendt. Clerk Board of Health. II. C. Shoepfle. M. D.. Health Officer. H. Baldwin. M. I).. Health officer. None. H. B. Gibbon. M. D., Health Officer. Cincinnati (a w) . City ordinance. City ordinance State law State law Cleveland (am) Columbus (m) Dayton (a) 100, 799 20, 078 10,699 17,613 9,219 27, 670 12,186 9, 855 27, 702 22, 730 20, 142 16,396 14,001 13, 054 9,305 20, 491 18. 564 20,714 i 20, 378 42, 069 14,925 11,078 1 East Liverpool State law P^lvria State law. Findlay State law Fremont (a m) . State law Hamilton. . State law State law Ironton Lancaster State law Lima State law Lorain (a) State law City ordinance . State law Mansfield Marietta Marion State law City ordinance . State law State law State law State law State law Mnssillon (a) Middletown (al Newark (m) Piqua .. .. Portsmouth (a) Springfield Both Steubenville State law Tiffin (a) ... State law... 1 In Statistics of Ohio by Secretary of State. - In Report of State Board of Health. 3 Report to State Board of Health. 79 STATES AND CITIES. (Reports and bulletins see explanatory note, p. 71.) Estimated population, 1906. State law or city ordinance. Name and official title of registrar. (Remarks.) OHIO Continued. *Toledo (a m) 159, 980 State law J. C. Reinhart, M. D., Health Officer. Warren 10, 071 State law J. H. Jameson Clerk Board of Health Wellston 10,247 State law None. 9,356 State law. *Youngstown (a) 52, 710 Citv ordinance. G. C. Steventon, Registrar and City 24,856 State law Chemist. None. OKLAHOMA 590, 247 Guthrie 13, 808 City ordinance. E. W. Kinnan, City Clerk. Oklahoma Citv 20 990 None None. OREGON (b m) 474, 738 State law R. C. Yennev M. D Secretarv State \storia 9, 701 State law. Board of Health, Portland. F. V. Mohn, M. D., Citv Phvsician. * Portland (m) 109, 884 Citv ordinance. E. Moore, Clerk Board "of Health. *1 > KNNSYI.VAM A (a) f \llegheny (am) 6,928,515 145, 240 State law State law. W. R. Batt, M. D., State Registrar of Vital Statistics, Harrisburg. H. K. Beattv M. D. Superintendent Bu- f Allentown (a) 41,595 Both reau of Health. J. A. McCafferty, Secretarv Board of t Altoo*na (a in ) 47, 910 State law Health. S. B. Trees, Secretary Board of Health. Beaver Falls borough (in) 10, 246 State law T G. McPherson Registrar Braddock borough 19, 218 State law L. L. Todd, Registrar of Vital Statistics. -(-Bradford (a) 16, 577 Both . J C. Walker M. D Registrar Butler borough (a) 1" 1".") State law T M Maxwell M D Registrar of Vital fCarbondale (a m ) 14, 976 Both Statistics. F W Lewis Secretarv Board of Health Carlisle borough 10, 832 State law A. Wiener, Registrar of Vital Statistics. Chambersburg 9,658 State law Chester (a x 38,002 State law H. Harkson, Registrar. 'Columbia borough (a) 13, 423 State law H B Clepper Secretarv Board of Health. Danville borough 8 066 State law Dubois borough (a) 11,313 State -law W. J. Smathers, M. D. Registrar. Dunmore borough 15,145 State law 'Duquesne borough 11,634 State law 'Easton 28 317 State law Erie (a) 59, 993 State law .T. W. Wright, M. D., Health Officer. 'Harrisburg . 55, 735 State law Hazelton (a) ' 15, 771 State law S. J. Hughes, City Clerk. Homestead borough 15,486 State law C. C. Huff M I). Registrar of Vital Sta- fJohnstown (am) .. .. 43, 250 State law . tistics. F. H. Singer. Secretarv Board of Health. Lancaster (a) 47, 129 Both M W Raub Registrar 'Lebanon (m) 19, 404 State law E. L. Kreider, Secretarv Board of Health. McKeesport (a) 43, 438 Stale law A J Richards Secretarv Board of Health. Mahanov City borough (a). 14, 836 State law J. H. Kirchner, Secretarv Board of Health. Meadville (a) 11,769 State law Mt. Carmel borough 16, 187 State law ' Nanticoke borough (a) ... 13,358 State law A. Werth. Health Officer. 'Newcastle (am) 36 847 State law C C Homer Registrar of Vital Statistics. Norristown borough (a m). 23, 747 State law C. E. White, Registrar. Oil Citv (a) 14 662 State law J T Fahey Registrar tPhiladelphia (a w) 1,441,735 State law G. W. Atherholt, Chief Division of Vital tPhoeuixville borough [Pitteburg (m w) 9,604 375, 082 State law State law. . .. Statistics, Bureau of Health. J F. Edwards, M. D., Superintendent Bu- fPittston 13,906 State law reau of Health. fPlvmouth borough (am) 16 235 State law R J. Williams M D. Secretarv Board of fPottstown borough 13 942 State law . Health. J B. Evans Secretarv Board of Health. t Pott^vi lie borough 16 664 State law fRi'ading (a) 91,141 State law F. P. Heine, Secretarv Board of Health. fScranton (m) 118 692 State law tshamokin borough (a) 20 482 Both T. C. Roberts, Seoretarv Board of Health. rSharon borough 11 909 State law tShonandoah borough 22, 949 State law [South Bethlehem borough fb). fSteelton borough 15,005 13,911 State law State law S. B. Keener, Secretary Board of Health. fSunburv borough 10 968 State law B. F Heckert, Registrar of Vital Statistics. rTitugyiile (a) 8 346 Both W. Varian, M. D.. Health Officer. t Warren borough (a) 10, 647 State law C. W. Schmehl, M. D., Registrar of Vital fWrst Chester borough (a) .. tWilkesbarre (m) . . 10,424 60, 121 State law Both .. Statistics. C. E. Woodward. M. D., Registrar of Vital Statistics. F. H. Gates, Citv Clerk. 80 STATES AND CITIES. Estimated Name and official title of registrar. , D AWknWlr-c< \ explanatory note, p. 71.) 1906. [ nemarKS. ) *PENNSYLVANIA Con. (Wilkinsburg borough 16,949 State law W Elder Registrar (Williamsport (a) . . 29, 735 State law R. B. staner, Registrar. York (am) 39,168 State law J. H. Bennett, M. D. Subregistrar of Vital *RHODE ISLAND (a) ... 490,387 State law Statistics. G. T. Swarts, M. D., Secretary State Board (Central Falls 19 702 State law of Health, Providence. C F Crawford City Clerk (Cranston town 18,415 State law D. D. Waterman, Town Clerk. (Cumberland town... 9,469 State law.. [East Providence town 14, 072 State law Lincoln town 9,279 State law D. D. Johnston, Town Clerk. (Newport (w) 25 559 State law D Stevens Citv Clerk hPawtucket 44,211 State law J. W. Rowe, Citv Clerk. Providence (a) 203, 243 Both . . C. V. Chapin M. D Superintendent of \ Warwick 25, 464 State law Health. (Woonsocket (a m) 32, 994 State law W C Mason City Clerk SOUTH CAROLINA 1,453,818 "Charleston (a) 56,317 Citv ordinance . J. M. Green, M. D., Health Officer. Columbia 24,564 Both E. C McGregor Secretarv Board of Greenville 13,810 Health. Spartanburg 14 905 Both H E Heinitsh jr Secretarv *SOUTH DAKOTA (a)... 465,908 State law Hon. Doane Robinson, Superintendent of (Sioux Falls 12,681 Both Vital Statistics. Pierre. A. H. Tufts, M. D., Health Officer. TENNESSEE 2 172 476 Chattanooga (m) 34 297 Clarksville 10,337 City ordinance . R. B. Macon, M. D., Health Officer. Jackson . . ... 17 193 None None. Knoxville (a) l 36 051 Citv ordinance W R Cochrane M D Secretarv Board "Memphis (m) 125 018 City ordinance of Health. "Nashville (am) 84,703 Citv ordinance . L. B. Smith, M. D., City Health Officer. TEXAS (b) 3 536 618 State law W Brumbv M D State Health Officer, Austin 25 290 State law Austin. Beaumont 13 105 State law None Corsicana 12,275 State law . Dallas 52 793 State law . Denison - 12, 317 State law J. D. Yocorn, Citv Secretarv. El Paso 19 248 State law Fort Worth (a) 27,096 Citv ordinance . W. J. Estes, Citv Secretarv. "Galveston (q) .. 34 355 Citv ordinance C. W. Trueheart, M. D"., Citv Health Houston 58,132 State law Physician. Laredo 14 695 State law Palestine 9,773 State law None. Paris 10 018 Both M. A. Walker, M. D., Health Officer. "San Antonio (m) Sherman 62, 711 11,989 City ordinance . State law Tyler 8,765 D. H. Connally, M. D., Health Officer. Waco 24, 430 State law UTAH (m) 316 331 State law T. B Beatty, M. D., Secretary State Board Ogden 17 165 State law of Health, Salt Lake City. "Salt Lake Citv (m w) 61 202 Both M. R. Stewart, M. D., Health Commis- *VERMONT (b) 350 373 State law sioner. H. D. Holton, M. D., Secretarv State Board (Barre (a) 11 028 State law of Health, Brattleboro. J. Mackav, Citv Clerk. (Burlington (a) 21 070 State law M. C. Grandy, Citv Clerk. (Rutland 11,961 State law H. B. Whittier, City Clerk. VIRGINIA 1 973 104 "Alexandria (a) 14, 642 City ordinance . E. F. Price, Auditor. Danville (a m) 17 972 City ordinance J. W. Robinson, M. D., Health Officer. "Lynchburg 22,850 Citv ordinance . "Not in city." Manchester (a) 9 997 Both M. P. Rucker, M. I)., President Board of Newport News 28,749 Health. ^Norfolk (bin) 66 931 Both A. P. Pannill. Asst. Health Commissioner. "Petersburg (am)... 21,810 Citv ordinance . V. L. Weddell. Secretarv Board of Health- 1 Monthly bulletins issued until 1907. 2 Record kept only of interments in city limits. 81 STATES AND CITIES. (Reports and bulletins see explanatory note, p. 71.) Estimated population, 1906. State law or city ordinance. Name and official title of registrar. (Remarks.) VIRGINIA Continued. Portsmouth (m) 18, 627 State law F. S. Hope, M. D., Health Officer. *Richmond (a m) 87 246 City ordinance . J. M. Donahoe, Registrar of Vital Statis- Roanoke 24,699 tics. WASHINGTON (b) 614 625 State law E E Heg M D Secretary State Board of *Seattle (m) 104 169 State law Health. Seattle C Calhoun M D Health Officer *Spokane (am) 47,006 Both M. B. Grieve, M. D., Health Officer 55 392 State law A de Y Green M D. Commissioner of Wallawalla (m) . ... 13 253 Both Health. A E Braden, M.D., Health Officer WEST VIRGINIA (b) 1,076,406 State law H. A. Barbee, M D , Secretary State 13 715 City ordinance Board of Health, Point Pleasant. J S Ross City Recorder Huntington ... 13 015 16 477 City ordinance C W Hudson M D Health Officer *Wheeling (a q) 41,494 Citv ordinance . W. H. McLain, M. D., Health Officer. WISCONSIN (b) 2 260 930 State law l C A Harper M D Secretary State Board *Appleton 17 383 State law of Health, 'Madison. J V Canavan M D Health Officer Ashland 14, 808 State law *Beloit (q) 13 339 State law H O Delaney M D Health Officer Chippewa Falls 9,192 State law None. *Eau Claire 18 981 State law J F Fair M D Health Physician Fond du Lac '. 17,719 State law None. *Green Bay 23 688 State law H. P. Rhode M D. Commissioner of Janesville 13,887 State law .. Health. W D. Merritt.M.D .HealthCommissioner. Kenosha .... 17 061 State law None La Crosse 29, 115 State law Register of Deeds. *Madison 25 128 State law O S Norsman City Clerk *Manitowoc 12,922 State law I. E. Meany, M. D., Health Officer *Marinette 15, 186 State law S P. Jones M D Health Commissioner Merrill 9 329 State law None *Milwaukee (a m) 317, 903 State law F. E. Darling M. D Registrar of Vital Oshkosh 31,033 Both.. Statistics. A. H. Brocho, M. D., HealthCommissioner Racine 32 928 Neither C Harms Acting Health Officer Sheboygan (q) 24 239 State law H C Reich M D Commissioner of Stevens Point 8 922 State law Health. 37 643 Both Watertown 8,659 State law \Vausau 14 879 State law WYOMING 103 673 Cheyenne 13, 570 City ordinance W A Burgess M D Health Officer Laramie 7 480 State law None 1 New law in effect, 1907. 915907- . , oc, [off., T.M.Reg. U.S. Pat. Off. THE UNIVERSITY OF CALIFORNIA LIBRARY