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BUREAU OF THE CENSUS
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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 <ln
(matin ou soir.)
1. Sexe: masculin fminin
/n'indiquer les mois d'age que pour\
2. Date etlieul Ne le __ - du mois d ^-19 \ les enfants ayant moins de5 ans. /
de \
naissance. J a ,. departement d
S'il s'agit d'un a<lnltc: gil s'aytt d , i ,-fant de mains de cinq ans:
Clibataire
Marie .. Depui.s ^gitinfe? ...
3. Etat civil. ^ cnmbien
Veuf Tan
Divorc6__. n6es? premier n.
Age au mariage
Si F enfant a moms d'un an:
4. Si le Nombred'enfantsvivantsoumorts
<f. decede issus du mariage (morts-n6s non , ^ u ge j n
etait compris) Mode
*>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 <f registrar.
(Remark-. ,
*NEW YORK Con.
fNewburg (a)
26, 593
27, 827
10,348
14,842
10,202
22,419
13, 768
10,445
9,757
25,369
185, 703
17 726
Both
A. P. Templeton, Registrar of Vital sta
tistics.
W. 1'. Home, Registrar of Vital Statistics,
i J. H. Tillitson, Registrar of Vital Sta tistics.
' P>. 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.
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