CHAPTER II.

REGISTRATION OF BIRTHS AND DEATHS.

History of Registration.-System of Registration.-Defects of Registration.Number of Uncertified Deaths.-Number of Inquests.-Improvements of Registration required.-Medical Registrars.-Registration of Causes of Death.-Deaths from ill-defined Causes.-Lack of Uniformity of Nomenclature.-Classification of Diseases.-The Royal College of Physicians on Nomenclature and Classification.-The Registrar-General's Classification of Causes of Death.

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EXT to a correct enumeration of population, the accurate and complete registration of births, marriages, and deaths constitutes an essential basis of vital statistics. The question of registration of disease will be discussed in the next chapter.

Such is the importance of this matter, that the late Dr. Parkes only expresses the literal truth when he says: "The attention now paid to public health is in a large degree owing to the careful collection of the statistics of births and deaths, and of the causes of death, made in England during the last forty years. It may truly be said, indeed, that not only all Europe, but gradually the entire world, has been influenced by the work of the Registrar-General of England. We are now able to determine with some precision the limits of mortality and its causes, and are being led up to the consideration of the causes which bring about a high death-rate."

History of Registration. The office of Registrar-General of England was created in 1836, and civil registration began as the result of an Act of Parliament on July 1st, 1837. The first of the series of annual reports of the Registrar-General was

published in 1839, and to this first report Dr. W. Farr, who acted as Compiler of Abstracts in the newly created General Register Office, contributed the first of that long series of letters, addressed to the Registrar-General, on the causes of death in England, which have become so widely known, and must be constantly referred to by all who write on Vital Statistics. Even in this first letter he emphasized the importance of a correct and exact medical momenclature, saying that "the nomenclature is of as much importance in this department of inquiry as weights and measures in the physical sciences." Successive amendments to the law of registration were made, and in 1874 a new law was enacted, rendering the registration of births and deaths compulsory, with penalties for noncompliance.

In the 39 years before registration became compulsory, the registration of births was defective, the proportion of unregistered births being estimated at about 5 per cent. Only a small proportion of deaths were believed to have escaped registration, though in a considerable proportion the medical certificate of cause of death was either unsatisfactory or altogether wanting. The returns of 1876 showed the excellent effect of the compulsory law. The stated birth-rate of that year, 36-6 per thousand, was the highest on record, being 1.2 per thousand higher than the average for the ten previous years; while the number of uncertified deaths had greatly decreased.

System of Registration. The registration of births and of deaths is performed either at the offices of local registrars or the houses of the people. Copies of the certificates are forwarded to the General Register Office, Somerset House, where they are collated and abstracted; and from these abstracts the weekly, quarterly, and annual reports of the Registrar-General are prepared. For the twenty-eight great English towns a weekly report is issued on the Tuesday morning next following the end of the week, which contains fuller information in regard to the causes of death in London, and states also the death-rate in the principal foreign towns, as well as the meteorological facts of the week. The quarterly reports for

England and Wales are issued in the month following the end of the quarter, while the annual reports appear toward the end of the year subsequent to the year to which they apply. An annual summary, however; appears at an earlier date, and in regard to the delay in the issue of the annual reports, it must be remembered that they are works of much labour and skill, and necessarily occupy considerable time in preparation. As Dr. Farr says: "They may be regarded as storehouses of facts, which have been arranged on methods that are approved as the most useful and convenient, and to which, both now and in future years, students of vital statistics may resort for the elucidation of questions bearing on the social condition of the people, on national progress, on life, health, and disease. It is important they should be done well. It is desirable only in the next degree that they should be done quickly."

The admirable decennial supplements of Dr. Farr have been continued since his decease by Dr. Ogle, and we shall have frequently to refer to their contents.

The value of these various reports can scarcely be exaggerated. The rates of mortality in the weekly reports require, however, to be accepted with caution, as large fluctuations in short periods may be due to accidental causes. But in indicating the character and amount of prevalent diseases, and their geographical distribution, they are invaluable. As Farr eloquently puts it: "Thus observers, like watchmen on the walls, are ever on the look out, so that they can see exactly what is going on, and neither plague, cholera, nor any other great epidemic can take the nations by surprise. The deaths serve the purpose of a self-registering inspection. Death cannot be deceived by sham defences."

Imperfections of Registration.-In order that registration may have its full value, the facts should be given uniformly, accurately, and completely. There are imperfections in the present system of registration, which are, however, steadily diminishing in extent and importance.

1. A certain proportion of the births remain unregistered. (a) There is strong reason for thinking that a certain number

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of children born alive are buried as still-born. (b) In addition to these, a small proportion of births escape registration from negligence; in other cases (c) owing to the shame of illegitimacy, especially in large towns; others (d) in order to avoid compulsory vaccination; and also (e) among migratory people, as gypsies, Italians, etc. The Act of 1837 made registration voluntary on the part of the parent, saying he shall give information when requested to do so by the local registrar, but there being no penalty for refusal. Spite of this deficiency in the law, the number of unregistered births steadily decreased. The estimate of the annual deficiency in births registered during 1861-70 (founded on the Census Report) was 13,614 out of 763,623, as compared with an annual deficiency of 19,323 in 1851-60, and of 38,036 in the years 1841-50.

2. The registration of deaths, both as regard the fact itself and the cause of death, is steadily becoming more satisfactory, as will be shown shortly. There is still, however, a possibility of deaths escaping registration. In my annual report (1884) as Medical Officer of Health for Clapham, I made the following remarks, which refer to this point. "An important defect of the Registration of Deaths Act may be here alluded to. It is not necessary to register the death of any person before burial, but the 17th section of 37 and 38 Vict., cap. 58, provides that the person who buries or performs any religious service for the burial of any dead body as to which no order or certificate under this section is delivered to him, shall within seven days after the burial give notice thereof to the registrar, and if he fail to do so shall be liable to a fine not exceeding £10. In the case which drew attention to this defect in the Act, the parents, who were unmarried, only lived two days in this subdistrict before their child died. They then took the body to Chelsea, obtained a death certificate from a medical man who had previously known the child, and subsequently buried the child at Hanwell. A week after the burial, and two weeks after the death, a misdirected postcard was received by the Clapham registrar from the person who officiated at the burial, baldly stating this fact. It is evident that such a conjunction

of circumstances renders evasion of investigation in suspicious cases a comparatively easy task."

Number of Uncertified Deaths.-In 1886 the causes of 490,264, or 91.3 per cent., of the total deaths were certified by registered medical practitioners; while the causes of 28,690, or 5.3 per cent., were certified by coroners; and the causes of 18,322, or 3-4 per cent. of the total deaths, were not certified. In the previous years the proportion of uncertified deaths had steadily declined from 4.7 per cent. in 1879 to 3.5 per cent. in 1885. The number of uncertified deaths varies greatly in different parts of the country. Thus in 1886 the proportion in the metropolis was only 1.1 per cent., while in Durham it was 5.6, in Cornwall and Huntingdonshire 6·0, in Herefordshire 6.3 and in Wales 8.1 per cent.

A considerable proportion of these uncertified deaths were submitted by the registrars to the coroner, who in an informal manner decided that no inquest was required. Such a procedure would be justifiable if a private medical investigation were instituted, but as matters now stand there is little reason to doubt that many crimes remain undetected, which investigation would have brought to light. Even when a coroner's inquest is held, the result is often little if at all more satisfactory.

Number of Inquests.-During the year 1886, 28,690 inquests were held; i.e., on 5.3 per cent of the total deaths, the proportion having varied in the seven preceding years from