CHAPTER III.

REGISTRATION OF SICKNESS.

Estimation of Prevalence of a Disease from its Mortality.-Economically Sickness more important than Death.-Attempts made to Register Sickness. Requirements of Sickness Registration.-Information now Available.-Object Prophylactic as well as Scientific.-Compulsory Notification of Infectious Diseases.-Advantages of Notification.Methods.-Extension of Notification.-Diseases to be Notified.Effect on Zymotic Mortality.-National Registration of Infectious Diseases.

HE registration of deaths gives a very imperfect view of the prevalence of disease. Sanitarians would have a greatly increased power of protecting the public health if they could by early information of every case of preventible disease track its development and progress, and adopt measures of prevention. Dr. Lyon Playfair, in 1874, emphasized the importance of registration of sickness in these words: "The record of deaths only registers, as it were, the wrecks which strew the shore, but it gives no account of the vessels which were tossed in the billows of sickness, strained and maimed as they often are by the effects of recurrent storms. Registration of sickness would tell us of the coming storms and enable us to trim our vessels to meet them."

Mortality statistics necessarily "ignore all that precedes the close of life." Can we from them obtain any idea as to the prevalence of a given disease in the absence of registration of disease? Under certain circumstances this may be possible, when a disease usually attacks an individual but once in a lifetime, and its fatality has been determined by observation on a sufficiently large scale. Thus in the year 1876

there were 2,297 deaths from scarlet fever in London. In the metropolitan hospitals there were during the same year 1,355 cases, with deaths in a little over 10 per cent. Assuming the same rate of mortality, within and out of the hospitals, there were at least 22,885 cases of scarlet fever in London during that year. But the severer cases were more likely to be taken to the hospital, and the mortality would in that event be greater among hospital patients; on which assumption the total number of scarlet fever patients in London was greater than estimated above. Nearly 70 per cent. of the fatal cases occurred among children under five years of age, whence the Registrar-General infers that at least 15,000 out of the 453,171 children living under that age in London, or about 1 in 30, had scarlet fever during the year.

In other cases, however, as rheumatism, ague, asthma, it would be impossible to form even a rough idea of the prevalence of a given disease from its fatality, as it may recur an indefinite number of times in the same individual.

In a few cases, such as hydrophobia, splenic fever, and possibly cancer (which may, however, not recur after operation), the number of deaths may be taken as indicating the number of cases.

It is very fallacious, however, to assume any fixed ratio between sickness and mortality. In order to obtain a rough idea of the prevalence of scarlet fever from the number of deaths and the number treated in hospitals, it was necessary to wait until after the occurrence of a large number of cases, when the information was of no practical value. The fatality of a given disease varies greatly in different outbreaks under varying circumstances. The highest ratio of sickness is occasionally found associated with a favourable rate of mortality. Cholera is much less fatal towards the end of an epidemic than at its beginning; so a conclusion drawn simply from the death returns might easily exaggerate the diminution in the prevalence of the disease.

There are some diseases, again, the knowledge of which is desirable, but which do not perceptibly affect the mortality

(except in some cases, through secondary consequences), as quinsy, influenza, mumps, chicken-pox, gonorrhoea.

The medical officer of health, who only knows of fatal cases of preventible diseases, often feels himself in the impotent position of a mere recorder of events. If he knew of every case, preventive measures could be adopted at an early stage, and the outbreak could be tracked to its true origin, as not a single link in the chain of evidence would be missing.

Death returns are silent about the large mass of common sickness, which, although it may disable a man, is not "unto death." From an economical point of view, this sickness is more important than deaths, "for it is the amount and duration of sickness rather than the mortality that tell on the prosperity of a community" (Dr. Dickson). Or as Charles Dickens has stated it: "It concerns a man more to know his risks of the fifty illnesscs that may throw him on his back than the possible date of the one death that must come. must have a list of killed and of the wounded too!" Local returns of disabling sickness of every description would not only enable us to deal promptly with epidemic disease, but would also throw great light on the influence of season and climate, of social condition, and of trades and manufactures on health, and would thus enable preventive measures of diverse kinds to be brought into action.

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It is evident that even were it possible it is hardly required to know of every case of sickness. The lines of demarcation between health and sickness are ill-defined, and the data, particulars of which will be given in a later chapter (page 275), are practically limited to the disabling diseases.

Attempts made to Register Sickness.-Without attempting to give a history of the various attempts made in this country to obtain registration of prevalent diseases in different towns, including Dr. B. W. Richardson's experiment, we can only allude to two organized efforts which were for some time successful.

The first was made by the Metropolitan Association of Health officers in 1857, and included sickness of all kinds attended at the

public expense, in hospitals, and by poor law medical officers, dispensaries, workhouses, etc. The returns were contributed voluntarily by the respective medical officers, the general Board of Health undertaking to print and circulate the weekly and quarterly tables. Of 109 hospitals and dispensaries, generally less than 50 contributed; in some cases boards of guardians refused to supply information; and before the expiration of the second year, the tables, which had never been complete for all sickness attended at the public expense, ceased to appear, voluntary co-operation being evidently unequal to the enterprise. It should be noted also that the returns were not entirely trustworthy so far as they went, for the diseases and accidents notified were not all new cases; that many returns represented patients who had come up from country districts for hospital treatment; and that an indefinite number of patients, who wander from hospital to hospital, must have been notified more than once. Dr. Ransome and the Sanitary Association of Manchester and Salford organized in 1860 a system of registration of sickness for these towns which appears to have been very complete and exact, and was not finally abandoned until the compulsory notification of infectious diseases came into force nearly twenty-five years later. An attempt was made, at Dr. Ransome's suggestion, to obtain simultaneously with the returns of disease a record of the mortality occurring amongst the cases reported. This was then compared with the total mortality, and a very fair guess could thus be made as to the total number of cases occurring within the district.

The Requirements of a Plan for the registration of disease have been set forth by Dr. Farr as follows, in the supplement to the Registrar-General's Thirty-fifth Annual Report: "The reports of the existing medical officers are of great practical value, and will become more valuable every day. What is wanted is a staff officer in every county or great city, with clerks, to enable him to analyse and publish the results of weekly returns of sickness, to be procured from every district; distinguishing, as the army returns do, the new cases, the recoveries, the deaths reported weekly, and the patients remaining

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in the several hospitals, dispensaries, and workhouses. These compiled on a uniform plan, when consolidated in the metropolis, would be of national concern. It has been suggested that the returns of sickness should, to save time, be sent to London, and there analysed on a uniform system, as the causes of death are. That with the present postal arrangements is quite practicable. The thing to aim at ultimately is a return of the cases of sickness in the civil population as complete as is now procured from the army in England. It will be an invaluable contribution to therapeutics, as well as to hygiene: for it will enable the therapeutists to determine the duration and the fatality of all forms of disease, under the several existing systems of treatment, in the various sanitary and social conditions of the people. Illusion will be dispelled, quackery, as completely as astrology, suppressed, a science of therapeutics created, suffering diminished, life shielded from many dangers. The national returns of cases and of causes of death will be an arsenal which the genius of English healers cannot fail to turn to account."

Information now Available.-1. Under an order made by the Local Government Board in February, 1879, it is incumbent on all district and workhouse medical officers appointed since that date to furnish the medical officers of health with returns of pauper sickness and deaths, as well as to notify the outbreak of dangerous infectious disease. A similar obligation has been imposed upon medical officers of district schools appointed after June, 1879.

By means of these returns of pauper sickness a fair estimate of the prevalence of disease among the poorest classes can be obtained. The information is not quite so valuable as might be expected, especially in large towns, owing to the fact that only a small proportion of cases of enteric fever, diphtheria, etc., are treated at the patients' own home; the chief exception to this rule being diarrhoea.

2. The keeper of a common lodging house is bound to give information to the local authority of any case of dangerous infectious disease occurring on his premises.