Mr. Watt, of Montreal, endeavours to prove what he terms the fallacies of the Registrar-General's conclusions with respect to the mortality tables of towns, He states that the mere death-rate of a place is no criterion as to its salubrity, unless corrected by means of factors taken from the birth-rate. The immigration into or the emigration out of a town also affect the conclusions deducible from the mortality tables. Dr. Letheby agrees with Mr. Watt. He

states

"In the weekly and quarterly returns of the Registrar-General, the death-rates of certain British and continental towns and cities are so prominently stated that the reader is apt to conclude they are the direct expressions of their sanitary condition. But nothing can be more fallacious; for the town with the lowest death rate may be the most unhealthy, and so also conversely. To take, for example, the list of places referred to by the Registrar-General in his quarterly report, it would seem that Dublin, with a death-rate of 22.72 per 1,000 of the population, must be considerably more healthy than Liverpool with a mortality of 27-29 per 1,000. In reality, however, it is the reverse; for, if measured by the birthrate as well as the death-rate, it will be found that Liverpool is in a better sanitary condition than Dublin. Taking, in fact, the average birth-rate (35 08 per 1,000) and the death-rate (22-58 per 1,000) of England as the standards for comparison, it will be seen that the actual death-rates of these places during the year which has just expired are very different from the calculated death-rates; and that little or no estimate can be made of the comparative salubrity of these places by mere reference to the observed death-rates.

In the cities marked with a star the population is estimated; in others, actual.

40

Relation between Birth and Death-rate.

OBSERVED ANNUAL BIRTH-RATE AND DEATH-RATE PER 1,000 OF THE POPULATION, AND THE CALCULATED DEATH-RATE.

It is but fair to state, that in the full reports published by the Registrar-General he points out that fallacious conclusions might be drawn from his statistics; and he explains the necessary corrections which must be made in comparing the mortality returns of towns with those of the rural districts. In the weekly returns published in the newspapers these corrections are not, however, given; and consequently the inhabitants of very unhealthy towns, the observed death-rate of which may happen to be low, conclude from the Registrar-General's returns that their sanitary state is excellent.

REGISTRATION OF DISEASE AND DEATH.

Sanitarians generally attach great importance to the periodical publication of the status of disease. It has been suggested that the usual weekly returns of illness made out by the ordinary poorlaw medical officers should be applied in such a way as would render them available for national, instead of purely local purposes. Each dispensary physician makes a weekly return to his board of guardians; a copy of this return might be forwarded to a central office-for example, to the office of the Registrar-General-where

the facts contained in it, and other similar returns, would be classified, and published with reports upon them, conveying valuable information to the local health authorities and to the general public.

If a system of disease registration were initiated by the poor-law authorities, statistics of disease would very soon follow from hospitals, infirmaries, asylums, private dispensaries, medical relief associations, and from other sources: even private practitioners might ultimately be induced to co-operate in securing a really general national system of disease registration, which would be invaluable as a means of investigating the etiology of the zymotics, and perhaps of other maladies.

In the second report (vol. iii.) of the Royal Sanitary Commission, we learn that the Commission heard evidence relative to death registration in Ireland. Dr. W. M. Burke, the medical superintendent of statistics, gave very strong testimony against the present system of registration, which, especially in the country districts, was "very imperfect." Dr. Burke stated that the form of death register (which is prescribed in the act applicable to Ireland) is objected to by medical men, because in signing it they testify to the actual death, which in most cases they do not witness, or of which they have no ocular proof. The certificate to be signed by the medical attendant should merely state the maladies under which the deceased laboured when last seen by the medical attendant. Dr. Burke stated that medical men 66 very often" refuse to sign death certificates. In reply to a question put to him, he said "medical men object more to the wording of the certificate than anything else. I think I can illustrate this by a circumstance which occurred in Dublin: I cannot fix the date of the occurrence, but it is not very long since. A physician, in large

The

practice in Dublin, was told that a patient of his was dead. physician, on being informed of his death, went up to the patient's room and found him alive. The certificate goes on to say, 'I hereby certify that I attended' so-and-so; 'who was apparently aged, or was stated to be aged,' so many years. That I last saw

6

him on' such a date, and that he died on a certain day; that the cause of his death was' so-and-so; and that the disease had continued for' a certain period. The physicians and surgeons of Ireland object to be asked to furnish all those details, and to furnish them gratuitously. In the majority of cases they say that they may not have been present when the patient died; and all the evidence they have of the patient's death is the information which they receive from some of the family, or other persons. They are, generally speaking, willing and anxious to certify as to the cause of death, but they object to be informants of the death."

One-and the chief cause of the defect in the registration of births and deaths in Ireland is the negligence of the people. There should be a heavy penalty imposed upon those whose duty it is to register those events. Dr. Burke said that the services of the police could be rendered available in ascertaining the occurrence

D

42

Reform in Death Registration.

of births and deaths. These events could hardly take place in the rural districts without coming to the knowledge of the police, if the latter had a special reason for acquiring such information. The special reason should be a douceur in the shape of a small coin. I believe that if the services of the police were enlisted in this matter, the registration of vital statistics in Ireland would, so far as ascertaining the number of births and deaths is concerned, soon approach perfection.

It is evident that the birth-rate amongst a population cannot be actually determined if the still-born children are not taken into account. The births of still-born children are not registered in Ireland; and Dr. Burke stated that it would be impracticable to do so it would, however, be most desirable to make their registration compulsory, for in such case a large proportion of them would be recorded in the registrars' lists.

Dr. Burke is of opinion that practitioners would not, and should not, afford information relative to the diseases from which their private patients suffered. He thinks the statistics of disease could be sufficiently collected from hospitals, dispensaries, work-houses, lunatic asylums, jails, and public institutions. The statistics obtained from these sources would, according to Dr. Burke, give a fair account of disease generally in the country. As practitioners constantly publish cases of disease occurring amongst their private patients, suppressing, of course, their names, they might probably see no impropriety in furnishing to the registrars periodically confidential statements (omitting names), showing the number of cases of particular disease which they had treated during a particular time, and within certain areas.

Sir Dominic Corrigan condemns the form of death certificate at present in use; and he states that he refused to sign death certificates; for only once during the last eight years which have occurred since the passing of the Registration Act was he able to testify from actual personal knowledge to the time at which the death of a patient occurred.

"Let," says Sir Dominic, "the Legislature mend its ways and correct the present defective state of the law, without expecting the medical profession to sacrifice truth and self-respect to prop blundering Acts of Parliament.

"I hope this state of things will soon be amended. A revised code of sanitary laws is almost now under consideration, and I trust our legislators will learn that, in framing such laws, they should seek for assistance from those bodies that understand the subject."

The Irish Census Commissioners, in their report for 1851, included in their Social Survey an inquiry as to the health of the people, and, by means of forms constructed for the purpose, ascertained not only the number of the sick in hospitals, workhouses, and sanitary institutions, but also the number of persons labouring under sickness in their own homes, together with the

description of the disease under which they suffered. Similar inquiries were made by the Commissioners of 1861 and 1871, and the following are the general results afforded by each :-On the night of the 30th March, 1851, the number of persons labouring under permanent or temporary diseases in Ireland was found to be 104,495, or 1,595 in every 100,000 of the population. On the night of the 7th of April, 1861, the number was 76,008, or 1,311 in a like number of the population; and on the night of the 2nd of April, 1871, the number returned was but 71,612, or 1,324 in every 100,000 persons. It must, however, be borne in mind that these numbers include persons afflicted with permanent diseases, such as deaf-dumbness, blindness, &c.

The following table shows the number of persons returned on the three occasions as suffering from zymotic diseases :

From the foregoing table it will be observed that in 1851 as many as 534 in every 100,000 of the population were suffering from zymotic or epidemic diseases; that in 1861 the proportionate number was 169; and that in 1871 it was but 97. The disease in this class most prevalent on each occasion was fever, from which as many as 13,777 were suffering on the census night in 1851; 2,350 in 1861; and but 2,070 in 1871. It may, therefore, be inferred from these comparisons that the state of public health in Ireland was favourable in 1871.

If the number suffering from permanent diseases, such as deafdumbness, blindness, insanity, idiocy, &c., were excluded from the total of sick returned in 1871, there would be a balance of 42,390 persons labouring under diseases which are for the most part temporary. The daily average of deaths registered during the months of April, May, and June, 1871-the quarter which includes the census day-amounts to 246-6, so that the rate of mortality to sickness would be as 1 to every 171.9. The number of the sick,