3. Care and special knowledge on the part of the attending physician, health officer, or coroner in making a definite statement of the primary and secondary causes of death, with the duration of each.

4. Interest and care on the part of the local registrar in seeing that the certificates filed with him are completely and properly filled out and that all births and deaths which occur in his district are promptly registered.

5. Alert supervision by the State Registrar so that the law will be thoroughly enforced in all parts of the state; with the will and power to compel obedience on the part of the undertakers, physicians, midwives, and local registrars when necessary.

6. Careful examination of the returns by the State Registrar and prompt securing of missing data or corrections of imperfect statements of causes of death.

7. Accurate copying (which implies comparison) of the original certificates upon the transcripts sent to the Bureau of the Census.

8. Prompt examination of transcripts upon receipt by the Bureau of the Census, and immediate correspondence for necessary corrections.

9. Careful "editing," especially for the classification of causes of death, by expert compilers thoroughly acquainted with the International Classification and the use of medical terms.

10. Accurate transferal of data to the punched tabulation card. These are pared back" with the original transcripts in order to insure correctness.

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11. Careful tabulation of punched cards. Electrical tabulating machinery has reduced this to a mechanical basis and thus largely eliminated the "personal equation."

12. Lastly, the editorial work proper, or the analysis of the figures presented in a registration report. The analysis is subject to error, but the figures themselves, if correct, stand as witnesses of their own significance. Figures do not lie—when carefully compiled and interpreted.

PROBLEMS AND DEFECTS OF THE PRESENT SYSTEM OF VITAL

STATISTICS.

From the preceding account of the process of registration and return of the materials of vital statistics to the Bureau of the Census and from the nature of the development of the various state registration services which supply these materials, it is evident that the Federal registration service in its work of collecting and compiling the vital statistics of the United States is hindered by certain unfavorable conditions which it has no power to remove. It is easy to criticize present defects. "The United States is practically the only country among civilized nations without an effective system of vital statistics." But it is not easy to point out, or rather to work out, the remedy. The reform does not pertain entirely or even largely to the Federal service itself. The problem of the Federal registration service is how to unify all the various agencies concerned in registration and thus to build up an efficient machinery which will be fully dependable from the first step in registration-the making out of the original birth and death certificates by physicians, midwives, and undertakers-through all the successive stages of treatment in the local and state offices and in the Census Bureau.until the completed

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statistical product is available. It must begin, not in the Federal office, not in the state offices primarily, but in the far-flung local registration offices and in the education of the local registrars and of the persons charged by law with the duty of filing certificates. It will only be thoroughly effective when the public generally, through constant enlightenment, is brought to understand the great importance of complete and accurate vital records.

Some of the more obvious imperfections may be listed:

1. The greatest defect of the vital statistics of the United States at present is the lack of registration of deaths for the entire country. While the "registration area for deaths" has increased very rapidly during the past fifteen years, it seems ridiculous that the United States should be represented in the International statistics, for example, those published by the Registrar-General of England and Wales in his annual reports, by anything less than figures representing the entire country. As the registration area increases from year to year the rates presented are not comparable; many important sections of the country are not shown; and the returns for the colored and rural populations are especially incomplete. Hence the most important duty of the Federal registration service and of all its cooperating agencies is to extend the registration area for deaths until it includes the entire United States, Alaska, and all our insular possessions.

2. Our next most serious defect lies in the imperfect registration of births. A "registration area for births" should be established at the earliest practicable moment and every effort be made to extend it until, with the "registration area for deaths," it embraces the entire population under the American flag.1 The provisional birth registration area of 1910 included only about one-fourth of the population, so that it is evidently a more difficult task than that of complete registration of deaths.

3. Even for the registration area for deaths as at present constituted, we do not have full assurance that the registration is uniformly complete in all states. The standard of admission is low-90 per cent and the means of testing the compliance therewith are inadequate. Efforts should be made to test and standardize the thoroughness of registration both for deaths and births, the results of such tests should be published in connection with the statistics, and states which fall below the minimum standard of requirement should be dropped from the Federal compilation. As soon as feasible the standard should be elevated so that it will represent practically 100 per cent of efficiency.

4. The quality of the returns is poor in some cases, especially in the recently admitted states, and in all is susceptible of improvement.

1 See note on p. 7.

Many important questions relating to birthplace of the decedent or his parents are often disregarded or answered with lack of precision. Greater stress should be laid by state and local registration officials upon requiring all the questions upon the standard certificates to be answered fully as affording record information which may perhaps be of great legal value. There would then be little difficulty with respect to the completeness of the returns for statistical purposes. Perhaps the greatest degree of imperfection is found in the statements of occupation (and industry) and cause of death. To improve the latter, physicians must be instructed, beginning with lectures on the subject in the curriculum of the medical school, and constant correspondence be carried on for the correction of unsatisfactory statements. Autopsies should be encouraged and some means be found of insuring that the results thereof be reported instead of the frequently misleading clinical diagnoses alone. It would be well for the standard certificate of death to provide, after its next decennial revision, for statement of post-mortem in connection with the cause of death. The Swiss method of confidential reports for statistical purposes might be employed to obtain exact information concerning certain causes relative to which physicians are reluctant to make reports on the ordinary death certificates which are open to public inspection. It should not be understood in the foregoing criticisms of the quality of the returns of vital statistics that the data are markedly inferior to those of other countries. An unusually large proportion of deaths are certified by physicians, and the chief defects with respect to the statements of causes are due to lack of knowledge as to what is required for a satisfactory statistical compilation and to the small number of autopsies. Rapid improvement usually follows the admission of a state to the registration area and special inquiries for the verification of diagnoses, such as were made by the census in the recent investigation of cancer, have an excellent effect.

5. The usefulness of the annual compilations of vital statistics which are made by the Bureau of the Census and by state and city registration offices may be discussed. Undoubtedly there is much duplication of labor and data may differ as presented for the same areas in Federal, state, and municipal reports. This condition is incident to the state of transition through which the registration of vital statistics in the United States is passing. Prior to 1900 there were no annual reports on mortality published by the Government, hence reliance was necessarily placed on the state and city reports. The Bureau of the Census has each year since 1900 presented tables showing, for the most essential details, the results of registration for all states and cities in the registration area, places of 8,000 (or 10,000 since 1910) being shown separately and also rural counties. The

Federal statistics are compiled with a high degree of uniformity, which was not true of the state and city reports considered as a whole, and rates are presented based on uniformly estimated populations. For general reference, therefore, the Federal compilation should replace the state and municipal compilations, and it is merely a question of detail as to how it can be made more fully to serve the purposes of the users of statistics. State and city offices may very properly desire to present data concerning minor civil divisions, villages, towns, and wards, which it would not be feasible to include in the Federal compilations as printed. It would perhaps be possible for the Census Bureau to supply the more general tables in manuscript for the use of state and city offices, leaving further details to be worked out locally; or duplicate punched cards might be placed at the disposition of the state or city offices. As a result the Federal, state, and municipal compilations would be in greater accord and the proper sphere of each would be defined. If the state services could give greater attention to the thorough enforcement of law, the attainment of practically complete registration of both births and deaths, and the elimination of indefinite and unsatisfactory records, relying upon the Federal service for the statistical compilation of the data, the general purpose would be more fully accomplished.

6. The question of the inclusion or exclusion of the deaths of nonresidents has aroused much discussion. It has been the practice of the Census Bureau and of most state offices to base the compilation of mortality statistics on the total number of deaths which occurred in each area. For 1914 a separation of nonresidents will be given in one table and efforts are being made in the American Public Health Association to devise rules for this purpose. The practical treatment is very difficult, involves many perplexing questions, as deaths removed from one area should be assigned to another, and can not be satisfactorily carried out for the country as a whole until it is all included in the registration area.

7. Too much stress is sometimes laid upon the comparison of crude or general death rates for the purpose of establishing the healthfulness of American states or cities. Such rates are presented in the census reports with all necessary cautions, and also for white and colored separately for areas where the colored population forms a considerable proportion of the total. Age and sex distribution sometimes have a marked influence on the rates, hence an effort should be made to present corrected or standardized rates, at least for census years. It is necessary, for the purposes of vital statistics, that there should be more frequent enumerations of population, so that postcensal estimates, with some detail of color and age distribution, can be made with greater precision. Specific death rates, limited to definite groups of age, sex, and color, should replace the

general rates now chiefly used for the study of the incidence of various diseases. The Life Tables now in course of preparation by the Census will be of great value and should be continued for each decennial period. Figures of occupational mortality should have been prepared and the population data should be presented in a form available for that use. Also in the general census of population, both Federal and state, the primary age and sex distribution of population, by color, should be given for each county so that rural and urban mortality may be studied in detail.

There are many other features which might be mentioned as susceptible of improvement or as deserving commendation and encouragement. That vital statistics reports may be made as useful as possible, especially for public health purposes, requires the helpful suggestions and constructive criticism of all concerned. It would be well if an authoritative advisory board or council could be constituted, with representatives of the American Statistical Association, American Public Health Association, American Medical Association, and other organizations and services. Methods of presentation, however, are secondary to the prime duty of complete collection of the fundamental data by thorough registration.

WHEN AND HOW WILL THE UNITED STATES OBTAIN COMPLETE REGISTRATION OF VITAL STATISTICS?

It is with some feeling of mortification that we are obliged to confess in the presence of this Second Pan American Scientific Congress that the United States does not now possess the means of recording the births and deaths of all its inhabitants, a matter deemed most important among all civilized nations. It is with even greater regret that it must be admitted that, according to the present rate of progress, unless motives unforeseen should induce the American people to demand more speedy action, it will be many years before this object is accomplished. It may be of service to glance at some predictions which have been made in the past in order to see how likely our hopes of the future are to be justified.

Some of the colonies took action at a very early date for the registration of vital records. Virginia passed such a law in 1632, Massachusetts Bay in 1639, Connecticut in 1644, and New Plymouth in 1646. The "Fundamental Constitutions," prepared in 1669 for the government of Carolina by the philosopher John Locke, contained stringent provisions for a "Registry in every Signiory, Barony, and Colony, wherein shall be recorded all the births, marriages, and deaths that shall happen." According to Kuczynski, "Massachusetts

1 See letter from Dr. J. Howard Way, Journal of American Medical Association, Sept. 18, 1915, p. 1048.

* Publications American Statistical Association, September, 1900.