REPORT OF THE SECRETARY.

REGISTRATION OF BIRTHS AND DEATHS.

The last report to the State Board of Health began with an account of the registration law enacted by the General Assembly of 1898, and pointed out some of the difficulties which were anticipated in its administration. We shall be able to show in the present report the results which the law has yielded during the year ending June 30th, 1899.

We shall not present numerical tables, because the returns as collected by the State Registrar would in that form be seriously misleading. Our returns of death on file at the central office represents not more than fifty-five per cent. of the true mortality of the State outside of Baltimore City, and the returns of birth are certainly under fifty per cent. of the actual birth rate.

Full returns of deaths were collected, during the year ending June 30th, 1899, only by local registrars for Brunswick and Frederick, in Frederick County, and for Lonaconing and Frostburg, in Allegany County. Cumberland, the most important town in the State, after Baltimore, has had a burial permit ordinance for many years, but the local registrar for that town is not known to have made a single record in the year of any birth or death. Thus Cumberland is shown to be less enlightene upon her own sanitary condition and in this respect more indifferent to the welfare of her citizens than the smaller towns of Lonaconing and Frostburg, in the same county.

Since June 30th, 1899, Annapolis and Hagerstown have passed burial permit ordinances, and full returns are now being collected. Easton, Ellicott City, Havre de Grace, Canton, Highlandtown, Cambridge, Laurel, Pocomoke City, Steelton, Towson, Centreville, Williamsport, Port Deposit, Chestertown, Elkton, Westminster, Belair, Crisfield, and Salisbury are but little less indifferent to the rent-roll of death than is Cumberland. While such statistics as we possess cannot be used for all purposes which they were intended to serve, they are probably worth the little money which the State has expended upon their collection. They do not take the absolute measure of any of the causes of death, but they do show the relations of the various diseases to each other, to seasonal influences, to age periods, and to locality.

It is quite unnecessary, if not extravagant, to continue collecting such fractional returns of death and birth, when

slight modifications of the present law would, without increasing the cost, produce full returns.

The present methods are certainly extravagant in one respect, namely, that they make great demands upon the State registrar's time, diverting him from matters of higher and more immediate importance. How much avoidable labor has been involved in collecting the statistics may be guessed after reading an account of the first year's operations of the law.

HOW THE RETURNS ARE Collected.

Local registrars are supplied with two books-one a register of deaths and the other a register of births. Each of these books consists of two hundred pages, admitting seven records on each page, fourteen hundred to each book. They are of a size convenient for storage in an ordinary safe. Transcripts are made in these registers of death and birth certificates in the order of their receipt. There is no alphabetical index.

The blanks for certificates of death are printed on salmoncolored library cards, perforated for filing. The registrars have each a japanned iron guide rod box in which to keep the certificates returned. Before the tenth of each month all of the certificates in his possession are sent by mail to the State Registrar. The birth certificate blanks are printed on white library cards, and are filed, recorded, and returned in the same manner as the "death" cards. These cards are distributed to the local registrar in packages of fifteen or twenty, each package enclosed in an envelope. On the back of the envelope the manner of filling out a certificate is illustrated for the guidance of those whose duty it may be to certify.

Nearly a hundred newspapers come regularly from all parts of the State to the office of the State Board of Health. These are all examined for information bearing upon local sanitary conditions, and especially for death notices. All the essential facts of record contained in the newspaper notes are transcribed to cards, and filed under an index card for the month.

When the monthly returns come in they are compared with this current list of deaths, and duplicates are eliminated. Two lists are then made out and forwarded to each local registrar, one of all certificates of deaths occurring in his sanitary district and reaching us by other routes than through this office, and one of all deaths known to have. occurred, but for which no certificates have been turned in. The local registrar is requested to obtain the missing information, and at the same time the State Registrar sends out tracers in pursuit of the legal certificates. A large number of incomplete certificates are placed in a special drawer labelled "Further Inquiry."

For the purposes of "further inquiry," some circular letters. had to be devised. The newspaper notices are found to contain most frequently the name of the clergyman officiating at the funeral, less frequently the name of the undertaker, and sometimes the name of the attending physician. We accordingly use a formal letter addressed to undertakers, another addressed to clergymen, and another addressed to physicians. Each of these letters has a device for numbering, that addressed to undertakers being marked U. I., No.-, printed on yellow paper; that to clergymen being marked C. I., No.-, on blue paper; that to physicians P. I., No.-, on white paper. All are printed with copying ink. Thus it is possible to bring together all the papers relating to a given case with relatively little trouble. The purpose of these special inquiry letters is, of course, to reach at last the attending physician, and to obtain from him a proper death certificate.

Every certificate, from whatever source, must be scrutinized in every item which it contains. Those who certify frequently omit such important matters as the date of death, the age, sex or color of the decedent, or else make a statement concerning the cause of death so confusing that a classification of the card is impossible. These matters must become subjects of special inquiry, and it is impossible to devise any formal letter which would apply to any considerable number of these questions. We usually send a letter of inquiry concerning these missing items and enclose a postal card already written, except as to the one or two essential words. When all the necessary information has at last been obtained, the office record now completed, or the original certificate in the handwriting of the attending physician, as the case may be, is put into another drawer marked "Finished Inquiry." The cards containing the information on which the pursuit of the legal record was based are all preserved in a third drawer. Meanwhile, the properly returned certificates are tabulated on the mortality sheets, and then permanently filed alphabetically and by counties. All the cards in the "Finished Inquiry" drawer are kept until another monthly return is made, when, if no duplication of records is found, they are tabulated and filed. The "Further Inquiry" cards represent the certificates of death which have been most expensive to collect. It has several times happened that our tracers have brought us in four or five certificates of the same death at a cost of sixteen cents or more in postage. Nevertheless, this plan has a very good effect in impressing upon persons whose duty it is to certify, the fact that neglect of this duty is not likely to pass unnoticed.

After we have exhausted all the means above described in an effort to obtain physicians' certificates, we have a large number of cards on hand which contain no information beyond that which was contained in the newspaper notices. These have not cost

much to obtain, but they are worthless for all purposes, save mere enumeration. A glance at the chart, which shows the comparative importance of the causes of death, will demonstrate the commanding importance of the column marked "Unknown." This column represents the greater part of those deaths which are reported to us by the newspapers of the State, and shows also what a large part of the work properly belonging to local registrars is done in the office of the State Registrar. Besides the reports represented by this column, the newspaper contributions have swelled the other columns by as many notices as contained either a statement of the cause of death, or some item of information upon which we could press further inquiry till an authoritative certificate was obtained.

It will thus appear that of all the records of death filed in the central office of the State Registrar, quite one-half were begun and completed in the central office, without the aid of a local registrar. If our returns for the period are taken to represent fifty-five per cent. of the actual mortality of the State, it will be seen that of every one hundred deaths occurring seventytwo were unnoticed in the locality where they happened. This poor showing is not due to general neglect of the law, but to particular indifference in certain sections of the State, ascribable partly to the carelessness of the local officers, partly to hostility of boards of county commissioners, and wherever poor results. are apparent, to want of popular enlightenment on the subject. In some portions of the State the local returns have been really far worse than our figures show. Thus the showing made by Carroll County, poor as it is, owes next to nothing to the local registrar. Nearly all of the returns we possess were obtained without the aid of that functionary. The returns from Baltimore County would have been worse than those of Carroll but for the fact that so many bodies from that county are carried through Baltimore City to the places of interment. The Health Department of Baltimore City has made prompt returns of all such death certificates. The returns from Baltimore County owe nothing to the local officers except Dr. C. L. Mattfeldt, who has made almost complete returns from Catonsville and vicinity. The physicians of Baltimore County are as ready and willing to perform their duties as those in Baltimore City, and the Baltimore County Commissioners have needed nothing more than that the importance of this work should be put fairly before them. In these two counties, Baltimore and Carroll, the known character and abilities of the recently appointed local health officers* will bring about substantial improvement in this and other directions.

Allegany County owes nothing to Cumberland. In Cumberland the passing citizen receives no notice save from the press.

*Dr. Stevenson, of Sherwood, and Dr. Foutz, of Westminster.