From the Eighth Annual Report of the State Board of Health of Massachusetts. 
REGISTRATION 
OP 
Deaths and of Diseases.. 
By CHARLES F. FOLSOM, M.D. 
Secretary of the Board. 
ALBERT J. WRIGHT, STATE PRINTER, 
73 Milk Street, Coe neb Federal Stkeet. 
1877. From the Eighth Annual Report of the State Board of Health of Massachusetts, 
REGISTRATION 
OF 
Deaths and of Diseases. 
By CHARLES F. FOLSOM, M.D. 
Secretary of the Board. 
BOSTON: 
ALBERT J. WRIGHT, STATE PRINTER, 
79 Mirk Street, Corner Fedeeai, Street. 
1877. REGISTRATION OF DEATHS AND OE DISEASES. 
One of the leading sanitarians of the United States recently 
said, "No method has yet been found, or at least acted upon, 
whereby the actual death-rate can be positively ascertained 
for the United States, or, so far as I know, for any single 
State.”* 
It has seemed desirable to ascertain how we stand in refer- 
ence to so sweeping a criticism, and the result of the inquiry 
has been that we can only say that we are a little better than 
some of our neighbors. 
The first of the following series of questions was sent to 
the medical correspondents of the Board in October; and the 
second, a little later, to the clerks of the cities and towns 
throughout the State :— 
I. Is the registration of deaths and causes of death complete and 
satisfactory in your town? If not, please suggest any deficiencies 
of which you are aware, whether all deaths are returned to the under- 
takers, whether the undertakers themselves return them promptly 
and accurately to the clerks, whether causes of death are reported 
by the physicians in all cases, etc., etc.? 
II. Will you be kind enough to inform us whether the registra- 
tion of deaths and causes of death is complete and satisfactory in 
your town ? If not, please suggest any deficiencies of which you are 
aware, whether all deaths are returned to the undertakers, whether 
the undertakers themselves return them promptly and accurately to 
the clerks, in what proportion of cases the causes of death are 
reported by physicians, etc., etc.? 
* Report on the Death-rate of each sex in Michigan, and a comparison with Dr. 
Farr’s Life Tables of Healthy Districts in England. By Henry B. Baker, M. D., 
Secretary of the State Board of Health and Registrar of Vital Statistics of Michigan. 
1876. 6 
Registration of Deaths. 
Information from Physicians. 
One hundred and ninety-six physicians replied to our circu- 
lars. Of these, 44 reported that the registration is satisfac- 
tory, 118 reported that it is not satisfactory, and 34 replied so 
indefinitely that it was not possible to say from their returns 
whether the law is complied with or competent to meet all 
requirements, if obeyed, or not. 
In regard to the registration of the full number of deaths, 
without regard to their causes, 54 have reason to think that 
this is fully done, 45 reply that it is not done, and 97 answer 
indefinitely ; that is, they do not answer that particular ques- 
tion, they have no suggestions, they do not know, or the 
reply is so worded as not to convey a definite statement. 
The very large number of "indefinite” answers as to the 
registration of the full number of deaths, may be explained 
on the ground that it is a question on which comparatively few 
have an opportunity of getting exact information. 
Of course, it is not expected that absolutely "satisfactory” 
registration can be got in all cases. The word, therefore, in 
tabulating the returns, has been used to express as satisfac- 
tory a registration as we can expect with the present degree 
of human imperfection and until we have some system or law 
regulating the practice of medicine. For instance, the fol- 
lowing two replies (10 and 26, p. 7,) were classed as "satis- 
factory.” Strictly speaking, the first indicates a condition 
of things which is very far from "satisfactory”; and the 
importance of some legal restrictions upon irregular and 
incompetent physicians is great. In tabulating the returns, 
however, it was thought best to confine attention to those 
defects which were referred to in the circular sent out. 
It would be very easy, however, to have a registration of 
physicians in our State, as has been done in Europe and in 
some of the cities of our own country, notably Brooklyn and 
New York. In such case, any person not possessing a diplo- 
ma from some responsible medical college should be excluded 
from the privilege of signing any medical certificate involving 
responsibility. 
A certain portion of the community will always prefer to 
consult "healing mediums,” etc., and probably could not be Registration of Deaths. 
prevented from so doing by any law; but it is of importance 
to the State that every death should be as faithfully and 
intelligently certified to as is possible, and the public should 
see to it that this is done in every case. 
10. In this town, as in nearly every town in the Commonwealth, we have 
some irregular and incompetent practitioners of medicine, whose diagnoses 
would be of doubtful accuracy and not to be relied on for scientific conclu- 
sions. Yet the registration of deaths and causes of death is as complete 
and satisfactory in this town as in most towns probably. 
26. The registration of deaths is apparently quite complete. The cause of 
death is not always correctly given, owing oftentimes to an impossibility of 
obtaining an autopsy. Probably the returns to the undertakers are as com- 
plete as they could be made by any legislation. 
Nothing would be gained by quoting affirmative replies at 
length; enough of the others are given to illustrate all the 
deficiencies in the present methods. 
Our correspondents generally testify that the town clerks 
are ready to heartily cooperate in the work of good registra- 
tion, and that, where there is any deficiency on their part, it 
is from following established custom or from inherent diffi- 
culties. 
Replies of Medical Correspondents. 
1. The registration of deaths in this town is quite complete and satisfac- 
tory, with perhaps the exception that the cause of death is reported in too 
general terms, a matter that can be easily remedied by physicians making 
the report, which is not done in all cases now. The deaths are returned by 
the undertaker to the clerk once a year; this, perhaps, is not as often as it 
should be done, but such matters, I think, cannot be attended to conven- 
iently with that promptness in country places as in cities. 
2. I presume that our town authorities are not remiss in reporting all 
cases of death, but are certainly not over-particular in the minuti® of the 
subject,—in fact, have not in a single case referred to me for such particulars. 
5. Undoubtedly the number of deaths is given the clerk with sufficient 
accuracy, but the causes of death in many cases must be quite imaginary, 
as the physicians are not consulted about this. 
7. The cause of death is invariably returned on the undertaker’s certificate 
and is given by the friends of the deceased. I am never asked to make out 
a physician’s certificate. 
9. In a few instances, decedents are taken to other places for burial with 
out the town clerk’s license [and probably escape registration]. 8 
Registration of Deaths. 
17. I think all deaths are returned, but I think that the value of registra- 
tion is essentially impaired by wrong causes being reported, usually through 
ignorance; there is evidently no intentional misrepresentation. Perhaps 
the physician’s signature accompanies about two per cent, of all certificates. 
18. It has been the custom for the undertaker to take around, once or twice a 
year, to physicians, their blanks, filled out in other respects, and get the 
attending physician to certify. If not disposed, they have filled them out 
themselves. 
19. The registration of deaths and their causes in this town is very incom- 
plete and unsatisfactory, and I am aware all the deaths are not recorded. The 
custom has been for the town clerk to go through the town once a year and 
“ collect the births and deaths ”—while during the year many births and 
deaths have occurred in families who have removed from town; conse- 
quently no record can be made of them. There being no particular under- 
taker, I think no one ever makes any return to the clerk, and I think the 
cause of death is never reported by any of our physicians. I have long been 
aware of the unsatisfactory manner and incompleteness of the registration 
of deaths and causes of death, not only in this town, but in many other 
towns. 
24. Since I received your circular I have had an interview with the town 
clerk. He says the registration is all a farce. I inquired how he procured 
his information, and he said it was supposed he would send to every house, 
hut I think he takes the neighborhood reports. 
244. The undertaker usually puts down the cause from hearsay oftener 
than he ascertains from the attending physician the real cause. 
25. I think the registration of deaths is generally made quite promptly, 
hut the undertakers are not careful enough to inquire of the physicians as 
to the causes of death, and one often sees names given which are altogether 
outside of medical nomenclature. The physicians are equally careless in the 
same thing, and one would often he in doubt to know what the true cause of 
death was, unless they had attended the cases themselves, as our yearly 
death-list will testify. The law does not oblige a physician to give the cause, 
unless applied to for it, and then he is liable to a fiue of ten dollars if he 
does not make the return in fifteen days. I think an improvement can he 
made by obliging the physicians to fill blanks in a scientific manner and 
return them to the clerk without having the undertaker as a medium. 
28. I would suggest as an amendment to the statutes on this subject, that 
no interment he allowed to take place, under a severe penalty, in any town or 
city, without the certificate of the clerk of the town or city in which the 
death occurred (or the deceased resided) having been first obtained. There 
seems to me to he no necessity for any exceptions. 
34. In a full practice in this town for more than forty-four years I hav.e 
never been asked for the causes of death, nor have I ever so reported. We 
do not have, in the country towns, “ undertakers,” and of course no returns 
of such persons have been made to clerks. Registration of Deaths 
9 
35. There are a considerable number of cases of death among the foreign 
population who die without any regular medical attendance. I have sup- 
posed they were reported by the sexton as deaths, but the cause of death 
would often be random guessing on the part of relatives. 
36. I have never been called upon to give the causes of deaths, and there- 
fore cannot say whether they are accurate or not. 
37. The registration of deaths, and the causes of death, in this town, has 
been very imperfect; and, as far as sanitary purposes are concerned, worse 
than useless. Last year I made a formal protest to our selectmen, the regis- 
tration was so incorrect, especially as to the causes of death, more than one- 
tenth being recorded incorrectly. The undertaker has been in the habit of 
asking the friends the “ cause,” and once in two or three months reporting 
to the town clerk. Of course such statistics are worse than useless. Statis- 
tics, to be of any value, should be themselves correct. This year I have been 
asked in a few cases to certify as to the cause of death; for several years 
past, not once. There ought to be a law compelling the sexton to require 
of the physician iu charge to certify to the cause of every death, before 
interment, with a penalty attached for non-performance. No respectable 
physician would ever object to doing this. The law now is, I believe, that 
the physician shall give a certificate when required to do so; but no one is 
compelled to make the request. No body should be removed from town, or 
interred, without a proper certificate of the cause of death from the attend- 
ing physician. 
39. Many times the physician never sees the return at all. The statement 
of some member of the family is all the authority. I don’t think, during 
my practice, that fifty per cent, of the deaths were returned in a proper 
manner. 
43. The registration of deaths in our town is done after a poor fashion. 
Near the end of the year, or rather, near the time to make the annual returns, 
the town clerk himself, or some one for him, goes around and “ picks up ” 
all the deaths he or she can hear of; the cause of death is learned from 
friends or neighbors. I do not, nor does any other physician, make any 
returns to the clerk, in our town. 
44. The registration of deaths here is not satisfactory. There is one 
undertaker, and he is negligent in this matter, frequently letting the half- 
filled blanks remain on his hands and accumulate till the end of the year, 
then getting the physicians to certify to the causes of death from memory, 
which in many cases involves inaccuracy. I do not know but all cases may 
be returned, but I do know, that by reason of the slack way in which it is 
attended to, there is much guesswork in the final report when it is made up. 
47. Before burial in our cemeteries, it is of course necessary to secure a per- 
mit from the city authorities, and so far the registration is complete. What- 
ever return there is of the cause of death comes from the undertakers, and from 
them alone. I do not remember to have been asked the cause of death in 
more than two or three instances for many years. The undertakers prepare 
the statement from reports of friends. The city clerk informs me that there 
is much delay in the sending in of these reports, generally requiring his 10 
Registration of Deaths. 
personal attention to obtain them, and then not very satisfactory in every 
case. 
48. I can unhesitatingly say that the registration of the causes of deaths is 
anything but satisfactory. I think there is no doubt but that all deaths are 
recorded. 
49. The registration of deaths in this city is complete, in so far that the 
total number is correctly returned. It is not satisfactory, in that there 
is some confusion in the important item, “ cause of death.” It has been 
customary for the undertaker to fill up the blanks, generally without con- 
sultation with the attending physician, relying upon friends for his infor- 
mation. In cases which he considered doubtful, the physician is sometimes 
called upon for his opinion, and to fill the blank. In the cases in which the 
cause of death is given to the satisfaction of the undertaker by friends of 
the deceased, he inserts the name of the physician, though he has not seen 
the 'certificate. I have to-day examined the certificates returned to the 
clerk’s office for a couple of months past, perhaps fifty in number. The name 
of the attending physician has been inserted in all, but in only two or three 
instances by himself. 
50. The registration of deaths and causes of death is, I think, very 
unsatisfactory, so far as our city is concerned. I think, however, that hut 
few deaths escape registration. So far as “ causes of death” are concerned, 
the record is of comparatively little value. The undertakers almost never 
take the certificate of return to the physician who attended the deceased for 
his signature of cause of death, hut put down as cause of death whatever 
the family say the doctor said was the cause. I got the returns of the last 
year from the city clerk to look through, to find out about some of these 
things I have mentioned. We have a yearly mortality of about two hundred 
or more at present. I think there were obtained, last year, three certificates 
of death with signatures of physicians, out of two hundred. 
A case of “ chronic rheumatism” was cirrhotic kidney ; a case of “ ulcer- 
ation of the bowels ” was cancer of rectum ; a case of “ heart-disease ” was 
septicaemia or pyaemia, following amputation for old disease of knee-joint; 
a case of “tumor” was aneurism of the aorta. “Infancy” is down for 
twelve deaths, etc., etc. 
I have been trying to do something to make our registration better, and 
the city clerk has seen the undertakers, and they agree to take their cer- 
tificates of return to the physicians for their signatures. I brought up the 
subject in our local society, hut I did not succeed in getting the members 
interested apparently; nobody, with one, perhaps two exceptions, seemed to 
care anything about it. 
51. If the law provided that no burial could take place without the 
possession by the proper authority, of a certificate of the cause of death 
from the attending physician, it would seem that some of the faulty and 
unsatisfactory “ causes of death” might be avoided. 
55. As far as I can learn, both from my own experience and from inquiry 
of the clerk of the town, I think it (registration) has been done in an imper- 
fect manner, and necessarily, from the fact that the returns have been made 
once a year. Registration of Deaths. 
11 
56. So far as my experience and knowledge of registration of deaths 
extend, it is far from satisfactory; and this, I believe, is mainly due to neg- 
lect on the part of the undertakers in complying with the requirements of 
the law. Certificates of death are generally sent in some weeks and some- 
times months after burial. I always attend immediately to the filling out of 
certificates on receiving them. I have now upon my desk two that have been 
there several weeks awaiting the call of the undertaker. 
57. I am not called upon in half my cases to give the certificate. I under- 
stand that undertakers get them filled by the family, and I know that many 
certificates are wholly false as to cause of death. Almost any cough is 
reported either “consumption” or “lung fever,” and so in other diseases. 
61. The method of registration for this town is as follows: Two persons 
dig the graves and drive the hearses. These persons, at the end of the year, 
go about town and visit every house in which they learn of a death or birth 
having taken place during the year. The name, age, disease of which the 
person died, etc., are put down, and all are returned to the town clerk. The 
record is, therefore, made up wholly of the statements of the families in 
which the person died. Physicians make no return whatever. In a few 
instances, families, if uncertain of the causes of death, refer the sexton to 
the physician. More commonly they are better satisfied to give their own 
opinions than those of the physician, if they do not happen to coincide. 
Hence the record cannot be very accurate. In looking over the records for 
various purposes, I have been very much dissatisfied at what I found in 
many instances assigned as the cause of death in cases that I had treated. 
66. The undertaker fills out the blanks relating to causes of death, accord- 
ing to the dictation of the family. When the disease is obscure or peculiar, 
the physician is consulted to give the name of the disease, but this is often 
loosely done. I am not able to report as to the promptness of returns to the 
city clerk. 
67. So far as I can learn, all the deaths in this city are reported except 
still-births, of which I find no record. The city clerk informs me that the 
undertakers are generally prompt in their returns. Physicians do not make 
out certificates of the causes of death at all, that I can learn of, though on 
half a dozen returns rendered this year, I find the physician has filled out 
the cause-of-death blank (on the undertaker’s return), and signed his name 
in the space left for the name of the attending physician. In 60 of this year’s 
returns the name of the physician is given, hut his signature is not attached. 
In 134 of this year’s returns the name of the physician is omitted. The 
cause of death in many cases is obscurely or incorrectly given, as “weak- 
ness,” “cut with a knife,” “accidental,” “inward spasm,” “cold,” “troubled 
in the brain,” “dropsy,” “debility,” “teething,” etc. One return has the 
honest record of “don’t know,” which indeed causes many deaths. I would 
suggest that it be required for the physician to fill out and sign, in every 
case, the cause-of-death blank on the undertaker’s return before it is handed 
in to the clerk. 
71. Causes of death are never, or rarely, reported by the physicians of this 
town. The clerk makes up his report upon hearsay testimony, never asking 
information of the physician in charge of the case. I have known “puer- 12 
Registration of Deaths. 
peral fever”returned as “typhoid,” or, in another case, as “lung fever.” So 
far as my observation extends, in this and many other country towns in West- 
ern Massachusetts, very little dependence can be placed upon the statistics 
of causes of deaths as returned by town clerks. Undertakers never require 
any certificate from attending physicians. I would suggest that it be made a 
penal offence for an interment to occur without the undertaker having a cer- 
tificate from some respectable physician, and that a further penalty be added 
if the undertaker fails to return this certificate to the town clerk. 
74. As I have been town clerk for the last twenty years, I can speak from 
personal observation, and, when I say that the death-returns are incomplete 
and unsatisfactory, I only say what I know to be the truth. In fact, in some 
forty deaths returned the past year, I did not find five certificates from physi- 
cians, notwithstanding I had been careful to furnish them with a full supply 
of blanks for the purpose. As a matter of course, the great object in view 
is, to a great extent, lost. The number of deaths is promptly returned 
according to an understanding with the sexton, and, if physicians would only 
meet the requirements of law, our returns would become reliable. The only 
remedy which suggests itself to me at this moment, is, that a certificate from 
the clerk to the sexton, that all the requirements of law had been complied 
with, should be furnished previous to burial, and that the sexton shall be 
prohibited from making burials without such certificate, under penalty. Some 
efficient remedy should be applied soon in order to render the returns valu- 
able. 
75. I think the registration of deaths in this city has improved since I 
referred to it in a communication to you a year or two since. I have taken 
occasion to urge upon the undertakers the importance of obtaining the written 
statement of physicians in relation to the causes of death. Formerly it was 
customary, and it is practised, I fear, to some extent now, for the undertakers 
to take the statement of the friends of the deceased in regard to the cause of 
death, without consulting the attending physician. Most of the undertakers, 
however, submit the proper blanks to the attending physicians to be filled by 
them. It often happens, particularly among the poorer classes, who are not 
able to employ, or do not choose to employ, a physician through the course of 
a disease, that a physician is called, perhaps once, to prescribe for a patient, 
and, after that, his services are not requested, and the patient, after the lapse 
of an indefinite period of time, one, two, or more weeks, dies. When the 
return is made out by the undertaker, he may apply to the physician for 
the nature of the disease, but it is often quite impossible for the physician 
to state accurately the immediate and sometimes even the remote cause 
of death. In consequence of the great diversity of skill among those who 
have the title of “Doctor,” in this land of medical liberty or license, the 
nomenclature employed in reporting deaths is sometimes very inaccurate and 
indefinite. I note the following causes of death in the city clerk’s register 
for the present year: “Teething,” “worm fever,” “pharalithic rheumatism,” 
“canker,” “jaundice,” “pelvis malformation.” There ai'e, however, fewer of 
such indefinite terms employed, than might be expected. I have reason to 
believe that all deaths are reported to the undertakers, and by them promptly 
returned to the city clerk. 
78. I am never called upon in any way to report upon the causes of death, 
—at least have not been in late years. Registration of Deaths. 
13 
78-J. Our undertaker is a man of thirty years’ experience ; in early life a 
carpenter by trade; does not belong to any temperance society; he often 
has the difficult duty of deciding the cause of death from viewing the cada- 
ver, and he makes his returns in conformity with his own inquest. 
81. Could the public mind be educated up to the point of compulsory 
autopsies in all cases of death, such autopsies to be performed by duly qual- 
ified, legally appointed medical officers, would not both the science of medi- 
cine and the art of healing make large advances in our midst during the 
next half century ? What accomplished diagnosticians would arise as one 
result of such a measure ! But this is a Utopian idea; a thing to dream of, 
but never to be practically realized in this country. I may say, in conclu- 
sion, that the registration of deaths is “ complete and satisfactory,” at least 
very much so in my town. But the registration of the “ causes of death ” is 
not satisfactory ; that is, much less satisfactory. 
83. I have practised in this town five years, and have never been called 
upon for certificates of death during that time. The reports of the deaths 
in the town appear yearly in the clerk’s report, but his information is 
derived from other sources than through physicians. 
84. During the past two years, of all deaths returned, not one in three 
was signed by any physician. 
88. The undertakers make prompt returns, but the physicians are not 
prompt with the cause, and the town clerk is obliged to hunt up the cause 
before the end of the year. In regard to still-born children, if any under- 
taker is called, he makes a return; if, however, the friends bury the child, 
no return is made. 
89. Cases have occurred in the past, where the body has been taken just 
across the line into Lawrence, and no return made to the clerk here. 
91. All deaths are supposed to be returned; hut the causes of deaths, at 
returned, are frequently very unsatisfactory; about one-lialf are judged to bt 
misnamed. 
93. The clerk said, further, that he found it very difficult, in many cases, 
to obtain the facts and information necessary for him to make the records 
on the town hooks complete. Some would he attended by physicians out of 
town; other families would move out of town soon after a death, without 
making or leaving any record of the death or cause of death for the clerk. 
Transient persons, shop hands, etc., would sicken and die suddenly, their 
ffiends would come and take their remains to some distant place for inter- 
ment, without making any returns of the death to the clerk. 
94. I had a talk with the town clerk this morning, and he informs me that 
returns of deaths are not made promptly Tby the undertakers to him, and 
that only myself and one other physician make out certificates of causes of 
death. There are four practising medical men here, and no one hut myself 
appears to be in the practice of making out a certificate immediately after 
the occurrence of a death. The principal undertaker seldom calls for a cer- 
tificate, and, the doctors only being required by law to give a certificate 14 
Registration of Deaths. 
when it is called for, the whole matter is neglected in a majority of the 
deaths. The present town clerk appears to have tried to get his returns in 
promptly, but the undertakers and the medical attendants have been care- 
less and remiss. 
95. Empirics, often grossly ignorant, report causes in a large proportion 
of deaths; these reports are received on a par with those of the educated 
physician. 
96. To my mind the registration of deaths and causes of death in this 
city is not at all satisfactory or complete, when viewed from a medical 
stand-point. In fact, as far as statistics or the use of such registration in 
matters affecting the public health are concerned, the matter is a mere 
farce. I have no means of knowing whether all deaths are returned to the 
undertakers or not. Upon inquiry of the undertakers, I find that they 
make their return to the city clerk once a month, and that, as a rule, they 
obtain their knowledge of causes of death from inquiring of the family. 
Certificates of the causes of death are not given in this city by any physi- 
cian, they never being requested to do so. 
98. Iu regard to the registration of the causes of deaths, there is room 
and good reason for making a radical change. In a majority of instances, 
the undertaker makes his return, giving the cause of death aud the name of 
the attending physician from information obtained from the parents or rela- 
tives of the deceased. I have in mind an instance which has occurred 
within ten days, where the cause of death was reported as “pneumonia,” 
and I know, from personal examination, that the party died from “ phthisis.” 
It seems to me that in order to obtain a correct registration as to causes of 
death, and have a report that would be reliable on which to base a statisti- 
cal report, that it should he made obligatory on the part of the physician in 
attendance at the time of death of the patient, to sign, in his own hand- 
writing, the undertaker’s return, as to the cause of death. Some way should 
be devised to prevent the undertakers from making their returns, without 
first obtaining their information as to causes of death from the physician in 
attendance. As the returns are now made, there is no responsibility on the 
part of the physician ; it is left entirely in the hands of irresponsible parties, 
and, of course, the attending physician is the only one qualified to make a 
correct return. 
99. I think the attending physician is very seldom interrogated in rela- 
tion to the matter, and do not know that I ever was. A nearer approxima- 
tion (I think) would he made to the truth, if every physician were obliged 
to furnish a certificate to the undertaker or to the clerk of the town, for a 
record of each death that may occur in his practice, with a penalty, should 
an undertaker officiate without such certificate. 
100. The town clerk informs me that the registration of deaths and the 
causes of death is incomplete; that at least one corpse a month, on the aver- 
age, is removed from town without any return being made, either of the 
death itself or of the causes of it. 
101. I called upon our undertaker. He informs me that all deaths are 
returned to him, and he returns them to the clerk. It is not his custom to Registration of Deaths. 
15 
call upon physicians in all cases for the cause of death, but takes the state- 
ment of the family unless they refer him to the physician. I have no sug- 
gestions to offer, but it seems to me the statistics would be much more valu- 
able, if, in every instance, the cause of death was certified by the attending 
physician. 
103. The registration of deaths and causes thereof is satisfactory and 
correct, so far as I can find out, except that the undertaker or friends of 
deceased often neglect to present the return of death to the attending phy- 
sician for his opinion of cause of death and signature, but fill it in them- 
selves, so that omissions and mistakes are frequent. I do not think that I 
have signed more than half the returns of deaths which have occurred in 
my own practice for the last eight years. 
105. I am seldom asked to fill out a blank, and know but little of the 
reports. 
108. The town clerk’s record is well kept, so far as he can be expected to 
keep it; yet even in the record are evidences that the neglect of the law 
relating to physicians’ certificates occasions much looseness in the record of 
the causes of death. The law in relation to physicians’ certificates, I am 
informed, has never been enforced here. The town clerk also states, that in 
his yearly round for obtaining the births for registration, he has occasionally 
heard of a death which has not been reported to him. Another irregularity 
has been permitted in allowing undertakers of the neighboring city of Salem 
and those of the adjoining towns to make their returns of deaths at which 
they have officiated, semi-annually. 
109. I have never been asked to make a certificate of death and the cause 
of death for any one who has died in this town. 
113. It would be an important improvement in the present law if the 
physician’s certificate of cause of death were required in all cases, without 
exception, previous to interment, and cemetery authorities were forbidden 
to permit any interment except on presentation of an order or certificate 
from the town clerk. I cannot ascertain that any unrecorded interments 
have been made here the past two years; but such an occurrence is not at 
all impossible under existing regulations. 
122. The causes of death are at present registered with commendable 
painstaking by our municipal officers. Only a very small percentage of 
deaths are registered without a statement of the cause certified to by some 
medical attendant. But the provisions of the law last enacted to secure a 
registration are not strictly observed. From the nature of the work, I think 
the registration of causes of death should be at least subject to the super- 
vision of a medical officer. In our cities this could be made one of the 
duties of the city physician. Moreover, tables should be furnished to the 
recording officer and to physicians, indicating the general classification 
which is to be followed. I think that for the purposes sought through this 
registration, only a general classification should be attempted. A minute 
classification is likely to prove useless from the mixture of inaccurate diag- 
noses from ignorant practitioners, with the opinions of careful observers. 16 
Registration of Deaths. 
123. The town clerk employs a man to canvass the town every year to 
collect all the statistics and report to him at the beginning of the year. 
125. The town clerk informs me that there are a few returns which are 
not adequately filled. I cannot control returns of deaths of cases under the 
care of other physicians, but I am in the habit of calling at the office of 
the town clerk every year before he forwards his returns, and of assisting 
him, as far as possible, in making them complete in my department. 
131. The registration may be complete, yet I think not wholly satis- 
factory—the physician’s certificate frequently not being called for until 
several months have elapsed since a death, and then the circumstances not 
fully in mind. To decide whether such registration is satisfactory or not, I 
would first know the object of any registration. If for the basis of statis- 
tical tables of causes of death, prevalent diseases, etc., I should say not; if 
to satisfy the public whether the death was from disease or violence, I should 
say yes. 
133. The registration of deaths and the causes of death in this town is 
very incomplete; beyond the fact that the person is dead, it is of no utility 
at all. My impression is, that to be of any use, some uniform method should 
be established throughout the Commonwealth, making it the duty of the 
attending physician to make and return to some proper officer, within a cer- 
tain time, a certificate of the death, its immediate cause, etc. As long as 
every case of diarrhoea in children is called “ cholera infantum,” and every 
case attended with cough “consumption,” every sudden death “heart dis- 
ease,” what sensible man can peruse the record with confidence ? 
136. I see but one way to make the “returns of death” complete and sat- 
isfactory ; viz., forbid by law, under penalty, the interment of any body in 
any cemetery, or transportation in any public conveyance, without a certifi- 
cate of death signed by a physician, countersigned by the town clerk or some 
other responsible officer; this certificate to be retained by the person in 
charge of the cemetery or public conveyance, and returned to the officer 
issuing the same. The person issuing the certificate to be forbidden to give 
it unless he has in his possession a certificate of death of approved form, and 
signed by a physician. I have tried all other means, and am convinced that 
in this city no other plan as feasible will succeed. Many certificates of 
death have been signed by the undertakers, or not signed at all, and are 
returned in a lump at the end of the month. Notably is this the case with 
certain undertakers. The objection that has been urged against enforcing 
this law, or in fact any reasonable regulation, is, that it is difficult to find 
the doctor to sign, etc. Pass a law requiring every physician to send to the 
clerk or other official a certificate of the cause of death within twenty-four 
hours of death ; the city physician or health officer to furnish a certificate, 
if no physician is in immediate attendance. I am glad that some investiga- 
tion is being started about this matter. 
137|. The same idea (of requiring certificates from physicians) would 
lead us to prefer that all practitioners should be compelled to have diplomas 
or certificates of competency before being allowed to follow their profession. 
141-J-. The town clerk thinks some undertakers fail to get and return the 
required reports, so that some deaths fail of any registration whatever; Registration of Deaths. 
17 
others return promptly. Generally, the causes of death are not reported by 
physicians, but are obtained, as best they may be, from friends’ or neighbors’ 
reports of physicians’ opinions; often, of course, ill understood and improp- 
erly reported. In some cases, the attending physician’s name appears as 
having certified the cause of death, when he has really certified nothing, 
and only because he was known to have attended the case. Thus my own 
name appeared as certifying as cause of one death, “ Fall at Purgatory ” ! 
142. Out-of-town physicians, as well as resident physicians, have never 
returned any deaths, nor causes of death, except when the body was to be 
buried away from this place. For a period of sixteen years I have never 
been asked nor required to sign a certificate as to the cause of death, except 
as above stated. 
I believe that the nature of the disease or the cause of death is in 
seventy per cent, of cases mere guesswork. These returns form in many 
instances the bases of theories from which sanitarians deduce the most pos- 
itive conclusions. 
143. For two years I have neither filled out one [death-certificate] nor 
even seen one. For aught that I know they may be now obsolete. 
147. I have thought that our high death-rate from consumption, as shown 
by statistics, might perhaps be accounted for in a measure by the fact that 
the undertaker sometimes, in what he considers a clear case, fills out the 
blank. 
148. The registration of deaths and causes of death here is more satis- 
factory now than it was a few years ago, and it is intended by the present 
clerk to make it complete and satisfactory. I think the deaths here have all 
been recorded. The criticism I make is, that probably the former clerks 
have sometimes listened to common report as to the cause of death, and so, 
many of the deaths are recorded “ consumption” which are due to other 
causes. On examining the records for sixteen years ending with 1870, the 
deaths recorded number 563. Of these, 153 are recorded as caused by con- 
sumption, making 27 per cent, of the whole. Comparing this with the years 
1871 to 1876, inclusive, to the present time, the deaths recorded number 
187. Of these, 27 are reported as caused by consumption per cent.). 
149. The returns of deaths to the undertaker, and the registration of 
such deaths, have never, at least since my residence here (twenty-three years) 
been in any degree satisfactory. Such returns, except in individual cases, 
have been literally valueless. The sexton will ask, either at the time of the 
funeral or some indefinite time later, some one of the family, What did the 
deceased die of? and make his return in accordance with the answer and 
his own ideas of the case, the result requiring an entirely new nosological 
system to comprehend. 
150. The registration is inefficient and unsatisfactory; and principally 
because of the loose and indefinite way in which the physicians of the town 
and vicinity record their deaths, the nosology being defective and the cause 
often omitted as a trivial affair after all. I do not think all deaths get 
recorded, but most do. The undertakers are very prompt to ask for the cer- 
tificates, but do not always readily get them. 18 
Registration of Deaths. 
152. I think the value of the returns is much diminished by the certifi- 
cates of irregular and ignorant practitioners being received, hut as such 
attend quite a large proportion of the sick everywhere I see no present 
remedy. 
153. From inquiries, I judge that all deaths are returned to the under- 
takers, and quite promptly by them to the town clerk. The certificates are 
fully made out, but I find that the undertakers seldom obtain the names of 
the diseases and their causes from the attending physicians, and no doubt 
they are not unfrequently incorrectly stated. On this I would make a sug- 
gestion. The law does not oblige the attending physician to return the name 
and sex of the deceased, the disease and its causes, except when requested. 
My suggestion is to have the law changed so as to make it obligatory on the 
part of the attending physician to return the name and sex of the deceased, 
the name of the disease and its cause, to the town or city clerk; and on the 
part of the undertaker to obtain the name of the disease and its cause from 
the attending physician, the certificates retaining their present form. 
154. I think they [deaths] are all returned to the town clerk, but I see 
by examination to-day, of those for 1876 to date, that the disease is not 
stated by the attending physician in more than one-half of the certificates. 
156. I doubt if in every case of death the cause is certified by a medical 
man, for the reason that a certain number die every year without medical 
attendance, and under such circumstances that no physician could make an 
unconditional return without a post-mortem examination. In such cases, 
one can give a medical certificate to be used by parties known and supposed 
to be honest, with a declaration that it is based upon the representations of 
parents or friends. Such a document may be absolutely necessary to facili- 
tate interment. 
157. I have reason to believe that the causes of death are very indiffer- 
ently reported. Physicians’ certificates are not always required. 
157£. The deficiencies in the first place are with the undertakers, or those 
having the care of the funeral, or of the body of the deceased, to ascertain the 
facts in regard to the cause of death. In many cases the medical attendant 
is not even asked for the cause of death, or not even what ailed the patient; 
and when the return is made up there is some cause assigned in the certifi- 
cate which does or does not represent the true cause of the death, and there- 
fore not reliable for accurate statistical information. For an example, 
which occurred in my own practice: A gentleman died from cancer of the 
bladder and prostate gland, of several years’ duration; it was returned as 
kidney disease, or complaint. The undertaker was informed by myself of 
the true cause of the disease, while, as he says, the family said it was kidney 
disease, and he thought they ought to know best, and so he made his return 
as kidney disease ; and I find in my examination of the register very many 
errors of a like kind. It is my impression, and in fact I know, that the cause 
of death is not very generally reported by physicians in this town unless 
called for ; perhaps more so now than formerly, for I have been urging the 
undertakers to be more particular in regard to the matter of ascertaining 
the true cause of death, and fulfilling all the requirements of the laws of 
registration. Another fault is, the returns are not promptly made at the Registration of Deaths 
19 
time of death and burial. The return is often delayed for one or two 
months, and even longer, and has even been delayed until after the annual 
return lias been made to the secretary of the Commonwealth. This fact 
came under my own observation, for the returns were handed to me by the 
undertaker, saying that he forgot to hand them in before, and supposed that 
it would make no difference, as he was in the habit of making his returns but 
once a year. 
161. The town sexton reports all deaths to the town clerk once a year, 
bringing the blank forms to the physicians for them to fill out, guessing, as 
near as can be done, when, from any cause, physicians are unable to certify 
advisedly. My belief is, that if the sextons'were required to report every 
month at least, in country towns, the business would he performed more satis- 
factorily and with more exactness. Copies of the statutes relating to the 
matter should he posted up in some conspicuous place in town,—in the post- 
office, for instance,—so that all parties desiring to know what is law and 
usage, can thus be informed. 
162. The returns are hardly ever filled and given to the registrar until 
the close of the year, which might, in some cases, make a little jar in the 
correct filling of blanks. The sexton usually brings Ms blank to me at the 
close of the year to he revised and filled as to points he is unable to do him- 
self ; in some cases, the death is so far hack, that I am unable to he as cor- 
rect as I would like. I do not say this to find fault with the sexton, for I 
think him to be a very careful man ; it has been the custom for years, and 
he has only followed the custom. 
163. The causes of death are sometimes certified to by a physician, if he is 
handy ; if not, any one considers himself competent to assign the cause. In 
reply to the question, “Are three out of five certified to by physicians?” he 
(thetown clerk) said, “No, not so many.” 
164. When undertakers are employed, they generally obtain certificates 
of causes of death from the physician in charge; but there are quite a num- 
ber of burials by the family, where no undertaker is called upou, and in these 
cases no record is returned, unless the physician makes a point of returning 
the case himself, which few do. 
170. I think the registration, as far as the name of the person is concerned, 
is complete and accurate, hut of the causes of death, very inaccurate and 
deficient. The returns are made by the undertakers to the city clerk every 
week, and, as far as I know, they make returns of all the deaths, excepting 
in some cases of still-birth. But the causes assigned by the undertakers, in 
many cases, are very inaccurate and ridiculous, and in some instances with 
intentional deception. It is rare for the physicians to report the causes of 
the deaths. 
171. Deaths are returned by the undertakers to the clerks, they inserting 
the cause of death, and simply guessing at it. No certificate has ever been 
presented to me for signature or filling by undertakers. 
172. While perhaps all cases of death may he reported by the undertakers 
to the clerks, the causes are provokingly inaccurate, for the reason that 20 
Registration of Deaths. 
physicians are not required to return the causes of death, and the under- 
takers make returns of what they may be able to gather from the family. 
179. For many years I have been so disgusted with the manner of con- 
ducting this business, that I have lost all interest in the matter. 
180. Judging from returns of deaths coming under my own observation, 
I should say that undertakers are careful to make returns. In looking over 
the returns of causes of death in the clerk’s office, I should give my opinion 
that tables made from them would be of little value. 
182. I do not think all deaths are reported to the clerks—certainly not 
promptly. They are not returned by the physicians, but by the undertaker, 
who reports the cause of death as received from the friends. I have corrected 
the returns for the town clerk, as well as I could, for the past four or five 
years, but, of course, was not always sure of giving the accurate cause of 
death in every case, except where I have been the attendant. 
185. In the main, I have long regarded the returns of deaths very imper- 
fect. For instance, there were some 40 deaths returned by the clerk last 
year, and on my private list of deaths, which I keep from year to year, I 
had recorded 60. 
190. The returns are made pretty promptly every week. As to the causes 
of death, the returns are as unreliable as is popular rumor in general, for that 
is all they amount to. The cause of death very rarely comes direct from any 
physician. I wish you would suggest the best way of remedying this matter; 
of making these comparatively worthless records what they might be—a 
valuable store of facts. For we shall probably have an available mayor 
next year. 
191. I am glad you are going to present the subject of registration. It is 
one which has interested me for a long time. I have resolutely tried to have 
the system changed here, hut to no purpose, as the city government has 
been changed every year; and I have not been able to get the mayor inter- 
ested until the end of the year, when he has been turned out for a new man. 
Information from Town and City Clerks. 
Two hundred and sixty-two clerks replied to the circulars, 
as follows :— 
Registration of number of deaths satisfactory, . . 102 
“ “ “ not satisfactory, . 43 
Replies indefinite,. . . . . . .117 
Registration of causes of death satisfactory, . . .50 
“ “ “ not satisfactory, . .113 
Replies indefinite,....... 99 
There were 144 cities and towns from which both medical 
correspondents and clerks answered. In these— Registration of Deaths. 
21 
Town clerks and medical correspondents agree in . . 70 
“ “ “ do not agree in 74 
“ say satisfactory, and medical correspondents 
say not, in . . . . . .15 
Medical correspondents say satisfactory, and town and 
city clerks say not, in ...... 8 
Fifty-one of the seventy-four discrepancies in the replies 
are where one reports "indefinitely,” and, therefore, are not 
strictly at variance. 
Under the first head the clerks evidently often mean that 
their part of the work is satisfactory, and sometimes even 
say that the medical correspondents might think otherwise. 
Again, after saying that everything is satisfactory, they often 
add that they get returns only once a year by going for them 
personally, and one calls it satisfactory when he gets physi- 
cians’ certificates only "in more than fifty per cent, of the 
cases ”; others call the registration satisfactory, when they 
have not heard complaints. Some say that they have not 
given the subject much attention. One "cannot spare the 
time to give the subject that consideration which it deserves.” 
One clerk states that, in his opinion, all deaths are reported, 
but adds that he has often wondered why it was that" consump- 
tion, cancer, and heart disease prevail here ” so extensively. 
In this remark lies the key to the fact that prevalent dis- 
eases are reported in excess of what is due. So it is com- 
monly, or at least often, that wasting diseases are classified as 
consumption ; infantile diseases as cholera infantum, etc. For 
the same reason, during epidemics of scarlet fever and cere- 
bro-spiual meningitis, the mortality from those diseases ap- 
pears very much exaggerated. This was notably true of 
diphtheria in our State in 1874 and 1875. 
Many of the clerks remain in office only a short time, and 
do not really have their attention called to the subject farther 
than to follow precedents. Sometimes an efficient clerk gets 
his registration well in hand, and the next turn of the polit- 
ical wheel removes him and brings in another. It is, there- 
fore, impossible to say that the error in our returns is nearly 
the same from year to year. 
When the registration has been satisfactory, it has usually 22 
Registration of Deaths. 
been due to a local board of health, or to the gratuitous labor 
of some interested clerk, who does the work which, by the 
law, belongs to some one else. One of them even says, for 
instance, that the clerk has about as much work in making out 
his return at the end of the year as if the undertakers and 
physicians had nothing to do with it. 
By the personal efforts of the clerks, weekly returns are 
made of deaths and causes of death in the nineteen large 
towns and cities of the State ; but even in some of the largest 
cities, there are still such imperfections in the registration 
that these returns are only approximate. The difficulty of 
fixing the responsibility for accurate registration on any one 
person is evidently working badly, and some of the replies 
to our circulars contain this statement. 
It was not a part of the present plan to investigate the 
registration of births, and no questions bearing upon that 
matter were asked. Undoubtedly the liberal fee (when much 
travelling is not needed) stimulates the desire to get all cases. 
Still, some of the circulars were returned with the statement 
that the registration of births is even more unsatisfactory than 
that of deaths. 
The defects pointed out in our records of vital statistics are 
manifestly such that they cannot be rectified in the painstaking 
and able elaboration of them for publication, nor explained by 
the high professional talent employed in editing them. 
Replies of City and Town Clerics. 
8. The custom has been to return the deaths at the end of the year, 
except when the body is carried out of town for burial; then I get a return 
near the date of death. I very seldom get the physician’s certificate with 
the return; the cause of death is usually named, also the name of the 
physician; but all in the handwriting of the undertaker, and I tliink it is 
obtained from some member of the family of the deceased. I think the 
disease or cause of death is in many cases guessed at, so that my return to 
the department is not accurate as to the prevailing disease. 
10. I find that about six-sevenths of the returns are made by the under- 
takers; the other one-seventh seem to have been made by friends of the 
deceased, rather than by physicians. The undertakers may have received 
their information from physicians for aught I know. 
15. In answer to yonr inquiries, I would say that our undertaker makes 
full returns of all deaths where he officiates, hut that is not in one-half of . 
the cases. There are undertakers who come into this town and remove the Registration of Deaths 
23 
dead and make no returns; but when I go through the town for the births, 
and find a death, I get the best information I can. 
17. The undertaker is furnished with blanks to fill, and he gets the best 
information he can from the family of the deceased, when making prepa- 
rations for the funeral. These certificates are returned to the town clerk 
for registration at the close of each year. They usually contain some kind 
of a statement of the causes of death, sometimes attested by a physician 
and sometimes not. A section of our town always go to P for an under- 
taker, and the town clerk never gets any returns except such as he can 
gather when canvassing for the particulars concerning births. From this 
section, information as to the causes of deaths is very unsatisfactory. 
19. I fear that in some towns not one-half the causes of death are 
obtained. 
20. In small towns like this, where there is no undertaker, we do not get 
all the returns, and, if the clerk goes after them, it is very doubtful if he 
gets the cause of death corredt. 
24. A great many causes of death are returned as “heart disease,” and 
nothing more. That disease assumes so many forms I have thought whether 
to medical men that was satisfactory. 
27. I have never had reason to suspect any inaccuracy except in one 
instance, returned as “ inflammation of stomach,” where the death was 
probably caused by an attempt at abortion. 
29. It has become unfashionable to comply with the requisitions of the 
statutes, and, if any officer points out this neglect of duty, he is answered 
that other town clerks are not so particular, and that no one lives up to the 
laws. 
31. The law is in no case complied with, either as regards the undertaker, 
physician, or by the families themselves. At the close of the year, the births 
and deaths of the year past are collected by going from house to house 
throughout the town, making the result very unsatisfactory and expensive. 
36. I think all the deaths substantially are reported to the undertakers, 
and most of these return the deaths promptly and accurately, but not the 
causes of death. In the case of private cemeteries, some of the undertakers 
make no attempt to obtain certificates. One undertaker in this city has 
always been in arrears, more than all other undertakers together. I showed 
him this circular, and he has since brought in all the certificates that were 
wanting, to date. In some cases no physician is employed, and we have no 
“ city physician ” to investigate the cause of death. Incompetent persons, 
quacks of both sexes, midwives, professional or non-professional, are em- 
ployed in some cases, and their certificates are incorrect or worthless. Some 
of the regular physicians give a great deal of unnecessary trouble to the 
undertakers, who are often obliged to go many times before they can get 
a certificate. If the attention of physicians could be called to this matter, 
and if undertakers could know that they were liable to removal for not 
making full returns, most of the present difficulties would be removed. 24 
Registration of Deaths. 
38. There are not more than one-eighth of the causes of death certified to 
by physicians. 
40. Returns are sometimes made with the cause of death omitted, or 
inserted by the person making the return, and too often stated in a vague 
or general way. Unless a permit for removal of a body is required, under- 
takers do not make their returns, as a rule, until the close of the year. 
43. The certificates of physicians as to causes of death are rarely received 
at this office, and the record is dependent on the undertaker’s certificate. 
54. We have not any undertaker, but we usually employ those from 
the city of New Bedford, and they do not take the pains to make any 
returns in one-half the cases or more, and I seldom get the cause of death 
reported by a physician. 
68. I should say that all the facts I report in about fifty per cent, of the 
deaths, I obtain as best I can. 
74. During the present year, I have furnished the physicians and under- 
takers with all the proper blanks, together with pamphlet of instructions, 
but up to the present time not a single death has been returned to this office. 
76. I think our registration of deaths is about as complete as you could 
have it. Whether we get the causes of deaths as accurate as possible, is a 
matter the physicians know best about. I don’t think we do, in each and 
every case. 
79. It has been my practice for quite a number of years past, when clerk, 
to visit or send some competent person to visit the families where births and 
deaths have occurred, and to ascertain the facts and particulars before mak- 
ing returns to Boston. 
88. Physicians do not report any cases at all. 
90. I have been clerk of the town for six years in succession, and have 
employed a man to gather all the information in regard to births and deaths 
called for in the blanks sent to me for that purpose. I have never received 
any information from physicians or undertakers. 
93. If I were to make any suggestion, it would be that the people, espe- 
cially in the small towns like ours, be in some way reminded by the state 
authorities of tlieir duty in the matter of returning deaths, and other vital 
statistics, to the town clerk. As before stated, it now seems to remain with 
the clerk, in our town at least, to collect the facts concerning such deaths as 
may come to his knowledge, and it is only by keeping a close watch that he 
can be at all confident of accuracy. 
94. The physicians’ reports do not come so easily. The reason, I think, is, 
that the friends do not know that such a thing is required, so come unpre- 
pared, then of course forget to see the “ Medicos,” and the matter slips over. 
We have hut one physician here. I see him occasionally, and fill up cases that 
he knows about, but many people employ doctors from the neighboring vil- 
lages, and so I sometimes lose one. Registration of Deaths. 
25 
95. I also am quite sure that the undertaker obtains his information in 
regard to the cause of death, in a majority of cases, from some member of 
the family, rather than from the physician. The reports of causes of deaths 
are incomplete. 
97. Never until this year, has the returning of deaths been made in a 
proper manner; and I determined that I would have it properly done 
if the law was good for anything. I accordingly sent to or saw every 
physician and undertaker in the city and told them what I wanted to do, 
and that I must have their cooperation and assistance. I have had it, and 
must say that I am very well satisfied. It is only in the cases of those who 
are too poor to employ medical services, that the cause of death is not 
reported. 
108. I have been in the custom of getting the cause of death indirectly 
from the undertakers through the superintendent of burials, who is a physi- 
cian, and can give the technical name, which we would fail to get if we relied 
on the undertaker’s return, especially in cases where there was no physician 
in attendance. The undertakers complain that they have difficulty in obtain- 
ing the cause of death from the physician in attendance, in time to make the 
return to the city clerk within the time required by law. The registration 
in this city has been very complete and satisfactory, especially for the last 
three or four years. 
115. The causes of death, as returned by the undertakers, are not always 
correct, as they do not obtain the certificate of the attending physician. I 
therefore get the doctor’s statement myself, and often find that it does not 
agree with the undertaker’s return, which is made up from statements by the 
family of the deceased. 
119. The causes of deaths are not generally made known, except in an 
incomplete and unsatisfactory way. 
122. I have experienced some difficulty in obtaining the physicians’ certifi- 
cates as to the cause, etc.; that is to say, they delay the matter, and will not 
fill them out until solicited to do so by some one. I have always obtained or 
received them after a time. If they were required to fill them out immedi- 
ately, the returns would be more accurate, and it would certainly assist mat- 
ters. 
123. I have physicians’ reports of causes of death in 60 per cent, of the 
number of deaths. 
126. There being no resident physician in active practice here, the people 
are obliged to employ physicians from other towns, rendering it impractica- 
ble, in many cases, to obtain the physician’s certificate of the cause of death. 
Somewhat less than one-half of the deaths are so certified. All deaths are 
promptly returned by the undertaker, with a statement in each case of the 
cause of death, as correctly as it can be ascertained from the friends of the 
deceased. 
127. In this town I tliiuk all the deaths are registered—the facts being 
returned to the clerk by the undertakers, eacli week, they are surer to be 
right than if returned monthly; this I know by experience; for, when 26 
Registration of Deaths. 
returned monthly, as required by the statutes, it would often happen that 
some would he delayed for two or three months, and I found more difficulty 
in having them corrected. No certificates of the cause of death are ever 
given in this town by the physicians ; hence the cause of death, as returned 
to me, is very imperfect, in my opinion. 
129. The cause of death is not returned in more than one-fourth the cases, 
and I have been obliged to ascertain it and, in many instances, to fill the 
returns myself. I think there should be some method by which the returns 
of deaths may be made more complete. 
131. The only difficulty that I have experienced from the undertaker (for 
it is usually the same person from year to year) is, that he will insist upon 
keeping his returns until the end of the year, and making them in a body. 
132. In answer to your circular of the 1st inst., I have to say that since 
my connection with this office I have found it almost impossible to get the 
complete returns of deaths from the undertaker. I have taken it upon 
myself to obtain them, and believe that, for the past nine months, the regis- 
tration has been complete, except in a comparatively few cases, where phy- 
sicians have neglected to make returns of “causes of death,” when frequent 
applications have been made for them. How to remedy this neglect on the 
part of physicians and undertakers in small towns, is, in my opinion, a diffi- 
cult matter to solve, unless, perhaps, the whole duty of obtaining all the 
facts relating to a death be assigned to one person. 
135. In answer to your inquiries, I will state my impressions. I have 
kept the records since the year 1870, and have endeavored to have them cor- 
rect. The rules and regulations of the hoard of health, in this city, are so 
well observed that every death is recorded, and the cause of death, as 
returned, is usually correct. If I have any doubt, I immediately send a 
blank to the physician, and leave the filling of the record until I have it 
returned. 
136. To my knowledge, physicians’ certificates of causes of deaths have 
never been called for or reported by them, with, perhaps, one or two excep- 
tions, occurring some years ago. 
139. I consider the registration very nearly complete in this town; the 
only deficiency being now and then a body removed from town for burial 
elsewhere, without application for a permit. I think there may be twelve 
such cases in a year; the number registered being from two to three hun- 
dred. The causes of death are given in all cases. In this town the returns 
are made ,to the clerk by the sexton who has charge of the burial, so that 
we are sure of returns of every interment. The sextons make these returns 
on the proper blanks, once in six months. 
142. It is quite too common that the cause is not certified by a physician, 
especially in cases where no physician is in attendance; and I have heard 
the sexton say frequently that the doctors were rather indifferent as to the 
performance of the duty. 
146. I think the present system of registration in case of deaths works 
well in this town of about nine hundred inhabitants. Our undertaker is Registration of Deaths. 
27 
very careful to make full returns of all deaths; in nearly every instance the 
cause of death is reported and recorded. I presume more difficulty would 
he experienced in securing full returns in larger towns, especially among 
the foreign element. 
147. Strangers sometimes die and are removed to a distance for burial. 
Such are liable to be overlooked, as they rarely call on the town clerk for a 
license to remove the body, probably through ignorance that the law 
requires it. It might be well to prohibit railroad employes from passing 
such over the road without having a license pasted on the top of the box. 
158. In towns of over ten thousand inhabitants, it would seem that under- 
takers should make their returns at once, as soon as they are employed, and 
not be allowed a grace of seven days. The physician should make his certi- 
ficate and leave it with the family or persons having care of the deceased at 
once after death, and not have fifteen days of grace. If the physician 
attends to his duty, then the undertaker has most of the information 
required; and it would he only a moment’s work to fill up the necessary 
return complete, and the town clerk, with limited means for information, 
would not he obliged to supply all deficiencies, which is almost impossible 
in a town so large as this. 
We have two large cemeteries here, and the smaller towns send dur- 
ing the year a great many bodies to be buried here. In such case, we have 
to he without any “ permit to remove ” or a physician’s original certifi- 
cate, and have to take the word of the undertaker, who fills the blank 
according to what he may have remembered being told or heard. In many 
cases, corrections have been made at my own expense, but I have not been 
and am not able to give my whole attention to this particular branch of my 
duties. In most of these out-of-town cases, the undertaker waits ten days, 
and oftener two or three weeks, before making any return ; the record is 
then, at best, very meagre, and there is no way to make a full return. 
Everybody has shirked the matter or been careless, and all the town clerk 
has to do is to supply deficiencies and give the undertaker a permit, because 
the cemetery corporation has allowed the burial without a permit and the 
undertaker has really done the best he could (?). If the railroad and 
express companies would not receive a body unless there is the proper certifi- 
cate of removal accompanying it, and if the cemeteries would not allow a 
body to be buried without a “permit to bury,” I think the difficulty would 
be overcome. This might not be easy to carry out in small towns at first, 
but in large towns of ten thousand inhabitants and over, there would be no 
trouble after a few weeks, if the physician and undertaker would make 
their certificates as suggested. 
We rarely use the “ physician’s certificate,” but, instead, use the one on the 
return blank. I have tried my best to have the first used, but have given it 
up. There are so many “holes” in the statute that all we can do is “the 
best we can.” I do not know that I can suggest anything in regard to reg- 
istration, but can give you information regarding the work in this town 
and hope that we are not behind our neighbors. 
The average of time between decease and registration is about ten days. 
Permits to bury are granted in all our cases, but always after interment. 
In removal from town, our undertakers always get a “permit.” We rarely 
use a physician’s certificate-blank. In most cases, we are able to get a 28 
Registration of Deaths. 
physician’s certificate to the return; in case there is no doctor in attend- 
ance, we do without. We rarely receive permits to remove, with bodies 
coming from other towns in the State, excepting, always, the large cities. 
159. In a town of this size, there is not much danger that any death will 
escape registration. People seldom die here except from old age. 
165. Causes are not reported by the physicians as they should be, but, in 
more than half the deaths, causes are obtained from physicians before any 
record is made. 
168. As we are situated near the state line of Ehode Island, undertakers 
come from Providence, take charge of funerals and do not make any returns 
to me. For the last two years, since I have been town clerk, I remember 
of but one instance, in about twenty such cases, where they have made the 
returns that our law requires. 
169. The deaths are not all returned by the undertakers, but the fault 
seems to be with physicians, who are very negligent in the performance of 
that duty. At least twenty-five per cent, of the deaths, in this town, are 
reported from other sources. 
172. Probably the causes of about one-quarter of the deaths are certified 
to by a physician. The town is so small that the physician’s certificate is 
not necessary, as the cause is known generally. 
179. The registration of deaths in this town is all correct, so far as we 
can obtain returns, but the returns are not as prompt and certain as they 
should be. There were two or three deaths in town last year that were not 
reported, I have since learned, and they are not all returned in the manner 
the law directs. 
180. In reply to your circular received a short time since, I will say that 
neither the undertakers nor physicians make any report whatever in regard 
to deaths or the causes thereof. I have, at my own expense, sent a man 
over the town each year since I have been town clerk, with instructions to 
get all the facts and every name of persons who have died during said year. 
As to the accuracy of what he is able to gather respecting the “ causes of 
death,” you can judge better than I. The friends report what they have 
understood the physician to say was the disease or cause of death. 
182. The registration of the number of deaths is probably complete; 
causes, perhaps, not fully satisfactory, blanks for “returns of deaths” being 
seldom filled by the attendant physician, but by the acting undertaker or 
some individual chosen by the family of the deceased to take charge of the 
funeral ceremonies. 
186. The cause of death gives me most trouble. When families are not 
able to state it, I make a point of ascertaining it from the attending phy- 
sician, and do not always get it then. 
195. Of the 64 deaths registered here in 1875, 46 were certified by physi- 
cians, and the proportion is probably not very different from that in past 
years. Registration of Deaths. 
29 
196. Of all returns made, from fifty to sixty per cent, are certified by 
physicians. 
216. The great deficiency is in regard to the causes of death; very few 
physicians’ certificates are furnished, and the information of the under- 
takers, obtained from the families, is often partial and inaccurate. 
219. Nearly all the returns of the fact of death are promptly reported. 
There are some cases omitted where a sexton from out of town is employed, 
and in them I endeavor to supply the deficiency, as far as possible, when 
looking up the births. 
225. I think the registration is quite complete, and that the deaths are 
very fully registered. The causes of deaths are not nearly so satisfactory, 
the undertaker getting the information from the family, and, I think, quite 
rarely from the physician. I remedy this as much as possible by taking them 
to the physician myself at the eud of the year and getting him to revise 
them. I send you a few samples of causes of death, by which you will see 
the necessity for revision. If sextons were obliged, in all cases where there 
is an attending physician, to get the information from them, it would improve 
the character of the returns. 
230. The undertaker has generally left a blank at the time of the inter- 
ment, which, in some cases, has been retained to nearly the close of the year, 
and I have been obliged to hunt them up myself. Of thirteen returned to 
me the present year, six were without the cause of death certified by any 
physician. 
237. About half of the deaths are returned. The remainder are obtained 
by the clerk as he collects the births. Only in a few cases are the causes of 
death accurately and specifically given, the clerk being obliged to supple- 
ment that part of the work. Very few, if any, of the regular blanks are 
used, although there have always been plenty in the office here for that 
purpose. 
242. But very few of the causes of death are returned by physicians. 
None of our leading physicians have made any returns for some years, and 
never did so except in a very few cases. Some eight years since, I furnished 
all the physicians in this city with blank certificates for them to make 
returns of the cause of death, and only received a limited number of them. 
243. The causes of deaths are not returned generally as they should be. 
244. The returns by undertakers are made promptly, and I think I get 
them all except in case of foreigners who remove for burial. Sometimes they 
are not returned. The causes of deaths returned are not perhaps always 
satisfactory. 
245. In many cases, the causes of death are reported according to the 
received belief of the family and neighborhood. I get such returns as “ died 
by the visitation of God,” or “ by the hand of God,” quite often ; and “ heart 
disease” and “old age” constantly. When I know little or nothing about 
the case, I make the record according to the undertaker’s return. In other 
cases, although I am no physician, scientific or otherwise, I exercise some 
little discrimination of my own. 30 
Registratioji of Deaths. 
246. I would say that for six years that I have been clerk of this town, 
but one death has been returned to me by the parties required by law to 
do so. 
247. Probably three-fourths of the death-reports are accompanied by a 
statement of causes. I usually call upon the physicians a second time ; i. e., 
after the undertaker. In this way, I get most of them complete, but not 
any too accurate, I fear. 
250. I cannot recall a single instance, during the nine years I have been 
clerk of this town, of having received a physician’s certificate of cause of 
death ; and the causes, as reported by undertakers’ returns, are in many 
instances inaccurate and incomplete. 
254. Three or four years ago, when cerehro-spinal meningitis was preva- 
lent, I had from this class (irregular practitioners) one or two deaths returned 
from that disease, when I thought I knew absolutely that the cause of death 
was entirely different. In such case, has not the town clerk the power to 
alter and correct the returns ? I do. 
In considering: how to avert the recurrence of the terrible 
plagues which visited London in the sixteenth century, the 
first step was to find where and under what circumstances 
people died, and how variously different localities were 
affected. For this purpose registration was organized, 
imperfect, it is true, but sufficient to give many important 
hints. Much later, when the Poor-Law Board was created, 
a better system of registration was adopted ; but it was only 
in 1837 that it was carried out with all the force of an Act of 
Parliament, and with the cooperation of the physicians, sur- 
geons and apothecaries promised by the presidents of their 
associations. The law has been improved from time to time 
by many amendments; and finally physicians were compelled 
to return certificates of death under penalty, in 1874, as was 
then already the law in Scotland. 
To such a high degree of perfection has registration of deaths 
now arrived in England, that on each Tuesday a printed 
pamphlet of ten pages is prepared and sent over the kingdom, 
giving the causes of deaths, etc., with the conclusions and 
warnings to be drawn from them, for the week ending the 
previous Saturday, and collected from twenty-three towns, 
containing: over eig:ht million inhabitants. This return also 
contains the latest information from the large cities of the 
History of Registration of Deaths. Registration of Deaths 
31 
world,—from New York and Philadelphia to Calcutta and 
Bombay,—and fully justifies Dr. Farr’s enthusiastic remark, 
that "Thus observers, like watchmen on the walls, are ever 
on the lookout, so that they see exactly what is going on, 
and neither plague, cholera, nor any other great epidemic 
can take the nations by surprise.” * Quarterly, yearly and 
decennial reports are also published. 
The Imperial Board of Health of Germany have taken steps 
to collect and publish similar returns promptly from all cities 
in the empire containing 15,000 inhabitants and over, espe- 
cially with reference to getting early information in regard to 
epidemics. 
Our registration in Massachusetts followed four years after 
that of England, and is so similar as to justify the inference 
that it was taken almost directly from it. 
The law of Massachusetts regarding registration (chapter 
21 of the General Statutes) is as follows, the amendments 
being inserted in the places where they belong:— 
Section 1. The clerk of each city and town shall receive or obtain, and 
record and index, the following facts concerning the births, marriages, and 
deaths therein, separately, numbering and recording the same in the order 
in which he receives them, designating in separate columns : 
In the record of births, the date of the birth, the place of birth, the name 
of the child (if it have any), the sex and color of the child, the names and 
the places of birth of the parents, the occupation of the father, the residence 
of the parents, and the date of the record; 
In the record of marriages, the date of the marriage, the place of marriage, 
the name, residence, and official station of the person by whom married, the 
names and the places of birth of the parties, the residence of each, the age 
and color of each, the condition of each (whether single or widowed), the 
occupation, the names of the parents, and the date of the record ; 
In the record of deaths, the date of the death, the name of the deceased, 
the sex, the color, the condition (whether single, widowed, or married), the 
age, the residence, the occupation, the place of death, the place of birth, 
the names and places of birth of the parents, the disease or cause of death, 
the place of burial, and the date of the record. 
Section 2. Parents shall give notice to the clerk of their city or town of 
the births and deaths of their children ; every householder shall give like 
notice of every birth and death happening in his house; the eldest person 
next of kin shall give such notice of the death of his kindred ; the keeper of 
a workhouse, house of correction, prison, hospital, or almshouse, except the 
state almshouses at Tewksbury, Bridgewater, and Monson, and the master or 
other commanding officer of any ship shall give like notice of every birth 
and death happening among the persons under his charge. Whoever neg- 
* 37tli Report, p. vi. Registration of Deaths. 
lects to give such notice for the space of six months after a birth or death, 
shall forfeit a sum not exceeding five dollars. 
Section 3. Any physician having attended a person during his last ill- 
ness, shall—when requested within fifteen days after the decease of such 
person—forthwith furnish for registration a certificate of the duration of the 
last sickness, the disease of which the person died, and the date of his 
decease, as nearly as he can state the same. If any physician refuses or neg- 
lects to make such certificate, he shall forfeit and pay the sum of ten dollars 
to the use of the town in which he resides. 
Section 4. Every sexton, undertaker, or other person having charge of a 
burial-ground, or the superintendent of burials having charge of the obse- 
quies or funeral rites preliminary to the interment of a human body, shall 
forthwith obtain and return to the clerk of the city or town in which the 
deceased resided or the death occurred, the facts required by this chapter to 
be recorded by said officer, concerning the deceased, and the person making 
such return shall receive from his city or town the fee of ten [as amended, 
twenty-five] cents therefor. 
The clerk, upon recording such facts, shall forthwith give to the person 
making such return, a certificate that such return has been made, which 
certificate such person shall deliver to the person having charge of the inter- 
ment, if other than himself, before the burial when practicable, otherwise 
within seven days thereafter. When a burial takes place and no certificate 
is delivered as aforesaid, the sexton, undertaker, or other person having 
charge of the interment, shall forthwith give notice thereof to the clerk, 
under penalty of twenty dollars. 
Section 5. The clerk of each city and town shall annually on or before 
the first day of February [as amended, March] transmit to the secretary of 
the Commonwealth, certified copies of the records of the births, marriages, 
and deaths which have occurred therein during the year ending on the last 
day of the preceding December. 
Section 6. The record of the tow n clerk relative to any birth, marriage, 
or death shall be prima facie evidence, in legal proceedings, of the facts 
recorded. The certificate signed by the town clerk for the time being shall 
be admissible as evidence of any such record. 
Section 7. The clerk shall receive, from his city or town for obtaining, 
recording, indexing, and returning to the secretary of the Commonwealth, 
the facts in relation to a birth, twenty [as amended, fifty] cents; a marriage, 
ten [as amended, fifteen] cents; a death, twenty cents for each of the first 
twenty entries, and ten cents for each subsequent entry [as amended, if 
returned as provided in sections 2, 3 and 4 ; if obtained by the clerk himself, the 
fee is thirty-five cents'], as the same shall be certified by the secretary of the 
Commonwealth ; but a city or town containing more than ten thousand 
inhabitants may limit the aggregate compensation allowed to their clerk. 
He shall forfeit a sum not less than twenty nor more than one hundred 
dollars for each refusal or neglect to perform any duty required of him by 
this chapter. 
Section 8. The superintendents of the state almshouses at Tewksbury, 
Bridgewater and Monson shall obtain, record and make return of the facts 
iu relation to the births and deaths which occur in their respective institu- 
tions, in like manner as is required of town clerks. The clerks of said towns 
shall, in relation to the births and deaths of persons in said almshouses, be 
exempt from the duties otherwise required of them by this chapter. 
Section 9. Tlie secretary shall, at the expense of the Commonwealth, pre- Registration of Deaths. 
33 
pare and furnish to the clerks of the several cities and towns, and to the 
superintendents of the state almshouses, blank books of suitable quality 
and size to be used as books of record under this chapter, blank books for 
indexes thereto, and blank forms for returns, on paper of uniform size; and 
shall accompany the same with such instructions and explanations as may 
be necessary and useful. City and town clerks shall make such distribution 
of blank forms of returns furnished by the secretary as he shall direct. 
Section 10. The secretary shall cause the returns received by him for 
each year to be bound together in one or more volumes, with indexes thereto. 
He shall prepare from the returns such tabular results as will render them 
of practical utility, make report thereof annually to the legislature, and do 
all other acts necessary to carry into effect the provisions of this chapter. 
Section 11. Any city or town containing more than ten thousand inhab- 
itants may choose a person other than the clerk to be registrar, who shall 
be sworn, and to whom all the provisions of this chapter concerning clerks 
shall apply. The returns and notices required to be made and given to 
clerks shall be made and given to such registrar, under like penalties. 
Section 12. The secretary of this Commonwealth shall prosecute, by an 
action of tort, in the name of the Commonwealth, for the recovery of any 
penalty or forfeiture imposed by this chapter. 
Section 13. Any city or town may make rules and regulations to enforce 
the provisions of this chapter, or to secure a more perfect registration of 
births, marriages aud deaths thereiu. 
Faults in our Law 
From failure to enforce this law in some cases, and in oth- 
ers from its inadequacy, there are many defects in our vital 
statistics which may be remedied. Of course, there will be 
some errors always. There are some cases in which it is 
impossible to state accurately the cause of death without an 
autopsy, and it cannot alsvays be done then. The best men 
will make some mistakes, and charlatans will make a great 
many. 
It is important, therefore, that in all cases of sudden death 
at least, and better still, in all cases, the physician’s certifi- 
cate should state whether there was an autopsy, as is done 
now in Watertown at Dr. Hosmer’s suggestion. Competent 
physicians, too, should be registered, as in England; and 
reports signed by others, or where for any reason no physi- 
cian was able to get sufficient information as to cause of death, 
should be classified as uncertified. 
Errors arise, too, from want of uniformity in the practice 
of physicians as to certifying causes of death. For instance, 
of three persons dying from typhoid fever, suppose the imme- 
diate cause of death in one to be exhaustion, in another intes- 34 
Registration of Deaths. 
final hemorrhage, and in a third pneumonia. Here are four 
" causes of death ” as now happens ; namely, " typhoid fever,’' 
"exhaustion ” (consumption the undertakers call it), "hemor- 
rhage” and "pneumonia.” They should all be certified as 
typhoid fever, and the other facts should be stated. Instruc- 
tions relative to this and other kindred matters should be 
given from the central office. 
The infant who was reported as having died of " canker 
rash, diphtheria, dysentery and consumption,” and another, 
whose cause of death was returned as " five doctors,” doubtless 
had good reason to die; and "delicate from birth,” infancy,” 
" stopage,” " fitts,” " colera fantum,” " collocinphanton,” 
"cholry fanton,” "bled,” "direars” (? diarrhoea), "billirm 
(? delirium) feever,” "artry lung bursted,” "feusson (? effu- 
sion) on brane,” "canker on brain” and "infermation lungs” 
probably convey some ideas to the persons who wrote the 
terms ; but such returns cannot be of much use in a statistical 
point of view. 
For sudden deaths, and where no physician has been in 
attendance before death, the selectmen should be required to 
call upon some medical man for the best certificate possible 
under the circumstances. Inquests will often be needed, but 
the question of coroners* is too broad and important to be 
touched upon here, further than to say that many now in office 
are grossly incompetent, and that abuses are too common. 
In Europe many persons die without medical care ; and 
especially in some of the more populous places, leichenbe- 
schauer and medecins vcrificateurs (examiners) are employed 
by the city or by the state to learn the circumstances of 
death ; but this is chiefly to ascertain that the death was 
not by foul means. 
Where the town clerk rides about his circuit at the end 
of the year to collect the births and deaths, some must 
* One of our correspondents writes: “ I submitted the suggestion concerning the 
appointment of coroners, or investing physicians who may be members of local 
board of health with the powers exercised by those officers, to one of our most 
prominent lawyers, who coi’dially approved them, and wished me to write more at 
large npon the subject. I will not do so, however, further than to say that in this 
town of 6,000 inhabitants there is no coroner, and there has been none for the last 
forty years; nor is there, to my knowledge, at this time, one within twenty miles. 
So the impediments in the way of the judicial action that circumstances sometimes 
demand in the name of justice are very great.” Registration of Deaths. 
inevitably be lost by removal of families, forgetfulness, etc. 
Where the undertaker makes his reports only at long inter- 
vals, of course some will be overlooked. 
Generally, physicians readily give certificates when asked 
for them, so that this evil of delay may be avoided. If, how- 
ever, the family or friends of the deceased were responsible 
for getting the doctor’s certificate and the registrar’s permit, 
the doctors would undoubtedly take much more pains to have 
their part of the duty promptly done. The people would 
soon get accustomed to so reasonable a law, as they have 
already done in England, and as they have done here (in some 
towns) when the body is to be removed to a distance for 
burial, or in the case of marriage certificates. In such case 
there would be no reason why the undertakers should have 
their present fees. 
To make the law fully operative, there should be a penalty 
for burying in any private or public cemetery without a per- 
mit, to be enforced equally upon keepers of cemeteries and 
individuals. Exceptionally it might be necessary, in case of 
contagious diseases, in scattered communities, etc., to allow 
the permission of the selectmen or health officer to suffice, 
leaving the certificate to be returned later. 
Railways and public conveyances now carry bodies without 
permits, and such bodies are conveyed pretty much over the 
State, either for interment or reinterment. Of course, this 
should never be; in case of a contagious disease, it might 
involve serious danger to the public health. 
For the increased duties which town clerks would have 
under better enforcement of the registration laws, and with 
more efficient regulations, the present fee for registration of 
deaths is, in some cases, rather small, but it need not be as 
large as the clerk’s and the undertaker’s together now 
amount to. 
The section of the law by which " any city or town may 
make rules and regulations to enforce the provisions of this 
chapter or to secure a more perfect registration of births, 
marriages and deaths therein,” is apparently not often acted 
upon ; but it has been done in a few cases. The boards of 
health of Boston and of Brookline have done very efficient 
service in this regard ; and one of our correspondents writes : 36 
Registration of Diseases. 
"The registration of deaths in Woburn is complete and satis- 
factory. Physicians are required to make returns of the 
cause of death in every case, before the town clerk will issue 
a permit to the sexton for burial.” 
It is not too much to say that modern sanitary science owes 
its existence to the registration of deaths and the localization 
thereby of insanitary conditions. It has been very much 
advanced, too, by the careful enumeration of cases of sick- 
ness as well as of deaths, whereby epidemics and locally 
prevalent diseases have furnished the means of scientific study, 
from which general laws have been learned, and through which 
state medicine has become a necessity of modern life. 
Importance of Registration 
Registration of Diseases. 
As soon as it was recognized as a part of the duty of the 
State to prevent disease, something more was needed ; namely, 
a knowledge on the part of the health officers of the approach 
of epidemics. Of course, this want implied the existence of 
health officers, whose duty it should be to take measures to 
stop an epidemic, and w7ho should have the power to carry 
out proper measures for so doing. 
This need has indeed been recognized for many years, and 
in many countries; but usually the laws have referred solely 
to the more dangerous diseases, like small-pox, cholera, 
yellow fever and plague, or it has become the custom to 
interpret them in that way. 
The late Dr. George Derby suggested at one time the value 
of returns from the dispensary physicians and hospitals of 
the diseases treated,* to be reported to the State Board of 
Health weekly; a method which has yielded excellent results 
in the army medical departments in different countries. This 
has indeed been done to a certain extent in England, where 
the medical officers of the Poor-Law Board are required to 
report to the health officers the cases treated by them ; but it 
is only a partial and unsatisfactory method, because hospitals, 
almshouses, etc., etc., are so well protected that contagious 
* Third Report of the State Board of Health, p. 13. Registration of Diseases. 
37 
diseases often get thoroughly established in a community 
before appearing there, and for other reasons, so that numerous 
petitions have been sent to the English government for a more 
stringent law requiring registration of all cases of contagious 
diseases. The position of the physicians is well represented 
by the following extract from the report of Dr. John Whit- 
more, health officer of St. Marylebone for 1875 (p. 20) : "It 
is very certain that until the sanitary officials of the metropolis 
are able to obtain prompt information of every case of sick- 
ness from contagous or infectious diseases occurring in their 
respective parishes or districts, and are able, immediately on 
the receipt of such information, to adopt all necessary pre- 
cautions, and impose all necessary restrictions, to prevent its 
spread or diffusion among the healthy, there will be no material 
diminution in the death-rate from diseases of this class.” 
The same is wTell expressed by another authority: "The 
choice must be between an abandonment of any attempt to 
register sickness, and a scheme which, by the aid of compul- 
sory legislation, shall provide a registration of sickness which 
shall be of real use to the state and the community at large.”* 
A striking illustration of the fact that registration of dis- 
eases often secures results of importance which cannot be got 
from mortality returns or from physicians’ impressions, has 
been shown in Paris during the past year, where the mortality 
from typhoid fever was excessive, but its prevalence not 
unusually great. The additional interesting facts that the 
disease was most prevalent in the fall, when the ground-water 
was low, and most fatal in the spring, correspond with the 
results of Dr. Pinkham in his investigations with regard 
to diphtheria in Lynn, and given at a later page in this 
Report. 
In 1874 the British Medical Association appointed a com- 
mittee to consider the best method of accomplisliing this 
object, and they reported, in 1876, that the families and 
friends of the sick should be required by law to give inform- 
ation of all cases. In some few places in England physicians 
have volunteered to report to the health officers at once their 
cases of contagious diseases. In Newcastle-upon-Tyne "daily 
* Sanitary Record, March 4, 1876. 38 
Registration of Diseases. 
notice continues to be received, from the dispensary and other 
sources, of infectious diseases of all kinds, when, as hitherto, 
examination into its probable cause is at once proceeded with, 
and such recommendations and steps taken as are most suited 
to the nature of the case and best conduce to the extinction 
of the disease, including the gratuitous disinfection and purifi- 
cation of the premises of cases and the replacing of infected 
articles of bedding by others.”* 
Holland. 
In what has actually been done by the state, the Nether- 
lands are far in advance of the rest of the world. By the 
law of December 4, 1872, the following regulations (among 
others) were made relative to contagious and infectious dis- 
eases (small-pox and varioloid, scarlet fever, measles, typhus 
fever, typhoid fever, cholera and diphtheria, to which dysen- 
tery was added December 3, 1874) :f— 
Burgomasters may remove patients from tenement houses and taverns to 
a hospital, if they deem it necessary, and hy advice of a physician. 
They may temporarily close such public houses, etc., at the public expense, 
when the medical inspectors deem it necessary, t 
They may cleanse and disinfect houses, cottages, and vessels, upon the 
order of one of the inspectors or of a practising physician. 
They may, with medical authority, disinfect or destroy articles infected or 
suspected to he so. 
They may remove filth, cleanse streets, etc., etc., in preparation for a 
threatened epidemic. 
They may regulate, in various ways, the transportation of such sick per- 
sons, the attendance at school of children, and the discharge from the hos- 
pitals of those sent there. 
Neither teachers nor scholars are allowed to enter schools, who have not 
been vaccinated or have not had small-pox. 
In each district the authorities must furnish opportunity for free vaccina- 
tion at least once in every three months. 
They must provide proper places for the treatment of contagious diseases, 
when required hy general order to do so. 
They must provide dead-houses within a year after the passage of the law. 
* Report of the medical officer of health on the sanitary condition of Newcastle- 
upon-Tyne during the year 1875, by Henry E. Armstrong, M. R. C. S., 1876. 
t If deemed necessary, other diseases may he added to this list hy the authorities 
for the time being; but permanent additions must be made by royal statute. 
X By the law of June, 1865, there are seven inspectors in the kingdom, of whom 
each has a separate district. Five of these inspectors, having large districts, have 
assistants. jRegistration of Diseases 
39 
In case of death from contagious or infectious disease, they may send the 
corpse at once to the dead-house. 
Heads of houses, masters of vessels, etc., must report all cases of the above- 
mentioned diseases to the burgomaster, under penalty, within twenty-four 
hours. 
Doctors must report all cases of cholera and small-pox to the burgomaster, 
under penalty, within twenty-four hours. 
The houses in which there are contagious diseases must be conspicuously 
marked by the officials with the words “ Contagious Diseases,” and with the 
name of the disease. 
Public announcement of epidemics in any district must be made, and 
weekly reports of cases and deaths from all of the above diseases, except 
measles, must be published by the burgomaster; from measles, only the 
deaths. 
In case of cholera, there must be daily reports. 
Public fairs and festivals may be stopped on account of the presence of 
an epidemic. 
Medical inspectors have power to enter houses where there are contagious 
diseases. 
The penalties for violating the various provisions of this law are fines 
from five to one hundred florins, and imprisonment from three days to a 
month. 
According to Dr. Egeling, the medical inspector of South 
Holland, excellent results have been got by this law, and he 
gives a list of the persons who were fined in 1874 for viola- 
tion of it.* In many places it has been well enforced ; but in 
the report of the department of works at Rotterdam,f the 
ratio of deaths reported to the cases reported indicates that 
the law was not in all cases carried out. 
Germany. 
Iii Germany, an advisory board of health for the empire 
was appointed last summer, with Dr. Struck as chief medical 
officer. Their first work was to undertake to revise the san- 
itary statutes, especially with relation to vital statistics; and 
a commission had already reported favorably to the parliament 
on a law regarding registration of contagious and infectious 
diseases, as had been suggested by the German Public Health 
Association in 1875. In Prussia, already, every town of 
over 5,000 inhabitants must have a sanitdts-commission, who 
have large powers in the police of infectious diseases. 
* Verslag aan den Koning, etc., 1875 (pp. 248 et seq.). 
f Yerslag van den Toestand der Gemeente Rotterdam, 1875 (pp. 105 et seq. and 
Appendix F.). 40 
Registration of Diseases. 
In the United States, the board of health of Brooklyn 
began, May 1873, to require physicians to report all cases of 
contagious diseases, as the sanitary code provided, including 
especially cholera, yellow fever, small-pox, scarlet fever, 
cerebro-spinal meningitis, typhus fever, typhoid fever, 
diphtheria, and "any other disease publicly declared by the 
board of health dangerous to public health.” In their last 
report they say (page 11), "the report of transmissible dis- 
eases by physicians has been insisted on and enforced by the 
board,” and (page 12) "whenever it is found that there has 
been a failure to report, the matter is investigated, and, if 
not properly explained, is referred to the attorney of the 
board for prosecution.” 
United States. 
The number of cases reported from May, 1873, to January, 
1875, was 2,007 ; during 1874, 4,G37 ; and Dr. Hutchison, 
the health commissioner, says that under this ordinance the 
mortality for 1874 was 3.56 per cent, less than for previous 
years. "The decrease in the mortality was principally of the 
diseases termed ' infectious,’ and with the causes of which it 
is the duty of sanitary authorities to contend.” 
Many of the regulations of the board show great care; for 
instance, "funerals after deaths from small-pox must be con- 
ducted without delay, and these also are superintended by an 
officer of the board.” 
The total number of actions commenced by the attorney of 
the board, on all cases, from September, 1873, to January, 
1875, was 1,288. 
All physicians possessing diplomas from medical schools 
are registered by the .board, and all deaths not certified by 
them are investigated by the proper officers. 
In Pittsburgh, similar work was done in 1875, and the 
health officer, Dr. Crosby Gray, reports that "the law is not 
as effective as it should be, as it fails to mention specifically 
some of the diseases which are regarded as infectious, and a 
few of our physicians are inclined to take advantage of the 
defect. However, a majority do comply, and all, I believe, 
report small-pox.” 
In Oakland, California, "Dr. C. S. Kittredge was elected Registration of Diseases. 
41 
registrar, to collect statistics to enable the health depart- 
ment to ascertain, as nearly as possible, the exact number of 
cases of sickness for each death occurring during any given 
period, properly classified. The value of such statistics, 
when accurately collected, and sufficiently large, is well 
recognized. Unfortunately, after some 1,200 cases had been 
collected, the returns, even after repeated appeals for con- 
tinuance were made, ceased almost entirely to be made, so 
that there was no possibility of the continuance of this 'labor 
of love.’ ” * 
During the year 1875, Dr. F. W. Draper ably carried out, 
under the authority of the Massachusetts State Board of Health, 
a plan of reporting prevalent diseases suggested by him. As 
nearly as can now be said, about one hundred and ten physi- 
cians, a little more than one-half the number who agreed to 
cooperate, sent in their reports each week from about ninety 
of the three hundred and forty-one cities and towns in the 
State. Unfortunately, too, for comparison, the physicians 
not reporting were not the same from week to week. 
According to the last census there are 2,345 male phy- 
sicians and 91 female physicians in the State, with a popula- 
tion of 1,651,912; and the Board therefore received one 
weekly report to represent 15,000 people, and from less than 
one physician in twenty. It was hoped that some method 
might be reached whereby a sufficient number of returns 
might be got each week to allow the generalizations from 
them to be based upon more complete and fuller knowledge; 
but, even allowing one return from an average of 3,000 people, 
the expense would be very much greater than the present 
appropriation of the Board would justify. There was the 
fact, too, that the information got would be general opinions 
and not positive facts, and, although they would have some 
local value, any trustworthy generalizations from them would 
be attended with such difficulty and must be so limited as to 
make their value somewhat questionable. 
The state board of health of Michigan have modified and 
are testing this experiment still further; but for the present, 
the Massachusetts Board are publishing, each week, in the 
"Boston Daily Journal,” the death-rates, etc., from cities and 
* Report of the Board of Health of Oakland, 1876, p. 5. 42 
Registration of Diseases. 
towns representing about one-half the population of the State, 
of which a copy is given :— 
“ Mortality in Massachusetts. 
“ Deaths reported in Seventeen Cities and Towns for the: Week ending 
November 4, 1876. 
CITIES. 
Estimated Popu- 
lation. 
No. of Deaths in 
each. 
Annual Death- 
rate per 1,000, 
during week. 
Death-rate from 
principal Zymo- 
tic Diseases. 
Boston, 
352,000 
131 
19.64 
3.84 
Worcester, .... 
51,300 
22 
22.30 
10.14 
Lowell, 
51,700 
33 
33.19 
16.09 
Chelsea, 
21,300 
9 
21.97 
4.88 
Cambridge, .... 
50,000 
7 
7.28 
1.04 
Salem, 
26,500 
13 
25.51 
9.81 
Lawrence, .... 
36,000 
10 
14.44 
4.33 
Springfield, .... 
31,400 
9 
14.90 
8.27 
Lynn, 
34,000 
14 
• 21.41 
6.11 
Gloucester, .... 
17,000 
7 
21.41 
15.29 
Fitchburg, .... 
12,600 
4 
16.51 
12.38 
Taunton, 
20,700 
4 
10.05 
2.51 
Newbury port, .... 
13,400 
6 
23.28 
7.43 
Fall River, .... 
47,200 
15 
16.53 
4.41 
Haverhill, 
15,000 
3 
10.04 
- 
Holyoke, 
17,300 
6 
18.03 
6.01 ' 
Pittsfield, 
12,500 
5 
20.80 
4.16 
Total, .... 
809,900 
298 
19.13 
5.78 
“ Deaths from prevalent diseases in the seventeen cities and towns :— 
Diphtheria and croup, thirteen cities and towns, . . .56 
Consumption, twelve cities and towns, 55 
Pneumonia, seven cities and towns, 17 
Typhoid fever, seven cities and towns, 11 
Scarlet fever, three cities and towns, 6 
“ The mortality from consumption and pneumonia remains very nearly 
as for the week previous. Diphtheria and croup and scarlet fever have 
slightly increased. Typhoid fever and the diarrhoeal diseases have 
decreased. No deaths are reported from small-pox; but there is one 
case in Holyoke (non-fatal). 
“ CnAS. F. Folsom, M. D. 
“ Secretary of the State Board of Health.” 
This is not, by any means, as satisfactory as the Board 
would desire; for it fails to include all the deaths in all the Registration of Diseases. 
43 
cities reporting, allows many local and non-fatal epidemics to 
escape being reported, and undoubtedly in some of the cities 
gives a certain number of erroneous causes of death ; but it is 
the least incomplete practical method at present, improves 
from year to year, and, at least, cannot seriously mislead. 
That there should be something more than this is evidently 
desirable ; and it is to be hoped that the means of informing 
the community promptly, with regard to the appearance of 
contagious diseases, may be one of the near possibilities.