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JOURNAL

OF THE ROYAL STATISTICAL SOCIETY

MARCH, 1896.

A NATIONAL SYSTEM of NOTIFICATION and REGISTRATION of SICKNESS.

By ARTHUR NEWS HOLME, M.D. Lond., M.R.C.P., Medical Officer of Health of Brighton.

[Read before the Royal Statistical Society, 17th December, 1895.
C. S. LOCH, Esq., B.A., Vice-President, in the Chair.]

THE subject which I have the honour to bring before you is not novel. Most of the proposals and suggestions which I shall make have been already made, more ably than I can hope to repeat them; and what is novel in my remarks is but the natural outcome of the pioneer advocacy by B. W. Richardson, Farr, Rumsey, and Ransome, and many others. The present time, however, seems opportune to reopen the question, review the progress already made, compare our experience and present condition as regards the notification of sickness with that of other countries, and indicate the directions in which reform and advance are urgently required and may be most advantageously pursued.

We shall in the first place briefly sketch the history of the question and the progress already made. This progress will in the next place be contrasted with that made in some other European countries, and, finally, proposals for further progress will be made.

Preliminary Considerations as to Sickness Registration.

The office of Registrar-General of Births, Deaths, and Marriages in England was created in 1836. The first report of the RegistrarGeneral was published in 1839, and to this report Dr. W. Farr contributed the first of that long series of essays which have been the basis of the science of vital statistics in this country. It' is not too much to say that the system of death certification and registration in this country is the foundation on which the great sanitary ameliorations already achieved have been built. The mortality of every district throughout the country has been the subject of analysis. The attention of local authorities has been compelled to any special incidence of deaths in their districts.

VOL. LIX. PART I.

B

Medical officers of health have been created throughout the country, one of whose chief duties is to draw forcible attention to the local incidence of deaths, and recommend measures tending to decrease the sickness and death-rate. Where the local supervision has been lax, or the medical officer's recommendations have not been carried out, the Registrar-General's periodical returns have enabled the medical staff of the Local Government Board to intervene and investigate any local outbreak of fatal disease. The publicity given to the Registrar-General's weekly, quarterly, and annual reports has evoked a spirit of inquisitiveness and even of emulation throughout the country; and, although the comparison of death-rates of great towns with each other, particularly for short periods, is fraught with fallacies, the general result of the publicity secured and of the consequent efforts on the part of local authorities has been an immense improvement in the public health of the community. The reduction in the general death-rate from 24'7 in town districts in 1851-60 to 20'2 in 1884-93, and from 199 in country districts in 1851-60 to 175 in 1884-93, and the reduction of the death-rate from "fever" from 792 per million in 1858-60 to 202 per million in 1886-90, are sufficient evidence of this.

It soon, however, became evident that registration of deaths gave a very imperfect view of the prevalence of disease. Some diseases are never fatal and yet cause serious incapacity and suffering. It is very fallacious to assume any fixed ratio between sickness and mortality. The fatality of infectious diseases, for instance, varies greatly in different outbreaks, under varying circumstances, and in different localities. Thus, if it be required to compare the amount of scarlet-fever in Brighton with that in London, in 1894 the death-rate from this disease in London was O'22, and the number of cases was 4'24 per 1,000 of the population. In Brighton in the same year the corresponding death-rate was 0'03, and the case-rate 185 per 1,000 of the population. It can easily be calculated from these data that the ratio of the scarletfever death-rate in Brighton and London was as I: 73, while the ratio of the corresponding case-rate was as I: 2.2. Thus the fatality of scarlet-fever in Brighton was I in 62 cases, while that in London was I in 19 cases. Hence while the deaths from scarlet-fever in London were over seven times as numerous (in proportion to population) as those in Brighton, the cases were only about twice as numerous.

This illustration serves to show that mortality is not necessarily a correct index of the morbidity of a community. The highest ratio of sickness is occasionally found associated with a favourable rate of mortality. Mortality statistics necessarily ignore every

thing that precedes the close of life. They are silent about the large mass of common sickness, which, although it may disable a man, is not “unto death." From the standpoint of the commonwealth and the common health, sickness is more important than death; for "it is the amount and duration of sickness rather than the mortality that tell on the prosperity of a community." (Dr. Dickson.) Or as Charles Dickens has stated it: "It concerns a man more to know the risk of the fifty illnesses that may throw "him on his back, than the possible date of the one death that must "come. We must have a list of killed and of the wounded too!"1

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If the progress already made in the prevention of disease is great, there is no reasonable doubt that the accurate and complete notification and registration of sickness would-firstly, by improving our knowledge of the conditions and circumstances. under which sickness occurs, and, secondly, by drawing attention to the magnitude of the distress and poverty caused by sicknesslead to a vast extension and improvement of our preventive measures, and insure a great reduction of disabling illness. Accurate statistics of sickness would further be of great value in determining the relative value of institutions for the treatment of the sick, and in the detection of any special condition impeding their full utility.

The advantages of registration of sickness in connection with special industries, and in connection with the experience of Friendly and allied Societies, will be considered later in the paper.

The History of Attempts to Establish Registration of Sickness. The history of the various stages of advocacy of a national system of registration of sickness, and the local attempts that have been made to carry it into effect, has never been written, and only a hasty sketch of it can be here attempted. If justice is not done to any pioneers who have worked in this important field, it is from lack of knowledge on the writer's part, the information on the subject being scattered in various pamphlets and periodicals, some inaccessible or out of print. Dr. Rumsey in drawing attention in 1875 to the fact that a public registration of disease was no new or strange demand, mentions that it was one of "twelve proposals "by which the lives of many thousands of the rich as well as the poor may be saved yearly," made to Parliament by Mr. John Bellers at the beginning of the eighteenth century, before the first of our modern hospitals was planned. It was again urged by Dr. Clifton, physician to the Prince of Wales, in 1732, with special reference to hospitals. Dr. Rumsey, in 1844, in his

"All the Year Round,” vol. iv, pp. 227 and 228.

2 "Essays and Papers on some Fallacies of Vital Statistics," 1875, p. 47.

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