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evidence before the Medical Poor Relief Committee of the House of Commons suggested a comprehensive plan for the uniform registration of the sickness which affects the poorer classes. In 1848 Dr. Liddle, subsequently medical officer of health for Whitechapel, proposed amended forms for the weekly medical returns made by their medical officers to Boards of Guardians, and the utilisation of these returns in general sanitary inquiries. About the same time it was suggested in the " Sanitary Review" (vol. iii, p. 317), that these returns might easily, with a few obvious modifications, be employed as a basis for the national registration of disease, especially in the record of epidemics. The same editorial article suggested the appointment of a registrargeneral of diseases in London as the central authority, to whom the district returns, after local use, should be forwarded for digest and publication.

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Dr. B. W. Richardson was, I believe, the first to carry any scheme for notification and registration of sickness into actual practice. The cases notified were tabulated in the "Journal of Public Health and Sanitary Review" of 1855; but he had written on the subject as far back as 1852. The registration was continued by Dr. Richardson for several years, "and in the end "had observers from Dr. Moyle of the Scilly Islands, to Dr. Spence "of Lerwick in the Shetlands. At one time he had 44 observers "from latitude 40° 50′ N. to 60° 9′ N., and from longitude 6° 24′ W. "to 1°8′ W. These observers were all admirable men, and many of "their local reports were most valuable, although now forgotten. "They entered their remarks on printed forms which were regularly posted to them each quarter. In the end the work became too " laborious for Dr. Richardson to carry out;' "4 and attempts to secure official support for the work having failed, the notification ceased.

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Dr. Richardson's personal pioneer effort to secure information as to sickness from different sources, was soon followed by the Metropolitan Association of Health Officers, which, in 1857, organised a combined effort to give authentic information concerning sickness of all kinds attended at the public expense.

The returns included sickness of all kinds attended at the public expense, in hospitals and dispensaries, and by poor-law medical officers, whether outdoor cases or in workhouses and infirmaries. The returns were contributed voluntarily and gratuitously by the respective medical officers of these institutions and the poor law medical officers. The General Board of Health

Op. cit., pp. 49 and 50.

4 Extracted from a private letter of Sir Benjamin W. Richardson to the writer.

undertook to print and circulate the weekly and quarterly tables, and meteorological tables were appended to each publication.

This magnificent voluntary effort for some time appeared likely to prosper. At the most successful period, however, rarely more than 50 of the 109 metropolitan hospitals and dispensaries contributed to the returns. The returns of poor-law cases were, at the best, from only 80 of the 180 poor law medical officers in the metropolis, and the official publication collapsed in November, 1858, before the end of its second year of publication. Perhaps this was in connection with the transfer of the medico-sanitary functions of the General Board of Health to the Privy Council; but we must not lose sight of the significant fact that nearly forty years ago a department of Government was actively engaged in collating and circulating information as to various kinds of sickness in the metropolis. Is it too much to expect that at the present time the Local Government Board should undertake similar duties? (See also p. 13.)

A much more successful attempt was organised in 1860 by the Sanitary Association of Manchester and Salford, Dr. Arthur Ransome being the moving central spirit in it. The work which this association has, through a long series of years, done to advance the science and art-the theory and practice of public health, has been most important; but among the various branches of its work, perhaps its highest claim to permanent gratitude consists in the fact that it proved the practicability of the registration of sickness on a large scale. The tables compiled by this association had one special merit, not shared by those of the Metropolitan Association: the number of deaths among the cases reported were stated, so that a complete comparison between the sickness and mortality in the groups and classes of population included in the reports could be made. The returns seem to have been conscientiously and completely made, thus giving them, as claimed by the honorary secretaries in 1862, a value which no similar "return has ever attained before."

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From this point the history of the attempt to establish registration of sickness is chiefly comprised in the proceedings of special committees of the Social Science and the British Medical Associations.

At the Bradford meeting of the Social Science Association, in 1859, Dr. Rumsey read two papers bearing on the registration of sickness, and on the general working of the system of registration of deaths, and, as the result of the discussion which followed, a committee comprising, among others, Drs. Acland, Farr, Greenhow

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and Southwood Smith, and Messrs. John Simon and Edwin Chadwick, was formed. This committee, in March, 1860, passed a resolution recommending the substitution, as vacancies occur, for the present non-scientific superintendent registrars of births and deaths, of "highly-qualified medical superintendents, whose "scientific acquirements and practical efficiency should be duly "tested by examination, or otherwise, before their appointment." They further recommended, that, in connection with this change the office of superintendent registrar of marriages should be separated from that of superintendent registrar of births and deaths; and that the superintendence of the registration of births and deaths should be combined with that of sickness attended at the public expense, and, as far as possible, that of sickness attended at public institutions. These resolutions were subsequently endorsed by the association, and brought under the notice of the Home Office.

At a meeting of the Lancashire and Cheshire Branch of the British Medical Association, held 24th October, 1862, it was resolved that a sub-committee be appointed "to consider and "report on the best means of carrying out the registration of "disease in large towns." In a circular letter on behalf of the committee, signed by Dr. Ransome, this resolution is quoted, and the importance of such a weekly record of sickness is emphasised. "It would show the influence upon sickness of the varying con"ditions of climate and season, of prosperity and distress, of "trades and manufactures, or of any other circumstances peculiar "to the district, &c."

A committee of the whole British Medical Association was appointed in 1865, at the instance of Dr. Ransome, and for ten subsequent years he prepared valuable reports, from which the following information is extracted:

At a meeting of the British Medical Association held in Dublin, on 9th August, 1867, the form of return proposed by the above committee for the uniform registration of disease was adopted; and in January, 1868, the registration of disease occurring in public practice was commenced upon the same plan, and with the same list of diseases, at Manchester and Salford, St. Marylebone, Birmingham, Newcastle-upon-Tyne, and Gateshead. The returns were made monthly at St. Marylebone, weekly at the other places. Reports of a similar nature had been previously made at all these places for several years; but they began in 1868, for the first time, to be made according to the same plan, and with the same schedule of diseases, as that recommended by the Association.

The same committee of the British Medical Association, in their report for 1870, drew attention to the fact that an influential deputation, headed by Dr. B. W. Richardson, had, in November,

1869, waited upon the President of the Poor Law Board to obtain the registration of disease. Mr. Goschen, who received the deputation, stated that "in spirit he was heartily with the deputation, in its sense of the importance of these returns, and of the advantages of utilising them, and that he approved generally of the suggestions that had been brought before him;" but he pointed out that care should be taken not to impose additional labour upon the "poor-law officers, and that the nomenclature of disease used "should be uniform."

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The committee recommended that a deputation of the British Medical Association should also seek an interview with Mr. Goschen, and should be instructed to state: "1. The importance "to the public and to science of such a registration of disease. “2. The success of the scheme adopted by this Association, and "its employment for ten years in Manchester and Salford and St. "Marylebone, for five years at Birmingham, for four years at "Newcastle-upon-Tyne, and for fifteen months at Preston. 3. That "the method of registration proposed provides for a uniform "schedule of disease. 4. That it need not entail any additional "labour upon the poor-law officers; and 5. That the appointment "of registration medical officers' would not only facilitate the "registration of disease, but would greatly improve other services "of State medicine."

At the meeting of the British Medical Association in 1870 a deputation consisting of Drs. Rumsey, Ransome and others was appointed. Mr. Goschen, in receiving this deputation, said that the arguments in favour of the registration of disease were very clear and strong, and that everyone must accept them. The chief points to be considered were by what machinery it could be carried out, how rapidly, and at what cost. He thought, however, that it would be undesirable for him to go into the matter until the report of the Royal Sanitary Commission had been considered by the Government.

This report appeared in the spring of 1871, and it may be gathered from it that the Commissioners were fully impressed with the importance of the subject, and with the necessity for obtaining sickness returns. No definite plan for this purpose was, however, proposed in their report, and nothing practical came out of the general approval of the proposal.

The British Medical Association continued its appeals to Government for the establishment of a "National System of "Registration of Disease," a memorial to this effect being presented in 1874 to the President of the Local Government Board, and a petition to the same effect being laid before the House of Commons by Dr. Lyon Playfair. Dr. (now Lord)

Playfair emphasised the importance of registration of sickness in these words: "The record of deaths only registers, as it were, "the wrecks which strew the shore, but it gives no account of the "vessels which were tossed in the billows of sickness, strained "and maimed as they often are by the effects of recurrent storms. Registration of sickness would tell us of the coming storms and "enable us to trim our vessels to meet them."

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One by one the towns contributing to the voluntary notification of sickness ceased their work, the efforts of Manchester and Salford being the most protracted and successful. It need cause no surprise that the voluntary co-operative principle has failed in this instance, notwithstanding the pertinacity and enthusiasm of its earlier advocates. "The voluntary principle, so powerful in "the diffusion of Christianity, in works of mercy, in struggles for “liberty, and in scientific discovery, has invariably proved quite unequal to the regular, constant, and universal performance of "laborious official duties, without any hope of profit or of praise." (Rumsey.)

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About this time Dr. Farr wrote in favour of the registration of disease, and his remarks, set forth in the supplement to the Registrar-General's "Thirty-fifth Annual Report," may be here quoted: "The reports of the existing medical officers are of great "practical value, and will become more valuable every day. "What is wanted is a staff officer in every county or great city, "with clerks, to enable him to analyse and publish the results of "weekly returns of sickness, to be procured from every district; 'distinguishing, as the army returns do, the new cases, the "recoveries, the deaths reported weekly, and the patients remain"ing in the several hospitals, dispensaries, and workhouses. "These compiled on a uniform plan, when consolidated in the metropolis, would be of national concern. It has been suggested "that the returns of sickness should, to save time, be sent to "London, and there analysed on a uniform system, as the causes "of death are. That with the present postal arrangements is "quite practicable. The thing to aim at ultimately is a retura "of the cases of sickness in the civil population as complete as "is now procured from the army in England. It will be an "invaluable contribution to therapeutics, as well as to hygiene; "for it will enable the therapeutists to determine the duration "and the fatality of all forms of disease, under the several existing systems of treatment, in the various sanitary and "social conditions of the people. Illusion will be dispelled, "quackery, as completely as astrology, suppressed, a science of "therapeutics created, suffering diminished, life shielded from "many dangers. The national returns of cases and of causes of

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