study of infant mortality is undertaken is a prerequisite if the work is to be done in the most effective and economical way. With the present status of birth registration in the United States, the bureau is not free to make its choice of territory to be investigated, solely according to location, industrial conditions, racial composition of the population, and other factors legitimately influencing such a choice, but must consider also the effectiveness of birth registration. As an illustration of the extent to which the limitation operates it may be cited that in selecting a single small city for beginning its first investigation of infant mortality the bureau, on account of the generally prevailing defective registration, had less than a dozen cities from which to choose.

Probable extent of infant mortality.-There are no complete records for the United States as a whole which show how many babies are born and how many babies die year by year, but Dr. Cressy L. Wilbur, vital statistician of the Census Bureau, estimates that approximately 300,000 babies die yearly in the United States before reaching the age of 1 year. A calculation based on census figures indicates that in the 10-year period between the last two enumerations of the census more than 2,500,000 of the children born in this country died before they reached the age of 1 year.

The details of these figures are given below, column 3 presenting an estimate for the entire country based on the true figures in columns 1 and 2:

1 Figures taken from Bureau of the Census Mortality Statistics for the respective years. 2 Figures taken from Bureau of the Census Mortality Statistics for 1910. On the basis that the ratio of infant deaths to population is the same for the country as a whole as it is for the registration area.

What do these figures mean? In terms of total population, it is as if Chicago, the second city of the United States, were to be wiped out of existence once every 10 years, not a single life being saved. It means the annihilation each decade of a population as large as that of the State of New Jersey, and greater than that of such States

as Alabama, California, Iowa, Kentucky, Minnesota, North Carolina, Tennessee, Virginia, or Wisconsin. In fact, only 10 States in the Union had each in 1910 a population as great as the infant mortality for the preceding decade. This mortality nearly equaled the combined population of Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, and Nevada.

Social significance of infant mortality.-A report of the International Congress on Prevention of Infant Mortality, prepared under the direction of Prof. Dietrich, of Berlin, said:

It was formerly believed that the rate of mortality among children who had not reached the first anniversary of their birth was a wise dispensation of nature intended to prevent children with a weak constitution from becoming too plentiful. To-day we know that a great infant mortality is a national disaster-on the one hand because numerous economic values are created without purpose and prematurely destroyed, and on the other because the causes of the high rate of infant mortality affect the powers of resistance of the other infants and weaken the strength of the nation in its next generation.

Dr. J. W. Schereschewsky, of the United States Public Health Service, in a recent address said:

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The mere business of being a baby must be classified as an extra-hazardous occupation, since the perils which ever encompass human existence are never so bitterly emphasized as in the first year of life. A necessary sequence to a high infant mortality rate is the larger number of children who, having weathered the storms of the first year, reach the haven of comparative safety of the other years of life in a battered, weakened, and crippled condition such as forever handicaps them in becoming efficient social units. It is therefore in the nature of an axiom that, in the degree to which the infant mortality rate is lowered, to a far greater degree will we diminish the great army of defective and degenerate children among us.

Infant mortality preventable.-If none of these infant deaths was preventable, we should have no stimulus for trying to find a remedy. But we are assured by the highest authorities that the number of deaths can be greatly reduced if we apply the best methods of the growing science of sanitation. Indeed, one great authority says that if children were well born and well cared for the infant mortality rate would be negligible. The New York State Department of Health has adopted for its legend these words: "Public health is purchasable; within natural limitations a community can determine its own death rate." Is not this statement a challenge to the patriotism of all public-spirited citizens? If it can be shown that birth registration can aid in preventing infant mortality, shall we not secure and utilize it?

Birth registration helps to reduce infant mortality.-The birth record is a safeguard for the newly born child. It furnishes to the health officer and the visiting nurse the name and address of every baby, and the community is thus enabled to send to the family in adverse circumstances a knowledge of hygiene and sanitation which

may save the life of the child. Dr. S. Josephine Baker, director of the Bureau of Child Hygiene of the New York City Department of Health, says:

The birth record is perhaps the starting point of about 75 per cent of our effective baby-saving work. * ** Under the present system we use the information contained on the birth returns in order that a nurse may be sent at once to see the mother and put her in touch with the various agencies that may be of service to her and at the same time give her instruction in baby care.

Dr. W. C. Woodward, health officer of the District of Columbia, describes in the following paragraph the reduction in the infant death rate which has taken place in the District within the last few years. It will be seen that the registration of births furnishes the indispensable starting point of his work:

In the District of Columbia between 1907 and 1912 death rates of white infants in the first year of life living on streets fell from 121 to 100 and among those living in alleys from 213 to 98; and among colored infants living on streets from 299 to 269 and among those living in alleys from 307 to 262. These rates are computed on the basis of the population corresponding in each instance in age, race, and location. Unfortunately the births registered in the District during the years named were not distributed according to alley and street residence of the mothers, and death rates can not be computed on the number of children born. That the diminished mortality is not as a whole due to the diminution in the number of births is shown, however, by the fact that from 1907 to 1912 the death rate of all white infants, computed on the basis of reported births, fell from 113 to 90, and the death rate of colored infants, similarly computed, fell from 263 to 208.

No one will deny, of course, that many factors tending to decrease infant mortality have been operative during the period covered by the foregoing statement. Certainly, however, some weight must be given to the fact that as early as 1907 the health department of the District began sending to the mother of each child born, upon the receipt of the birth report, printed instructions relative to the care of her baby, and that in 1908 the health department arranged for nurses in the service of the Instructive Visiting Nurses' Society to visit promptly every baby reported as having been born under the administrations of a midwife and certain other cases where there was reason to believe that the child had been born amid destitution and ignorance, and these measures for the prevention of infant mortality have been kept up ever since.

The report for 1911 of the committee on birth registration of the American Association for Study and Prevention of Infant Mortality, of which Dr. Wilmer R. Batt, of Harrisburg, was chairman, says:

The birth registration bureau in any locality should be the starting point of every line of prevention of infant mortality. Why should the visiting nurse or the medical inspector go groping blindly around the courts and tenements seeking babies, when a properly conducted birth registration bureau should send them on their journeys with absolute directness? * * * There is ample ammunition upon every standard birth certificate to equip every inspector in advance of house visitation with knowledge of the most vital character. The visiting nurse knows the plague spots of her particular district; she knows where poverty and overcrowding exist, where contagious diseases thrive, where dirt abounds, and where sunshine never penetrates. The mere statement of locality upon the birth certificate should bring the individual picture before her.

Prevention of blindness of newborn.-Ophthalmia neonatorum, or blindness of the newborn, is generally estimated to be responsible for at least 25 per cent of all cases of blindness among children under observation in schools for the blind. According to all authorities the disease is easily preventable. Certain cities, through their public health departments, are now furnishing the standard remedies free of charge and are striking at the trouble through their increasingly effective staffs of municipal nurses. It will be readily seen that any follow-up system of this character will be furthered by the prompt registration of births. In several States the birth certificate is used as a means of obtaining information as to whether the attending physician or midwife used any preventive for ophthalmia neonatorum. In some States the failure to answer the question upon the birth certificate "Were precautions taken against ophthalmia neonatorum?" renders unlawful all bills or charges for professional services in connection with the case. The birth certificate used in Boston contains a special notice to physicians in the form of an extract from the law covering the reporting of cases of ophthalmia neonatorum.

Promptness a factor. The promptness of the notification of births is an important factor. The commissioner of health of Milwaukee in his 1912 report says that while now the reporting of births is prompt in that city, and fairly satisfactory, "in former years, when physicians and midwives were given 30 days in which to file reports, the reports were either forgotten or overlooked, with the result that 45 per cent of such births have never been reported and therefore are not on file in this department." Dr. Woodward, health officer of the District of Columbia, says: "Promptness is a first requisite for preventive work." This is evidenced by the study of such vital · statistics as we have. Of the 154,373 infants in the registration area in 1910 who died before they were 12 months old, 14,946 lived less than one day, 36,351 less than one week, and 58,089 less than one month. If these children who die within the first few weeks of life are to be benefited by registration, obviously the registration must be prompt. We need quick notification, not for statistical poses, but for the purpose of saving lives. It has been demonstrated in certain American cities, and in England (where the immediate notification of births act requires registration within 36 hours), that prompt and authoritative notification serves greatly to increase the efficiency of the baby-saving agencies.

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Immediate effects.-The manifold ways in which cooperation between public and private effort tends to conserve the public health of infants is of course familiar to the general public in the great cities of this country. It is safe to say that wherever an area especially unfavorable to infant life has been studied and helped by

doctors and nurses and sanitary authorities there has been shown an immediate lessening of infant deaths. Thus a certain area of Philadelphia, a registration city, where vigorous baby-saving work was undertaken, showed a reduction in 1911 of 11.3 per cent in all deaths under 1 year from the 1910 figures and of 34.6 per cent in diarrheal deaths under 2 years. The beginning of the most effective work of this type must be the prompt recording of births, so that the doctors and nurses will know where to begin.

Results in New Zealand.-In New Zealand, where birth registration has existed for years, according to the last report of the Society for the Health of Women and Children, the city of Dunedin shows a stable and sustained decline in the infant death rate from 1907, when this society began its operations, until in 1912 it was only 3.8 for every 100 births, probably the lowest rate in the world. The work of the society is described in a pamphlet issued by the Children's Bureau1 which shows the way in which organized groups of citizens direct the work, cooperate in locating the places where assistance is needed, and through visiting nurses, correspondence with mothers, instruction of young girls, etc., stimulate interest in the health of the community. Pamphlets on the care of the baby are published by the Government and issued free to parents on the occasion of registering a birth. A letter from Mr. William Jenkins, foreign correspondent for the society, points to the value of registration in its baby-saving work, and says "Registration of births and deaths in New Zealand is accurate. Failure to comply with the Government regulations in this respect is a very serious offense."

Vital statistics the barometer of infant mortality. When we have adequate birth and death registration all over the country, the publichealth authorities can watch the infant mortality rate as the weather man watches his barometer, and they can pick out areas of social storm just as the weather man traces areas of ordinary storm, but with this one great difference: With our present knowledge the weather man can not change the weather, but the public-health official can change the infant-mortality rate, for, as the expert medical men tell us, half of the present infant mortality could be prevented if the methods already known to the medical and sanitary science could be given general application.

RELATION OF BIRTH REGISTRATION TO EDUCATION, EMPLOYMENT,

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Birth registration a protection for children at school and at work.— Enforcement of child-labor laws and compulsory education laws should dovetail and both must rest on a basis of birth registration. Our legislatures enact laws prescribing ages within which children

1 New Zealand Society for the Health of Women and Children, Children's Bureau, Department of Labor, Washington, D. C.