Annual Reports of the War Department

of alcoholic liquors, or by prostitution, or whether the stillbirths are produced by neglect of the mothers during the period of pregnancy. All of these, without question, are contributing causes.

The number of employees available for the statistical work is not sufficient to enable the department to make the statistics necessary to properly determine to what extent each one of these causes may be responsible.

GENERAL MORTALITY RATE.1

It is not my desire to express any difference of opinion from the one stated thereon by Dr. Gómez Brioso, but at the same time I desire to invite attention to the exact correspondence of this tremendous increase in deaths with the scarcity of food supplies which occurred during the early months of the year and which was distinctively prophesied in previous reports, and specially in the personal report made to you immediately after the cyclone in the month of August, 1916:

"Studying the mortality rate in Porto Rico this year is extremely important, not only because of the high rate, amounting to 28.5 per 1,000, but also because of the deductions which we are compelled to make in comparing the rates during the years from 1910 to 1917.

"This report is accompanied by a graphic statement of this comparison, the mortality occurring during the seven years being indicated month by month with lines of different forms. In this way we can see that the year of least mortality was the calendar year of 1914, which began with 1,959 deaths during January and closed with 2,205 in December, giving a monthly average of 1,861 deaths, the months of February, March, April, May, August, and September being those in which the rates were below the average, and the remaining months of January, July, June, October, and November those in which the rate of mortality exceeded the average. I invite your attention specially to the year 1914, because the mortality was 18.9 per thousand, which might be considered as ideal in Porto Rico, and this rate was obtained after the sanitary work was carried out so actively in the country from the year 1911, in which the service of sanitation was organized and immediately after the epidemic of bubonic plague, which give place to a complete cleaning of the island carried out with exceptional energy and good direction. The general mortality in this curve is exact, but the rates correspond to the calendar years 1913 and 1915, which show 20 per thousand and 21 per thousand in 1915. To these follows in importance those of 1910, showing 23.9 per thousand and 23.6 per thousand in 1912, as compared with those of 1910 and 1916, which showed a marked increase, the first being 25.1 per thousand and 24.5 per thousand in the latter. The estimates corresponding, not to the calendar years, but to the fiscal years 1916 and 1917, give a notable increase in mortality, which, as already stated, reaches 28.5 per thousand. If we examine carefully the mortality rates and compare them with the death rate, we see that outside of the light increase brought by the epidemic of measles in infantile population, there is not sufficient reason to explain in a definite manner the cause of the increase in the deaths. Studying separately as to the different kinds of diseases which might cause this increase, we note that the increase is general; but we are compelled to believe that the greater responsibility follows upon those rates which correspond to affections of the gastrointestinal apparatus and afterwards of the respiratory apparatus.

"It is not only the influence of the climate; not only the habits and customs of our people; not only the need that in general has been felt in the country lately, which serves as determining causes for the increase in the death rate. These being direct consequences of the ignorance of hygiene and of the defects of education, must not be considered responsible for the facts that we are studying, for these same conditions existed during the years 1913, 1915, and specially in 1914, when the mortality rate was reduced to normal terms.

"Time and space at our disposal will not allow of the extensive consideration of this question, nor of setting forth all the reasons that we might have to think that the mortality rate depends directly upon the form, manner, and time in which the work of sanitation is carried on throughout the island; but of the special attention which may be given to the kind and conditions of food generally used in the island. It is clear that the greatest aid to complete success in this matter, as was noted in the year 1914, consists in the education and cooperation of the people and in the instruction which our public schools give to the men of to-morrow with regard to the importance of health, as well as of the principles and rules of personal and collective hygiene.

1 The study of the question of mortality rate is translated directly from the report presented by Dr. José Gómez Brioso, chief of the bureau of statistics.

"On the other hand, from a study of this graphical statement of the mortality rate, we note that these curves descend in a decided and notable manner during the months of February and March, continuing straight during the months of April, May, and June, and beginning to ascend during July, August, September, and October, until in November and December."

The lowest points of all these curves correspond to the months of February, April, and May, and the higher to those of October, November, and December. It must be noted, however, that during the first six months of the calendar year 1917 the mortality curve is frankly rising until in the month of June it reaches the number of 2,574 deaths, the highest observed during the seven years.

A curve of the average mortality rate during the years 1910 and 1917 is inclosed. It shows clearly what is the actual situation which must be the object of our study in order to determine the causes and arrange the conditions with regard to the actual necessity.

INFANTILE MORTALITY.

One of the most important aspects of the study of mortality is that which refers to children; that is to say, to those less than 1 year of age. The mortality rate, as can be seen from the attached curve, is considerably increasing. The highest points during the year correspond to the months of June, 1916, May and June, 1917. The lowest curve corresponds to the month of September, 1916. I refer to the study of 18 months, counting from January, 1916, up to June, 1917. It will be seen that during the first six months of 1916 there were 3,515, as compared with 3,920 in the second six months, and 4,490 in the first six months of 1917. These figures therefore being 3,315, 3,920, and 4,490, respectively. During the fiscal year the number is 8,410, as compared with 6,951 in the previous year, giving a difference of 1,459.

The infantile mortality rate is 19.9 per cent of the general mortality rate and 6.8 per cent of the population. Comparing this rate with that of previous fiscal year, the infantile mortality rate is increased by 4.7 per cent, since in the previous year it was 15.17 per cent, and as compared with the general mortality rate it is 1.9 per cent less, since that of the previous fiscal year was 26 per cent, whereas with respect to the general population it is increased in 1.10 per thousand, as the rate corresponding to the previous year was 5.71 per thousand.

Studying this infantile mortality and noticing the causes which produce it, we see that due to diseases of early infancy there are reported only 195 as compared with 180 in the previous year; from lack of care, 147 as compared with 177; from bronchitis, 809 as compared with 583; from broncho-pneumonia, 385 as compared with 342: from infantile tetanus, 674 deaths as compared with 726; from rickets, 446 as compared with 353 in previous year; from congenital debility is noted the alarming figure of 1,380 as compared with 1,138 in previous year. I desire to call special attention to the figures corresponding to each disease as a cause of these deaths, because of measles there have been 155 deaths as compared with none in the previous year. It will be noted that the mortality rate is very low on the high number of cases occurring in the country during the epidemic. From undefined causes there occurred 140 deaths as compared with a like number in the previous year. This induces us to believe that generally there is no great amount of care taken in extending certificates of deaths and in assigning the causes thereof. Finally, from diseases included in the classification or diarrheal and enteritis, there occurred 2,773 deaths as compared with 2,240 in the previous year. The rate from this cause of death is exceedingly high this year, with an increase of 533 cases. But at the same time it should be noted that the rate of the previous year was also exceedingly high, which shows that the diseases of the digestive apparatus are those responsible for the high rate of mortality in the fiscal year to which this report refers.

The lack of care taken with nursing infants and the complete abandonment of the most elemental rules or hygiene and the ignorant conditions of the persons in charge of the care of nursing infants give rise to the fact that nearly one-fifth of the children born died during the first year of their life.

This shows that the evil increases with the bad quality of the food supply which is generally used in a Porto Rican home. The writer understands that it is imperatively necessary for the country, and specially in the cities of dense population, to attend to the sick children not only by the creation of hospitals but also by carrying to their homes by personal instructions the knowledge of the obligations of mothers toward their children until the age in which they can care for themselves, specially.

in the first months of their lives.

We are not mistaken nor are we exaggerating in believing that between tuberculosis in all its forms and the lack of care in the feeding of nursing infants, there is a considerable diminution not only in the richness of Porto Rico, but also in the index

of strength, and therefore of active men in society. Although the race may not diminish owing to the strong increment of population, its energies are largely weakened and it becomes unable to offer to the common good a healthy contribution for the progress of the island.

Table showing deaths from measles in some towns of the island during certain months of the fiscal year 1916-17.