ERRORS IN DEATH REGISTRATION IN THE INDUSTRIAL POPULATION OF FALL RIVER, MASS.

BY ARTHUR REED PERRY, M. D.

The value of vital statistics is coming to be generally recognized and the desirability of extending the registration area as rapidly as possible is being insisted upon more and more. No one could desire to minimize the importance of a complete registration of births and deaths, but in the course of some recent investigations into the prevalency and contributory causes of early death in the cotton manufacturing industry the writer has come across facts which make him feel that a large part of the present interest in mortality matters could be quite as profitably directed to increasing the accuracy as to extending the field of death registration.

These investigations were carried on in Fall River, Mass., for the purpose of obtaining facts as to the death hazard of male and female cotton operatives of each workroom occupation as compared with the corresponding hazard of persons of like age and sex who are not cotton operatives. The underlying idea of the studies is that "accurate age group mortality statistics of a given occupation as expressed in death rates per 1,000 of each specified population constitute the only indisputable evidence as to the healthfulness or unhealthfulness of that occupation to the persons engaged in it." The earlier of these studies, covering the period from 1905 to 1907, inclusive, has already been published.1 The second and more intensive supplementary study which is to appear at an early date covers the succeeding five years. The two studies therefore cover the Fall River mortality within the age period 10 to 64 years for a period from 1905 to 1912, inclusive. This is roughly equivalent to the deaths in an almost exclusively industrial city of a million people for the period of a single year.

1 Causes of Death Among Women and Child Cotton Mill Operatives, Vol. XIV of Condition of Woman and Child Wage Earners, Senate Document 645, Sixty-first Congress, first session, 1912, p. 430.

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In order to secure the accurate data required, the official certificates of all deaths, aggregating nearly 7,000, that had occurred within the periods covered were first copied by employees from the registrar's office. Visits were then made to the latest Fall River residence of each decedent, where the information of the death certificate was supplemented by fuller details gained from relatives, or, if there were none of these, from friends of the deceased, respecting the latter's family, habits as to drug addiction, occupational and conjugal experiences, exposure to communicable disease, and other facts of possible significance in explaining why the wage earner had died prematurely.

Error in official registration of death.-Though this inquiry at the home of the decedent was intended solely to provide data supplementary to the explanation of the death furnished by the official certificate, nevertheless, at an early stage of the investigation it became evident that these official records contained errors as to facts, and also omissions of facts which in their results were almost as misleading as actual misstatements.

These errors were of three kinds: The actual cause of death might be misstated; the immediate cause of death might be given accurately, but the existence of other debilitating factors which probably had much to do with bringing about death at that time might be passed over unrecorded; and the decedent's occupation might be incorrectly given. The first of these errors appeared most numerously in cases in which tuberculosis was the real though not the recorded cause of death; it also played an important part in concealing the number of deaths due to childbirth. The second also was found in connection with parturition cases. The third affected both operatives and nonoperatives, though in different degrees, some of each class being assigned to the other. The extent to which each of these errors prevailed, and the degree to which it was possible to correct the misleading data, will be discussed somewhat fully.

Error in the official record of deaths from tuberculosis.-There can be no doubt that the tuberculosis rate was diminished by inaccurate statement of the cause of death on the official certificate. In a large number of cases the cause of death certified to by the physician was contradictd by the history of the decedent's illness as reported by relatives. Thus, in cases in which the physician's certificate gave some such equivocal cause of death as bronchitis or hemorrhage, or some terminal conditions, such as broncho-pneumonia or heart failure or debility, relatives of the decedent testified that for possibly a year or more before death the decedent had had a bad cough, had expectorated profusely, had become extremely emaciated, had suffered

blood, and was the second or third in the family who had "died of consumption" within the last few years, or had parents one or both of whom had died long ago after years of such tuberculous manifestations. Such testimony as to matters of simple fact seems entitled to considerable credence.

Numerous instances of careless certification can be shown.

A French-Canadian woman, aged 23 years, married four years but never pregnant, for 7 years a spinner until she left the mill because of cough two years before death, was certified by her attending physician (now dead) as having died from "bronchitis." Another attending physician whose name is upon death certificates of two other family members did not "recall" this case. The seemingly tuberculous mother and brother of decedent affirmed that the latter had died from tuberculosis, " just as her father and three sisters did." These last mentioned four are certified as having died of tuberculosis between March, 1910, and August, 1912, and are so recorded in this study. Another sister was recommended to a tuberculosis hospital October, 1909, and is said to have recovered. This case was scheduled as nontuberculous.

Sometimes the statement of the certificate as to the cause of death was directly contrary to other official records. Thus one woman of 30 who died one hour after having miscarried at three months was certified as having died of congestion of the liver, and nothing on the certificate intimated that either tuberculosis or pregnancy was even a contributory death factor. Yet the decedent's brother and sister had died from tuberculosis, and she herself had been an inmate of the city tuberculosis hospital seven months before she died. The physician who signed the death certificate did not remember whether the case was tuberculosis or not. The hospital records, however, state that the case was one of tuberculosis. This case was scheduled as tuberculosis complicated with parturition.

A special canvass was made to see just how commonly tuberculosis was misreported on the official death certificate. There were 188 cases in which there was marked discrepancy between the cause of death as given on the death certificate, and the cause of death suggested by the history of the decedent's illness as given by the family. Every physician who had signed one of these 188 certificates, if still living and still in Fall River, was visited and questioned about the death. By this process the probable correctness of the certified cause was satisfactorily established concerning 31 of these cases.

1 For other illustrations of discrepancies between the cause of death as given on the death certificate and the statements of relatives as to the symptoms manifested by the patient, or the doctor's informal opinions as to the disease, see the earlier study already referred to, Causes of Death Among Woman and Child Cotton Mill Operatives, pp. 44, 45, Vol. XIV of the Report on Condition of Woman and Child Wage Earners in the

In 65 of the remaining 157 cases no further information was obtainable, because the certifying physician had either died or left Fall River, or else professed inability to remember and no other attending physician could be found. In not a few of these 65 cases the histories indicated overwhelmingly that these deaths were due to tuberculosis. Nevertheless the certificates were taken as correct unless an admission was secured from the certifying physician that the recorded cause of death was incorrect. Consequently these 65 cases have been counted as correctly certified.

The remaining 92 cases are either admittedly or demonstrably cases of tuberculous deaths. These have therefore been classed as tuberculous throughout this study. These 92 cases may be divided into the following classes:

1. Those in which the certifying physician unequivocally stated the cause of death to be tuberculosis. These numbered 70.

2. Those unequivocally vouched for as tuberculous by a physician who had attended the decedent in his last illness but had not signed the death certificate. Recourse was had to these other physicians only because in every one of these cases the physician who had signed the certificate had either died, left Fall River, or forgotten all about the case. This forgetfulness is explained by the fact that the signers of the certificate were sometimes city physicians, who had responded. to an emergency call and possibly had seen the decedent professionally only once. These cases numbered 12.

3. Those who, after a sputum examination, had been recorded on city or hospital records as tuberculous. Of these there were five.

4. Those stated by the certifying physician to have been "tuberculous probably." Two of these had not been certified as tuberculous, because no bacteriological examinations of the sputum had been made, "and so," said the physician concerning one of these, "though I knew the case was tuberculosis I couldn't actually swear it was." This group likewise numbered five.

As a result of this special canvass, it appears that not improbably one-sixth (17 per cent) of all the fatal tuberculosis in the city was misreported under nontuberculous diagnoses.

REASONS FOR ERRONEOUS CERTIFICATIONS OF DEATH.

The question of course arises why the true cause should be so often ignored or misleadingly reported on the death certificate. There seem to be several reasons for this. Some persons are sensitive as to the existence of a case of tuberculosis in their family and would seriously object to having such a cause recorded upon a certificate.

even in cases where no such prejudice exists. But apparently by far the most effective reason is the attitude of some of the insurance companies which may delay payment of. policies of decedents officially certified as having died from tuberculosis and which also not uncommonly refuse to insure other members of the family of such a decedent. Physicians when asked about these variant cases occasionally admitted that the certificates were designedly misleading, but justified them on the ground of personal financial expediency arising from intense medical competition, and on the added ground that sometimes only through such registration practices could the decedent's family secure promptly the amount they were entitled to from the insurance companies.

Errors in the official record of deaths from parturition.-Here, as in connection with deaths from tuberculosis, cases were found in which the record was absolutely false, cases in which investigation proved the death to have been really due to childbirth, but in which the official certificate gave some equivocal or designedly misleading term to designate the cause. But in addition to this, certificates of female decedents were often seriously defective in that they failed to give parturition as a contributory cause of death even when a pregnancy had terminated within so short a period before the death that it could hardly have failed to be a very important factor in bringing it about. Since the death certificate is supposed to give the contributory as well as the main cause of death, it is evident that such an omission may have almost as misleading effects as the failure to designate properly the principal cause of death. Indisputably these omissions have served to obscure the real risks involved in pregnancy.

Let us take up first the cases in which the official certificates contained absolutely erroneous statements as to the cause of death. In 34 cases in which death was immediately and indisputably the direct consequence either of parturition or of its gross mismanagement, the death record contained not the slightest intimation that pregnancy or childbirth had been in any way the cause, or even a contributory cause of death. In one case, for instance, a woman of 32 died without having regained consciousness after an operative delivery. Her death was certified as due to shock, with no intimation that four hours before death a baby had been born. In another case in which the certificate gave hemorrhage as the cause of death, investigation proved that it was due to intentional abortion. In another case a woman died one hour after a forceps delivery. The certificate ascribed her death to embolism, without even a suggestion that parturition had played any part in bringing it about. Cases of this