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Causes of death and their classification

Edward Higgs

As Benjamin Franklin noted: 'In this world nothing can be said to be certain, except death and taxes'. By extension one might think that a 'cause of death' was a quite straightforward concept, but this is not in fact the case. This was an important issue for the General Register Office (GRO), which was the body responsible for administering the system of civil registration of births, marriages and deaths in England and Wales from 1837 onwards. Although the civil registration system had been set up by the 1836 Registration Act mainly for the purpose of recording lines of descent to underpin property rights, cause of death data were also to be gathered. In time this became the basis of a statistical division within the GRO, producing medical data to inform medical science and the public health movement (Higgs, 2004, 1–44).

But in order to make sense of these cause of death data it was necessary for the GRO to place it in a classification system, which for causes of death is known as a 'nosology'. Given the constraints of the printed page and the human powers of understanding, it was necessary to reduce the thousands of causes of death given in death certificates to a few hundred headings (Higgs, 2003). But on what principles was this process of conflation to be undertaken? William Farr, the GRO's medical statistician in the period 1839 to 1879, began by assigning deaths to a single 'primary' cause in the GRO's publications. By doing so, Farr reduced the scope for seeing death in Galenic terms as the action of a multitude of external factors — cold, heat, moisture, aridity, diet, activity or sedentary life-style (the "regimen of the non-naturals") — on differing individual constitutions containing differing mixtures of humours (Niebyl).

Farr's zymotic theories further undermined constitutional or humoural medicine by conceiving disease in terms of the invasion of the body by distinct chemical or biological pathogens (Eyler, 1979, 95–108). On the whole, Farr's nosologies called for the assignment of death to specific diseases rather than allowing for causation in terms of the general effect of environment on the body. It was no longer possible to give the term 'Cold' as a cause of death, one needed to give a particular disease that the cold made the body susceptible to, such as pneumonia. This is very important, given the influence of the nosologies developed by Farr on the later International Classification of Diseases. According to Christopher Hamlin, this can be seen as part of a political process whereby radical demands for better diet, housing and working conditions - an holistic attitude to well-being — could be countered (Hamlin 1998).

Over time the way in which these causes of deaths were grouped in the GRO's nosologies shifted. In his first 'Letter to the Registrar General' in the First annual report, Farr organised causes of death into three groups:

By 1868 Farr was organising diseases under heading such as: 'zymotic diseases' (caused by 'zymots', eventually understood as germs); constitutional diseases; local diseases; developmental diseases; and violent deaths (Thirty-first Annual report of the registrar-general, contents page). By the end of the century the GRO used groupings such as: zymotic diseases, parasitic diseases, dietetic diseases, constitutional diseases, developmental diseases, local diseases, and violence (Sixty-first annual report of the Registrar General, xviii). Thus, specific causes of death were being moved around the GRO's nosologies as medical concepts changed.

However, the GRO had to work hard to establish its own authority within the medical community with respect to the terminology that could be used to describe mortality. The narrowing of the scope of disease causation was certainly not something that was immediately accepted by medical practitioners. Farr had to use the fourth official Annual Report of the Registrar General to refute the recommendation of a sub-committee of the Royal College of Physicians in Edinburgh, chaired by William Pulteney Alison, that causes of death should be classified according to the general seat of disease — 'acute disease of the windpipe' for example - rather than under specific names (Fourth annual report of the Registrar General, 123–7). Similarly, despite the publication of an official nosology in the first Annual report (First annual report of the Registrar General, 93–6), medical informants continued to provide cause of death data in terms of general environmental effects rather than specific diseases. In 1842, Farr published in the Annual report an 'Alphabetical list of diseases' in which such vague terminology was criticised from the point of view of disease-specific mortality (Fourth annual report of the Registrar General, 106–11).

In 1845, the GRO sent out standard medical certificates for doctors to fill in when certifying deaths, and encouraged them to use the terms in a 'statistical nosology' that was available from the Office (Seventh annual report of the Registrar General, 249–314). But even after the introduction of compulsory medical certification of deaths in 1874, there were still problems with the terminology used by medical practitioners. The Office had to resort to sending thousands of death certificates back to doctors in order to get them to provide replies that conformed to the models of disease causation implicit in its classifications (Hardy, 476).

In addition, the use of the terms 'primary' and 'secondary' in relation to cause of death on death certificates from the late Victorian period onwards allowed doctors considerable latitude of interpretation. They could define 'primary' in several ways, either chronologically, or in terms of the most important cause with regard to the termination of life (First and second report of the Select Committee on Death Certification, xvii). The introduction of the term 'contributory' as a variant of 'secondary' on the death certificate caused even more confusion, since it then became difficult to tell whether any 'secondary' cause was regarded as a consequence of the primary, or as of independent origin. Such problems led the GRO to begin to doubt the very objectivity of the concept of a primary cause of death, which had been the basis of its statistical analysis of mortality for nearly a century. In 1927 the order of the statement on cause of death in the death certificate was changed, by calling for the 'immediate' rather than the primary cause first, and then, in order, for any others of which it was the consequence. This then provided a more definite starting point for an analysis of the train of related causes (General Register Office 1929, 145).

REFERENCES

J. M. Eyler, Victorian Social Medicine: The Ideas and Methods of William Farr (London, 1979).

First and second report of the Select Committee on Death Certification, BPP 1893–4 XI.

First annual report of the Registrar General of marriages, births, and deaths in Ireland, BPP 1868—69 XVI. [View this document: First annual report of the registrar-general]

Fourth annual report of the Registrar General (1840–1841), BPP 1842 XIX (423). [View this document: Fourth annual report of the registrar-general]

General Register Office, Registrar General's statistical review for 1927 (London, 1929).

C. Hamlin, Public health and social justice in the age of Chadwick: Britain, 1800–1854 (Cambridge, 1998).

Anne Hardy '"Death is the cure of all disease": using the GRO cause of death statistics for 1837–1920', Social History of Medicine, 7 (1994), 472–92.

Edward Higgs, 'The General Register Office and the tabulation of data, 1837–1939' in Martin Campbell Kelly, Mary Croarkin, John Fauvel and Raymond Flood, eds, From Sumer to the spreadsheets: the curious history of tables (Oxford, 2003), 209–34.

Edward Higgs, Life, death and statistics: civil registration, censuses and the work of the General Register Office, 1837–1952 (Hatfield, 2004).

P. H. Niebyl, 'The non-naturals', Bulletin of the History of Medicine, 45 (1971), 486–92.

Seventh annual report of the Registrar General (1843–4), BPP 1846 XIX (727). [View this document: Seventh annual report of the registrar-general]

Sixty-first annual report of the Registrar General (1898), BPP 1899 XVI (C.9417). [View this document: Sixty-first annual report of the registrar-general ]

Thirty-first annual report of the Registrar General (1868), BPP 1870 XVI (C.97). [View this document: Thirty-first annual report of the registrar-general ]