NATIONAL CENTER 

For HEALTH STATISTICS 

VITAL and HEALTH STATISTICS PROPERTYOFTHE 

ANALWICAL STUDIES	 WM.ICATIONS ERANCII 

~fNTORIALLIBRARY 

Changesin ‘Mortality Trends, 

EnglandandWales 

1931=1961 

A study of trends in the death rates 

Wales ancrlyzed by sex, age, and cause 

of a survey of trends in the United 

countries. 

Washington, D.C. 

II S. DEPARTMF~T OF 

HEAITH, :DUCATION, AND Vvt LFARE 

John W. Gordner 

Secretary 

in England and 

of death as part 

States and other 

November 1965 

Public Health Service 

Luther L. Terry 

Surgeon General 
Public Health Service Publication No. 1000-Series 3-No. 3 

For sale hy the Superintendent of Documents, U.S. (lovermnent I’rinting Office 

Washin~ton, D. C., 20402 - Price 40 cents 
NATIONAL CENTER FOR HEALTH STATISTICS 

FORREST E. LINDER, PH. D., ~&’?C~O?’ 

THEODORE D.WOOLSEY,~@4tY ~;f’~C~OT 

OSWALD K.SAGEN,PH.D.,~$fhtant~hwtor’ 

WALT R.smhaom, M,A.,Statistical Aduhor 

ALICEM.WATERHOUSE, M.D.,Medical ~chifof’ 

JAMES E.KELLY,D.D.s.,Dental Advisor 

LOUISR,STOLCIS, M.A.,
Executive. Oj3cer

OFFICEOF HEALTH STATISTICS ANALYSIS 

IWAOM. MORXYAMA, PH. D., Cln’tf 

DIVISIONOF VITAL STATISTICS 

ROBERTD. GROVE,PH. D., Chief 

DIVISIONOF HEALTH”INTERVIEWSTATISTICS 

PHILIP S. LAWRENCE,Sc. D., Chief 

DIVISIONOF HEALTH RECORDSSTATISTICS 

MONROEG. SIRKEN,PH. D., Chief 

DIV1S1ONOF HEALTH EXAMINATIONSTATISTICS 

ARTFNJRJ. MCDOWELL, Chief 

DIVISIONOF DATA PROCESSING 

SIDNEYBINDER, Chief 

Public Health Service Publication No. 1000-Series 3-No. 3 

Library of congress Catalog Card Number 65-62150 
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CONTENTS


Page 

Introduction


Mortality Trends in England and Wales, 1841-1961------------------------

Validity of the Data ----------------------------------------------------


Administrative Changes


Advances in Medical Care


Methods of Classification----:---------------------------------------


Selection of Time Periods


Selection of Disease Categories


General Trend of Mortality, 1931-61


Age Group ------------------------------------------------------------


Infant Mortality Rates—Under 1 Year --------- .-----


Preschool—1-4 Years


School Child-5-14 Years


Adolescence and Early 20’s—15-24 Years


Young Adult—25-34 Years


The Adult—35-44 Years


Early Middle Age-45-.54.Years


Late Middle Age—55-64 Years


Retirement Age—65-74 Years


Old Age—75-84 Years


Senescence-85+ Years


Male to Female Mortality Ratio -----------------------------------------

Disease-Specific Mortality


Infectious Diseases


Neoplastic Diseases


Cardiovascular Diseases


Respiratory Diseases


Violent Maths


Calculated Age Trends


Discussion .-------_-

Summary and Conclusions


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24 

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30 

30 

33 

34 

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36 

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38 

39 

41 

42 

43 

45 

48 
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THIS REPORT is the third in a series of analytical studies from the 

Office of Health Statistics Analysis designed to ascevtain causes underlying the change in mortality trend observed in the United States and in 

a number of count~ies in recent years. 

These studies aye part of a program of the Office to encourage observation and interpretation of national trends by contyacts with responsible 

investigato~s in va~ious countries, in oyder to pvovide clues foy comparison with findings in the United States and other countyies. 

This analytical study of moytality trends in England and Wales examines 

the effects of certain economic, social, and medical changes on mortality and discusses the prospects for future changes in mortality. 

When allowances are made foy aytifacts of diagnosis and coding, a clear 

pattemz can be seen of declining mortality from infectious and YespiYatoyy diseases, little change foy neoplastic diseases and violence, and 

.gYadual incyeasefor vasculay diseases. In England and Wales the average age of the populatio~ is still increasing so that the death rate will 

vise in the futzme unless majo~ changes occur in the prevention and cuve 

of coronavy ayteyy disease. Except foy reduction in cigarette smoking 

theye is no major advance in medicine or public health in pyospect that 

is likely to altey the main tyend in mortality, which has shown no improvement in the last few yeays. 

The methodology, findings, and conclusions aye those of the investigator. 

SYMBOLS 

Data not availilble ---, 

Category not applicable . . . 

Quantity zero ­

ouantity more than O but less than 0.05---- 0.() 

Figure does not meet standards of 

reliability or precision * 
CHANGES IN MORTALITY TRENDS:


ENGLAND AND WALES


Hubert Campbell)l M.A., M.B., Senior Lectwev in Medical Statistics, Welsh National School of Medicine, and Statistician to the Epidemiolo@”cal Research Unit, South Wales 

INTRODUCTION eases is such that it would retard the downward course of the total death rate. 

In a previous report from the National That report also made a comparison beCenter for Health Statistics (Series 3, No. 1) tween the rates in the United States with those 

it was shown that there had been a recent of other countries in Europe, South America, 

change in the mortality trends for the United and Asia; and many of these countries showed 

States as a result of which the crude death similar trends. The improvement in certain 

rate had been more or less stationary for countries such as Chile and Japan were very 

the decade 1950 to 1960. In view of the med- marked indeed; whereas those in Norway, Sweical and social changes in the postwar years den, Denmark, and the Netherlands were roughly 

this failure of the crude death rate to im- similar to those experienced in the United States. 

prove was , surprising, and the report (Series In England and Wales, however, the crude mor3, No. 1) was a detailed analysis of the rea- tality rate had remained constant for over 30 

sons which lay behind this trend. It was con- years despite very large advances in social 

eluded that the recent changes in the trend and medical care. It is the purpose of this 

in the United States could not be attributed report to analyze in much greater detail the 

to the aging of the population or to artifacts trends that underline these figures in Engin calculating the mortality rate but stemmed land and Wales. 

from two other factors. The first was that 

the reduction of mortality due to infectious 

diseases had been so successful that there MORTALITY TRENDS IN ENGLAND 

was little possibility y of further improvement, and 

the second was that the diseases which were 

now prominent among the population of the AND WALES, 1841-1961 

United States were chronic degenerative diseases for which there had been no great im- It is possible to examine trends of comprovement in mortality trends in the past and parable mortality data in England and Wales 

none were likely in the near future. The rate for a longer period than in almost any other 

of change of these trends in the chronic dis - country except Sweden and to examine whether 

similar trends have appeared in the past. 

Civil registration of Births, Deaths, and 

Marriages was introduced by the Act of Parlhlortality rates by age and sex for each of the main causes 

of death for the individual years 1931 through 1961 may be ob- liament, 6th and 7th, William IV, Cap 86 in 

tained from Dr. H, Campbell, Welsh National School of h!edi- the year 1836. When this act was passed, repcine, The Parade, Cardi ff. The fee is $3.00. resentatives of the medical profession agreed 

1

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-- -- -- --- --- -----

to pledge themselves “To give in every in- many of the social reformers of the early 

stance that may fall under our care an au- Victorian period. Within 5 years several acts 

thentic name of the fatal disease, to procure were passed regulating employment in factories 

a better registration of the causes of death, and mines and the conditions in public health 

being convinced that such an improved Reg- and industrial hygiene, but there was no imistration cannot fail to lead to a more ac- provement in the mortality rate for at least 

curate statistical account of the prevalence of 30 years.


particular diseases. ” The period 1841-1961 (table A and fig, 1)


The work of registration began in July may be divided into four eras, each covering 

1837, and the new Registrar General appointed approximately one generation of 30 years, 

Dr. William Farr as abstracter “To prepare In the generation from 1841-71, which coan accurate statistical account of mortality in incided with the active professional career of 

England and Wales. ” There were preliminary Dr. Farr, mortality remained relatively conreports for the years 1838-40, but the first stant at about 22 deaths per 1,000 persons; 

detailed analysis of mortality was published and even when the rates are standardized for 

in 1841 which was a censal year, and similar changes in the age structure of the populareports have continued to appear annually. These tion, there is no evidence of any improvement. 

earlier reports shmked the conscience of so- It would appear that the concentration of popciety, and their effect on political life was con- ulation in large industrial cities more than 

siderable. They provided the ammunition for counterbalanced the advances in medical sciTable A. Death rates per 1,000 Population and standardizedmortality ratios (1950-52 

st&dard) by-sax: England and Wales, 1841-1960 

Year Both II Male Female sexes I ZzEEIEE 

Death rate per 1,000 Standardized mortality 

population ratio 

1956-60---------------------------- 11.6 12.3 10.9 91 94 89


-55---------------------------- 11.i’ 12.5 10.9 

1946-50---------------------------- 11.8 12,8 10.9 1:; ;: 1:; 

1941-45---------------------------- 12.8 15,1 11.1 112 110 113 

1936-40-----------” 12.5 13.5 11.6 128 123 132 

1931-35---------------------------- 12.0 12,7 11.4 134 127 141 

1951


1926-30---------------------------- 12.1 12.9 11.4 145 137 153


1921-25---------------------------- 12.1 12.9 11.4 157 147 166


1916-20---------------------------- 14.4 16,5 12.8 190 180 199


1911-15---------------------------- 14.3 15.4 L3.3 205 195 215


1906-10---------------------------- 14,7 15.6 13.8 221 208 234


1901-05---------------------------- 16.0 17.1 15.0 249 234 264


- ----- - -- 1896-1900 17.7 18,8 16.6 279 262 297 

1891-95---------------------------- 18.7 19.8 17.7 296 275 318 

1886-90---------------------------- 18.9 20.0 17.8 300 278 322 

1881-85---------------------------- 19.4 20.5 18.3 308 284 333 

18.76-80---------------------------- 20.8 22.1 19,5 328 302 354 

1871-75---------------------------- 22,0 23,3 20,7 342 314 371 

1866-70---------------------------- 22.4 23.7 21.2 349 318 380


1861-65---------------------------- 22,6 23.7 21.5 353 320 387


1856-60---------------------------- 21,8 22.6 21.0 341 306 377


1851-55---------------------------- 22,7 23.5 21.8 356 321 392


1846-50---------------------------- 23.3 24.1 22.6 369 331 409


1841-45---------------------------- 21,4 22,1 20.6 344 307 381


2

400 

Crude 

Death 

Rate 

per 

Lcco 

Figure 

24. 

23. 

22. 

21, 

20 

19 

18 

I7 

16 

15 

14. 

13 FEMALE 

12. 

Il. 

1~ ,.. . . 91. ~’a:ll. 21. 31. 41. 51.56. 

3C0 

MALE Standards ed


Mortality


Ratio.


2CQ 

ICC), 

80

l% , , 41..51. 61. 71. 81. 91. 1901.11. 21. 31. 41. 51.%. 

Year 

1. Death rates per 1,000 population and standardized mortality ratios (1950-52 Standard), 1841-1960. 

ence and that the early attempts at public health 

legislation were not entirely effective. 

Between 1871 and 1901, however, there 

was a complete change in the trend; and for 

30 years there was a steady but slow decline in mortality, the rate falling from 22 

to 17 per 1,000 and the age-standardized rates 

falling by 30 percent. New compulsory public health acts were passed, housing was improved, universal compulsory schooling was 

started in 1871; and although there was industrial and agricultural depressioninthe 1880’s, 

this was not serious enough to neutralize the 

effects of social advances, 

With the new century there was an increased renewal in social and medical reform, Pensions in old age and industrial health 

insurance were introduced in 1908 and 1911 

and new Factory Acts were also passed. Unfortunately, this legislation was to be followed 

by the war of 1914-18, Nevertheless, during 

the 30 years 1901-31 the mortality rate fell 

from 17 to 12 per 1,000 and the age-standardized rates fell by 35 percent. 

The next generation (1931 -61) provided even 

greater contrasts than any generation before. 

The beginning of the generation in 1931 was 

a period of depression, with widespread unemployment and a low level of wages throughout the entire country. Conditions improved 

slowly during the 1930’s, but they were to 

be followed by the cataclysm of war which 

lasted for 6 years in this country. After the 

war there was a period of far-reaching changes 

in the pattern of the health and welfare services, The National Health Service was widened 

to offer free access for all; and benefits in 

sickness, unemployment, and retirement were 

improved. The last decade of the period was 

one of increasing affluence and scientific advance. This generation also saw the introduction of the sulfonamides in the late 1930’s, 

of penicillin in the early 1940’s, and the other 

antibiotics in the later 1940’s. All these advances 

3 
provided possibilities for medical treatment that 

had not been previously available. Yet despite 

all this the crude mortality rate did not decline 

but remained fairly constant at about 12 per 

1,000 population. 

It is thus apparent that in England and 

Wales since 1840 the crude mortality rate has 

not reflected the trends in social and medical advances i“ the country. There have been 

periods of greater advances in medical knowledge and standards of living when the crude 

mortality rate has been constanq there @ve 

been other periods when conditions have been 

bad but the mortality rate has fallen. It is, 

therefore, necessary to analyze the mortality 

of a country in much greater detail both by 

age and sex and by cause of death in order 

to have any idea as to what are the relative 

changes and what are the possibilities of fu. 

ture trends. The present report proposes to 

examine in such detail the changes in mortality trends in England and Wales in the period 1931-61. 

VALIDITY OF THE DATA 

First it is necessary to consider whether 

administrative improvements, advances in medical diagnosis, or statistical methodology may 

have produced, by an artifact, a change in the 

rates. 

Administrative Changes 

The only major administrative advance 

in recent years has been the introduction of 

registration of stillbirths in 1928 which may 

have had an influence in improving birth registration and registration of infant deaths; but 

there has been no other major change in the 

method of registration or census taking in the 

period under review, and it is believed that 

there has been no improvement in the quality 

of registration. However, there have been several 

changes in the method of calculating death rates. 

During the decade 1939-49 many young men and 

women were in the armed services, all deaths 

of civilians which occurred in England and Wales 

were recorded, and the population used for 

calculating mortality rates was the civilian population only. Unfortunately, this civilian population was heavily weighted with people who 

were not fit for service and with servicemen, 

discharged usually for medical reasons; hence 

the death rates based upon this residual population are not a true picture of the trends in 

the country. As there were nearly .5 million men 

and women under arms by 1944 this method 

completely distorted the age-specific rates between the ages of 15 and 44 for this decade, and 

it is not possible to make retrospective adjustments for all these. factors. Consequently between these ages it is necessary to treat with 

great reserve the age-specific rates for the 

period 1939-49. 

Advances in Medical Care 

When the individual causes of death are 

to be considered, there are two factors of importance. First, changes in medical knowledge 

are such that it is difficult to compare diagnostic ability of 1961 with the diagnostic facilities 

available in 1931, and many diseases which are 

now known to be prevalent were not even recognized at the earlier period. It is necessary therefore to confine an analysis over many years to 

those diseases which were both common and 

readily recognized during the whole period of 

time. 

Second, there has been a relative increase in the number of doctors in the population; and access to medical care has been 

facilitated, but the effect of this on the standard of death certification cannot be estimated, 

Recent studies have been made by the Registrar General comparing clinical diagnosis of 

causes of death with the pathological findings, 

and it must be admitted that the findings are 

not entirely satisfactory. In consequence, it 

is necessary to confine detailed analysis of 

changes in mortality to widely defined causes 

of death. 

Methods of Classification 

Difficulties arise due to the method of 

classification of causes of death. During the 

31 years under review there have been four 

different revisions of the International Classification of Causes of Death (table B). From 

1931-39 the Fourth Revision was used; this 

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Table B. Classificationsused in the comparison of the various revisions of the Inter­


national Statistical Classificationof Diseases: England and Wales, 1931-65


> 

Revision number and years in use
 Cause of death
 I (SeventhRevision of the International Seventh Sixth Fifth Fourth
 Lists, 1955) Revision Revision Revision Revision


1956-1965 1950-1955 1940-1949 1930-1939


Infective and parasitic diseases 001-139 001-139 1-44 1-44 

Tuberculosis of the respiratory 

system 001-008 001-008 13 23 

Tuberculousmeningitis 010 010 14 24 

Measles------------------------------ 085 085 35 

Diphtheria


Influenza


Malignant neoplasms


Of digestive organs and peritoneum---


Of stomach


Of respiratory system


Of lung and bronchus


Of uterus


Of cervix


Of breast ---c----


Leukemia---.----


Vascular lesions affecting


central nervous system


Diseases of the circulatory system


Chronic rheumatic heart disease


Chronic endocarditisnot specified
 as rheumatic


Arterioscleroticheart disease,


including coronary disease


Other myocardial degeneration


Diseases of the heartl


Chronic affections of the valves


and endocardiuml


Diseases of the myocardiuml


Diseases of the coronary arteries


and angina pectorisl


Other diseases of the heartl


Diseases of the respiratory system


Influenza


Bronchitis


Pneumonia---.-


Deliveries and complicationsof preg­


nancy, childbirth, and the puerperium-


Congenital malformations


Accidents, poisonings, and violence----


055 055 10 J


See Resl .ratoryDiseases Class: ication


140-199 140-199 45-55 45-53 

150-159 150-159 46 

151 151 4% 46 

160-165 160-165 47 

162-165 162-165 4% N.A. 

171-174 171-174 48 48 

171 171 48a N.A. 

170 170 50 50 

204 204 74 72 

330-334 330-334 83 82,97.1 

400-468 400-468 

410-416 410-416 

421 421 

420 420 

422 422 

90-95 90-95 

92 92


93 93


94 94 

95 95 

470-527 470-527 104-114,33 104-114,11 

480-483 480-483 11 

500-502 500-502 1:: 106 

490-493 490-493 107-109 107-109 

640-689 640-689 140-150 140-150 

750-759 750-759 157 157 

E800-E999 E800-E999 163-198 163-198


Suicide E970-E979 E970-E979 163,164 163-171 

Accidents E800-E962 E800-E962 169-195 176-195 

206,208, 

Motor vehicle accidents E81O-E835 E81O-E835 170 210,211 

lFifth Revision of the InternationalLists, 1938.


5

had been introduced in 1930 and reflected the 

diagnostic practices of the late 1920’s. The 

instructions to the clerks who were doing the 

numerical coding of the certificates of death 

were such that if there were multiple causes 

of death indicated on the death certificate the 

clerks were to select the particular cause of 

death to be coded and give precedence from 

an arbitrary list of priority causes, 

In 1940 the Fifth Revision was introduced. 

This classification of causes of death followed 

the same general pattern as that of the Fourt~ 

there was almost no serious change in definitions introduced at this particular point, but 

the method of coding deaths changed considerably. The coding clerks were now instructed 

to accept the sequence in which a doctor certified 

multiple causes of death and to accept his definition 

of the underlying cause. This had a very marked 

effect upon certain causes. The Registrar General 

undertook dual coding of deaths occurring in 1939 

both by the Fourth Revision and by the rules of the 

Fifth Revision. The principal changes which 

were found are given in table C. 

This table shows that the revised method 

of coding made little difference in deaths attributed to infectious diseases, cancefs, diseases of the digestive system, or diseases 

of infant y and old age, and also in deaths 

from violence. There were, however, increases 

in diseases of the nervous system, of the respiratory system, of the genitourinar y s ys ­

tem and in deaths attributed to childb~aring 

and to congenital causes. There were falls 

in diseases of the endocrine system, blood 

and heart diseases, and in diseases of veins 

and arteries. 

The individual causes of death examined 

in conjunction with the revised instructions to 

coders suggest some reasons why the”re were 

drastic alterations in these causes of death. 

There was a fall of approximately 17,000 deaths 

due to arteriosclerosis and a rise of nearly 

20,000 in deaths due to vascular diseases of 

the nervotis systezm; this is simply due to certif ying doctors indicating that “stroke” was the 

underlying cause of death, whereas under the 

Fourth Revision coders had been instructed 

to attribute some of these deaths to arteriosclerotic diseases irrespective of the dcctor’s certificate. 

It was at this ktage that bronchitis became such an important statistical cause of 

death in England and Wales. The number of 

deaths attributed to this cause more than doubled, while there was a corresponding fall in 

deaths due to myocardial diseases and chronic 

endocarditis. Thus it appears that doctors in 

England and Wales in 1939 had frequently attributed terminaI myocardial disease to a pre. 

ceding bronchitis condition. Under the instructions contained in the Fourth Revision cardiac disease had priority over respiratory disease and so the deaths were attributed to the 

cardiac condition. Under the rules of the Fifth 

Revision, however, where the certifying doctor was allowed to select the underlying cause 

of death, these deaths were assigned to the 

underlying bronchitis condition. 

Diabetes was also affected by the changes 

in the Fifth Revision and no longer took precedence over other diseases unless the certificate indicated that it was a real underlying cause of death. 

The Fifth Revision was in use for 10 years 

until 1949 when the Sixth Revision was introduced. 

The major changes between the Fifth and 

Sixth Revisions based upon the death certificates for 1949 are shown in table D. 

Although this revision altered the terminology of diseases and brought the statistical 

classification in line with medical practice of 

the late 1940’s, there were fewer reclassifications necessary as a result of the recoding. 

Influenza was now classified witli the respiratory diseases rather than with the infectious 

diseases because many practitioners were inadequately discriminating between deaths due 

to influenza and those due to pneumonia. Leukemia was now regrouped with the malignant 

diseases and rheumatism was divided into rheumatic endocarditis and rheumatoid arthritis and 

reclassified with heart diseases and joint diseases, respectively. Hypertension now appeared 

as an important cause of death, and it would 

seem that it was easier under the Sixth Revision to classify a death as due to hypertension than it had been previously. Arteriosclerosis continued to decline as instructions 

made clear that deaths due to arteriosclerotic heart diseases were to be assigned to 

6 
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Table C. Comparison of the number of deaths for all ages assigned to selected causes
 according to the Fourth and Fifth Revisions of the InternationalLists: England and


Wales, 1939


—


Cause of death


(Fifth Revision of t.~9,nternationalLists,


All causes


Major cause groups


Infectious and parasitic diseases (including


Number of deaths


assigned according


to— Percent
 Change change


Fourth Fifth


Revision Revision


498,968 498,968


influenza)------------------------------------ 43,314 43,866 +552 +1.3 

Cancer and other tumors


Rheumatism, diseases of nutrition and of the


endocrine glands, other general diseases, and


avitaminoses


Diseases of the blood and blood-forming organs


(including leukemia)--------------------------


Diseases of the nervous system and sense


organs


Diseases of the circulatory system:


Diseases of the heart


Diseases of the arteries,and veins-----------
 Diseaaes of the respiratory system


Diseaaes of the digestive system


Diseases of the genitourinary system


Diseases of pregnancy, childbirth, and the


puerperium


Diseases of skin and bone


Congenital malformations


Diseases peculiar to the first year of life----


Senility


Violent or accidental deaths


ill-defined and unknown causes


Some specific diseases


Diabetes mellitus


Intracranial lesions of vascular origin


Chronic endocarditis


Diseases of the myocardium


Diseases of the coronary arteries


Arteriosclerosis


Bronchitis


Pneumonia


71,609 69,517 -2,092 -2,9 

14,943 10,343 -4,600 -30.8 

5,069 3,978 -1,091 -21.5 

41,101 57,679 +16,578 +40 .3 

139,232 125,894 -13,338 -9,6 

32,041 14,546 -17,495 -54.6 

41,959 61,509 +19 ,550 +46 .6 

23,030 22,996 -34 -0.1 

21,346 23,097 +1, 751 +8.2 

1,815 1,997 +182 +10 .0 

2,319 2,142 -177 -7.6 

4,152 4,629 +477 +11.5 

14,174 14,119 -55 -0,4 

17,328 17,267 -61 -0.4 

24,509 24,310 -199 -0.8 

1,027 1,079 +52 +5.1 

7,627 5,160 -2,467 -32.4 

28,975 48,666 +19,691 +68.0 

19,598 17,892 -1,706 -8.7 

92,031 82,632 -9,399 -10.2 

19,496 17,844 -1,652 -8.5 

27,449 10,570 -16,879 -61.5 

15,463 31,423 +15,960 +103.2 

22,209 23,370 +1,161 +5.2 

coronary artery disease and not to arteri- any furtherdetailed certification
 of thecauses


osclerosis. of death.In each year when therewas a change


The Seventh Revisionwas introducedin in classification,
 the coding clerks took all


1956,butthemodifications atthisrevision were thedeathcertificates
 and simplyrecategorized


small. them accordingto the revisedrules without


It must be remembered when considering furtherreferencetothecertifying
 practitioners.


these tablesthat these changes are not due The differencesin the resultsare entirely


to any advances in medical science nor to duetostatistical
 artifact.


7

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Table D. Comparison of the number of deaths for all ages assigned to selected causes
 accordinz to the Fifth and Sixth Revisions of the InternationalLists: England and


Wales, 1549


Number of deaths


Cause of death assigned according 

to­
 Percent
 (Sixth.Revisionof ~h&nternational Lists, lhange change


Fifth Sixth


Revision Revision


All causes 509,973 509,973


Major cause jzroups


Infective and parasitic diseases (excluding


influenza).................---------- 25,296 24,780 -516 -2,0


Malignant neo,plasms(includingleukemia)------- 84,397 8;,;;; +781 +0.9 

Various general diseases 6,787 > +1,130 +16.6 

Diseases of the blood and blood-formingorgans 

(excludingleukemia) 2,282 2,345 +63 +2.8


Diseases of the nervous system and mental dis­


orders 65,295 67,449 +2,154 -1-3.3


Diseases of the circulatory system:


Diseases of the heart 154,259 1;:,;:; -4,548 -3.0


Hypertension


Diseases of veins and arteries


Diseases of the respiratory system (including


influenza)


Diseases of the digestive system


Diseases of the ’genitourinarysystem


Deliveries and complicationsof pregnancy,


childbirth, and the p’uerperium


Diseases of skin and bone


Congenitalmalformations


Certain diseases of early infancy


Symptoms, senility, ill-defined conditions:


Senility --.-----~-


Symptoms and ill-defined conditions


Accidents, poisonings, and violence:


Violence .


Some specific diseases


Diabetes mellitus ......


Vascular lesions affecting central nervous
 system


Chronic rheumatic heart disease


Diseases of the myocardium


Diseases of the coronary arteries


Hypertension---..----
 ~-------


Arteriosclerosis------.---e.---e


Bronchitis


Pneumonia..------------------------­
 .......----


6,201 +10,556 +170.2 

16,057 14;153 -1,904 -11.9 

63,96: ::,$;; -4,542 -7.1 

17,314 -387 -2.2 

18,632 14:114 -4,518 -24.2 

727 727 . 

1,06: 2,643 +1,580 +148.i 

4,92C 4,644 -276 -5.6 

10,995 11,839 +844 +7.7 

12,88C 12,338 -542 -4.2 

18,64: 18,513 -132 -0.7 

26C 517 +257 +98.8 

3,444 3,438 -6 -0,2 

59,236 60,051 +815 +1.4 

13,79f 14,966 +1,17C +8.5 

92,382 82,200 -I0,18J -11.0 

42,92; ;;,y; +4,206 -1-9.8 

6,201 +10,556 +170.2 

13,66: 10;942 -2,721 -19:9 

30,43: 

20,781 

28,981 

20,132 

-1,452 .64~ 

-4,8 

-3.1 

8

SELECTION OF TIME PERIODS 

It is thus apparent that each one of the 

three timeperiods 1931-39, 1940-49, and 1950-61 

should be treated as separate entities. During 

each of the periods there was one method of 

calculating death rates in use, and there was 

one revision of the International Statistical Classification for coding the causes of death. But 

between each of these periods there was a 

discontinuity which can only be bridged by making 

calculations from the effect of the changes in 

a particular year. Thus throughout the report 

tables have been prepared based upon these 

periods of time, and graphs have been prepared showing the discontinuity between 1939 

and 1940 and between 1949 and” 1950. 

These changes mean that some information which was not available in an earlier period 

has had to be omitted in a later period; for 

instance, the Fourth Revision classified all malignant neoplasms of the respiratory system together, whereas in later revisions it was possible to 

specify cancer of the lung and bronchus. Therefore, to produce a consistent series over the 31 

years it has been necessary to make comparisons 

between the larger group of all cancers of the 

respiratory tract. Fortunately, in this instance 

cancers of the lung and bronchus account for 90 

percent of all respiratory cancers, andtrends for 

the larger group are also valid for the smaller. 

In the case of cancer of the cervix of the uterus, 

however, it is not possible to make com~arisons before 1940, when only cancers of the 

uterus were distinguished as an entity and no 

valid comparisons maybe made. 

The Registrar General did undertake speciul coding for some classifications which were 

not required for the International List, and 

sometimes it is possible to obtain a special 

tabulation covering a series of years, 

SELECTION OF DISEASE CATEGORIES 

It is possible to discuss a pattern of disease in a community at two different levels. 

At the first level wide groups based upon complete systems of diseases such as all infectious diseases or all cardiovascular diseases 

are examined. Although such broad categories 

are of interest to social scientists and public health administrators, they are of less interest to epidemiologists and physicians who 

wish to know details concerning specific diseases if these can be defined. At the second level 

specific diseases are examined but diagnostic 

changes may confuse the general picture of 

mortality. 

Table B shows the groupings which have been 

selected for analysis and shows how these categories may be subdivided into specific diseases 

or regrouped into broad systems. 

In the section of this report which deals with 

mortality within each age and sex group the five 

most important causes of death have been examined for each year from 1931 to 1961. If in any 

year a cause of death rises into the first five 

causes, the progress of this disease has been 

analyzed throughout the 31 years. Thus in every 

group at least 5 causes of death, and occasionally 

10, have been examined in detail. 

GENERAL TREND OF MORTALITY, 

1931-61 

When allowance is made for changes in 

the age of the population, the general trend 

of the mortality during this period has been 

downward. Crude death rates and standardized 

mortality ratios are given in table E and figure 2. 

At the beginning of the period the country 

was suffering from the effects of the worldwide industrial depression which was particularly severe in Northern England and in Wales, 

where the coal, steel, and textile industries 

were concentrated. It is difficult to estimate 

the real influence of social and economic environment upon the mortality rates in the country, but it is clear that as economic conditions improved in the 1930’s so did mortality. The Standardized Mortality Ratio (SMR) 2 

in 1931 was 142, in 1935 it was 127, and by 

1939 it had fallen to 122—an improvement of 

14 percent in 8 years. 

2The Standardized Mortality Ratio is the ratio percent of 

the observed number of deaths in a certain population in a 

given year divided by the number of deaths which might have 

occurred if the age- and sex-specific mortality rates for England and Wales in the 3 years 1950-52 had prevailed in that 

population. The population is enumerated by age and sex; 

the means of the mortality rates for 1950-52 are multiplied by 

the population to give an “expected” number of deaths, and 

these are totaled. The actual number of deaths is divided by 

the expected and multiplied by 100. This method is equivalent to finding in a given population, by indirect standardization, a Standard Mortality Rate and finding the ratio of that 

rate to the true rate in that population. 

9 
----

----

------

------

-----

------

------

------

------

--

-----

------

------

------

------

The influence of improved medical treatTable E. Death rates per 1,000 populationand st~dardized ment is also difficult to assess. Sulfonamides mortality ratios (1950-52standard)by sex: England and Wales,1931-61 were first introduced in 1935 and became widely

available in general medical practice from 1937 Year Sze: Male Female 

1 !zElz= onward, penicillin became available in 1940 Death rate per 1,000 tandardig~inyrtality but was ~ot frequently used in civilian prac - I population


1961------ 12.0 12.6 11.4 ’33 95 90 tice until the end of the war; the antituber- N%:-: 11.5 12.2 10.9 92 87 

- 11.6 12.3 11.0 91 94 89 CU1OUSdrugs were available in 1946-47 and 1958 11.7 12.4 11.0 92 95 90 

1957------ 11.5 12.3 10.7 91 94 

1956------ 11.7 12.5 10.9 !34 96 :: were used extensively as soon as they be1955------ 11.7 12.5 10.9 95 97 93 came commercially available; tetracycline and 1954------ 11.3 12.2 +::; 93 95 91 

1953------ 11.4 12.2 95 96 94 other broad-spectrum antibiotics followed in 1952------ 11.3 12.2 10.5 95 96 

1951------ 12.5 13.4 11.8 106 106 1% the early 1950’s. Although it is clear that clin­ :;&----- 11.6 12.3 11.0 98 101 

~;.: 12.6 11.1 1:? 103 ically all of these new methods of treatment p;------ 11.9 10.1 R 95 

- 12:3 13.6 11.3 1;; 106 108 were very effective in preventing many deaths, 1946----- 12.0 13.4 10,9 103 101 106
 -

1945 12.6 15.0 10.8 104 p: 106 it is often difficult to distinguish their sta- 1944 12.7 15.3 10.8 107 108


1943 13.0 15.3 11.3 112 109 114 tistical effect on mortality from the influence
 1942------ 12.3 14.4 10.7 110 109 111


1941------ 13,5 15,7 11.8 126 124 127 of other trends,
 1940 14.4 16,1 12.9 139 135 141


;;;;-:::-- 12.1 13.0 11.3 122 117 126 This country declared. war in 1939, and
 11.6 12.5 10.8 119 116 123 

1937: 12.4 13.2 11.7 130 124 135 the year 1940 was a very difficult one indeed. 1936 12.1 12.9 11.4 129 123 134 

1935 11.7 12.5 11.1 127 120 132 There was aerial bombardment, evacuation of 1934 11.t ~;.; 11.1 129 123 136


1933 12.: 11.7 138 129 146 the civilian population, and conscription of the
 1932------ 12.( 12:7 11.( 137 12s ;::
 --L 1931------ 12.: 13.0 11.t L142 13: young adults; but the major reason for the high 

mortality in 1940 (SMR 1939) was the severity of 

the weather as the winter of that year was comparable to the winters of 1929 and 1951, all of 

which caused a marked rise in the mortality rates. 

17. 150 

16.	 140
\ .>


A Is, 130 \- \ 

Standardhed 1 “1,/-” I \ Mortality \ hk Ratio PIA .. ,--1 \ .1 

Crude 120. ‘w” \\/-l Death ~.1 Rate 

per 

moo 1!0. 

lm-


90


FEMALE 

v hiIALE IQI so, r r)btssv~dldsdso 49515355575961 ml. 33.35. 37. 3P. 41. 43. 43.47. 4. 51.53. 55.57. 59. a. 

‘Year Year 

Figure 2. Death rates per 1,000 population and standardizedmortality ratios (1950-52 Standard),1931-61.


10 
-------

-------- ------------

------------ ----------

----------

----------

----------

----------

----------

----------

----------

---------- ------------

The following years of the war saw improved nutrition of the general population as 

a result of rationing with no recurrence (except in 1944) of the heavy civilian air raids. 

.is a consequence the mortality declined so 

that in 1945, the last year of the war, the 

SMR was 104-a decline of 15 percent in the


6 years from 1939.


The first5 years of the postwar era saw


many social and administrative changes in this 

country, with a revised national health service 

in 1947. The Standardized Mortality Ratio fell 

to 99 in 1950—a decline of 5 percent in 5 

years. 

The decade of the 1950’s was a more conservative one in which the affluence of the 

population increased, but the. mortality rates 

did not improve as rapidly as they had in 

the preceding 20 years. Between 1950 and 1956 

the SMR fell by 5 percent in 6 years to 94, 

and between 1956 and 1961 it fell by 2 percent in 5 years to 92. Thus the improvements 

in mortality which had been continuous for 

the preceding 90 years had almost worked themselves out. 

AGE GROUP 

The death rates for each age group and 

for both sexes in 1931 and 1961 are shown 

in table F and figure 3. The general pattern 

of mortality throughout life remains constant—the 

risk of death declines from birth until the 

age of about 10, it increases rapidly during 

adolescence, remains constant in early adult 

life, and then rises steadily throughout the 

rest of life. But within this general pattern 

there have been marked changes in the actual death rates during these 31 years. There 

has been an improvement in the rate for children almost of the order of eight times. There 

have been moderate changes in young adult 

life, but there has been very .Iittle change in 

old age. This ratio of the age-specific death 

rates in 1931 divided by the rates in 1961 

are shown in table F and in figure 4. 

At all ages, females have advanced more 

than males despite the fact that in 1931 female death rates were already lower than those 

for males. The ratio of the male to the feTable F. Age-specific death rates for all causes per 1,000 population and ratios by


Age


All ages


Under 1 yearl 1-4 years 

5-9 years 

10-14 years 

15-19 years 

20-24 years 

25-34 years 

35-44 years 

45-54 years 

55-64 years 

65-74 years 

75-84 years 

85+ years 

sex: England and Wales, 1931 and 1961


1931 to 1961 IMale to female
 Male Female ratio ratio


1931 1961 1931 1961 Male Female 1931 1961 

Rate per 1,000 population Ratio I 

13.0 12.6 11,6 11.4 1.03 1.02 1.12 1.11 

7;.: 23.9 5;.; 1:.: Hi ;:: 

1.3 

1.1 

1.3 

1.3 

2:3 A:! 2:0 0:3 4.6 6.7 1.2 1.7 

3.8 1.0 

H ::: H ::: 1.1 ;:! 

2.9 n 1.1 2.2 

N ;:; ::; 1.1 1.7 

2.4 ::: H 2.5 1.3 1.3 

1::: 7.2 8.3 1.6 1.9 

23.9 22.0 17.6 10.7 1.1 1.6 M H 

58.7 54.3 44.4 30.9 1.1 1.4 

138.4 124.0 114.4 87.1 1.1 ;:: ;:: 

295,9 257.4 255,3 227.1 1.1 H 1.2 1.1 

*Rate per 1,000 live births. 

11

MALE FEMALE 

260


200


I


’99


::


50


{

40 

30 

20 !
 Death 

Rate 

Per 

l.clx) 

10.


: -


6“


G :1


:1! 1931 4 

/

3


/


2 /


1%1
 : v. /


I


[.0-
 .9-


:\ ,;


\


\ /’


O,- I \/\. 15”102030.405Q 6070W 90100 0 K4E o-24-J . . . . 0~20=@&O@7b~ $b 100


Figure 3. Age-specific death rates per 1,000 population, 1!331 and 1961. 

male death rate for the same ages is given 1 and 84 did the male to female ratio decline 

in table F and in figure 5 for the 2 years 1931 during these 31 years. 

and 1961. In 1931 this ratio varied between 

Infant Mortality Rates–Under 1 Year 0.99 for ages IO-1.4 years, implying that


the male rate was slightly lower than the fe- It is not the intention of this report to


male rate, and 1.40 a; ages 45-54. But in 1961 study infant mortality rates in detail, During


the ratio varied between 1.30 for ages 1-4 the period under review, the infant mortality


and 2.19 for ages 15-24 years. At no age between rate has fallen by 70 percent, from a rate 

12

� 

� � 

� 

1931 - 1961 

Ratio of 

Dtmth Rate 

8 

7 

6 

5 

4 

3’ 

2. 

~ 

( � 10.20 .30”.40.S:.60 .70.80 .90 .100. 

Fiaure k Ratio of mortality in 1931 to mortality


in 196[, by-age,


of 75 per 1,000 births in 1931 to 22per 1,000 

births in 1961. An analysis of the ages at 

death of infants in 1931 compared with 1961 

shows that the greatest improvements have been 

made in protecting infants between the ages 

of 1 month and 1 year, whereas there has 

been only a relatively small improvement in 

infants from birth to the age of 1 month. When 

the causes of death are examined, it is seen 

that there has been almost a complete elimination of deaths due to gastroenteritis and 

a great reduction in the mortality from bronchopneumonia, but little improvement has been 

made in congenital diseases and in diseases 

of the respiratory system associated with immaturity, Because the infant mortality rate has 

fallen to a level as low as 20 per 1,000 births 

implies there is little room for further imRatiu of 

D,.,, th Rate 

Male/ 

Female 

3 

2.5 

I 

I

, 

0’ 10 20 30 40 50 60 70 80 90 100 

AGE 

Fiaure 5. Ratio of male mortality to female mor­


tality, by age, 1931 and” 1961.


provement. The causes of death under 1 year 

of age are now immaturity, congenital malformations, respiratory disease of the newborn, and birth injuries. Advances in the reduction of these causes of death are likely 

to be made by a general improvement in eugenics, antenatal care, and maternal education. 

Preschool —l-4 Years


The preschool child has benefited most 

of all from the advances of medical science 

during the last 31 years (fig. 6). In the early 

1930’s, 7 children out of every 1,000 died each 

year; in the late 1950’s this toll had been 

reduced to fewer than 1 out of every 1,000—a 

reduction of about 85 percent. The female improvement has been greater than the male. 

This rate of improvement was not constant during the period; there was a steady 

decline from 1931-39, and during the war years 

this improvement was accelerated and continued 

13

---

------

----

400 MALE


1


!50

n~.h --”,. - ./-.,/ /\ 

“\w.\ ..tiY\,- /“\._..-F;t.t... P.r 

100
 4
 90


70 I


60 ...-~.--,,zs,.--,,zs, 65-74
 ,,.\k--------_-

50 ._. _--, A,.--

t 40


30


55-64


20


‘~ 

19313335373241434547 49515255573961


l’--=­

.6


.5


.4


1 33 3S 37 39 41 43 45 47 49 51 S3 5S 57 59 61


9{ 

.2 ~


IW3 32 35 37 39 4! 43 45y,~ 49 51 53 55 57 59 61


FEMALE 

3m 

400 

1


D&h 

P., 

y. Q -..-../. .“~ A \ ,,., .,---.a04-04 90 ‘., %-.. . . m, \,,--

. . . . . . . . .. . . eo t 70. 

60


50,


~19 I 33 35 37 39 41 43 45 47 49 5! 53 55 5? 59 6!


20


I


:. 

7


6


5. 

4. 

~ ...-.s 

.-...-, .-.4::>.-.-., ---_, 

2 .J ‘___ ., “~ .-. 

. . %. D~t:h . ..-. \. 

. . . Per 

lCCO .%,, ‘“\.-, 

1.0 

‘. -.%.2s .34


8 ‘. ~.-,, -0


7 ~.
 .6 .


.5 . . 15-24


-. .’...- .
 4 . ... 

931 33 35 37 39 41 43 4s 47 49 51 53 55 s 59 b,


7


6


5


4


3 h 

,2 

031 33 35 37 39 41 43	 45 47 49 4 5“3 & 57 59 6


Year


Figure 6. Age-specific deai.lirates for all causes per 1,000 population, 1931-61.


14

for the following 5 years. By 1950, however, 

the impetus had died, and since 1955 there 

has been no real improvement in the mortality of this age group. 

This general trend has resulted in a complete transformation in the diseases causing 

death at this age. In 1931 the killing diseases 

were pneumonia, measles, diphtheria, whooping 

cough, tuberculous meningitis, and bronchitis, 

all of them infectious diseases, In 1961 pneumonia alone remained a major killer followed 

by congenital malformations, road accidents, 

and leukemia and other malignant diseases—only 

one of them an infectious disease. 

MA-E 

b, \

M ! \ 1#, 

t, ,*, 

\\ 

i! ‘~i\ 

1000. \ ‘p Imo. \ \i-4 

% 14 

\

\

‘, [ DEATH ‘,

lll;E ~1 ~. 

i ‘$ 

106 L ‘$, 

4 

Im -

10 10 

19’31 S5 39 43 4? 51 55 5961 /99k 3S 39 43 47 51 5S 5961 

It is interesting to follow the pattern of 

change in each of these major diseases as 

their trends may be attributed to different causes 

in each case. 

Pneumonia has remained the major cause 

of death throughout the whole period (fig. 7), 

and the curve of this disease reflects the general pattern of the age group. There was a 

steady but slow improvement throughout the 

period 1931-39; but in 1940-41 there was 

a sudden exacerbation of the disease, probably due to poor conditions and the severe 

weather of these years, which declined rapidly in 1942 and this decline continLled until 

MALE 

10 101 

.9313539454751559ti i9313334347515559m 

YEAR 

Figure 7. Death rates by age for influenza and pneumonia per million population, 1931-61.


15

.

about 1954. Since that time mortality has been 

relatively constant at about 130 deaths per million children. Itisunlikely that all these changes 

in mortality can be entirely attributed to drug 

therapy as the improvement occurred during the 

early 1930’s before the introduction ofsulfonamides, and there has been little improvementin 

the 1950’safter the introductionof tetracycline. 

It improbable that social changers, improved maternal care, healthierchildren, andbettermedical 

facilities as well as medical treatment have 

been important influences in the decline of 

deaths from pneumonia among preschool children. 

Diphtheria was one of the few diseases that 

was on the increase in the 1930’s, reaching 

a maximum in 1934 with a secondary peak 

in 1941 (fig. 8). An intensive national immunization campaign started in 1940-41 and was 

.. 

I.

1 

pressed vigorously throughout the war years. 

Within 10 years the mortality had been reduced by 99 percent, and in 1959 no deaths 

from diphtheria were recorded in the whole 

country. It is probable that this remarkable 

success may be attributed almost entirely to 

the immunization campaign, but in view of similar falls in some of the other infectious diseases which have to be attributed to social 

conditions, this attribution is not absolute proof. 

Measles is notoriously an endemic disease with epidemic peaks at intervals of 2 

years. The disease still remains endemic in 

England and Wales, although incomplete notification makes it difficult to draw adequate 

comparisons over a period of years (fig. 9). 

Deaths from measles, however, have declined 

during the period so that each successive peak 

and trough of an epidemic wave has been lower 

than the preceding wave. It is thus clear that 

Ioa MALE ! 

v 

(0[ 

I-4 

!lE.ITI 

RPXETRE 

,06

I-4 

. 

\ 

\ 

. . !C 

/i 

5-14 b 

.

[, 

lq 35 39 43 47 51 55 5961 3S 39434751 S5596! 

19’31 ?s 39 43 ‘i7 51 55 5961 @hR% 39 43 47 51 55 59 51 

Figure 8. Death rates for diphtheria per million Figure 9. Death rates for measles ger mill ion


population aged l-l! years, 1931-6i, population aged I-4 years, 193[:61.


16

the case fatality rate has declined considerably, This decline in the mortality cannot be 

attributed to immunization because no form 

of prophylaxis had been introduced generally 

in the population by 1960, and the incidence 

of the disease has shown only a relatively 

small decline. Consequently, as pneumonia is 

the usual terminal cause of death, factors similar to those causing the decline in pneumonia 

death rates are probably responsible for the 

improvement in deaths from measles. 

Whooping cough has the distinction of being one of the few diseases for which the female death rate is higher than the male rate 

(fig. 10). In the early 1930’s it was one of the 

major killing diseases of preschool children, 

Figure 10. Death rates for whooping cough per


million population aged I-14 years, i931-61.


Sce MALE FEMALE 

b

IW \ 

‘“% j\4 

‘1, ‘4 

““\ 

544 “ 

\ “% 

\ 

\ -\, 

\ 

. 

d____ 1931 S 3943475153596 

Figure 11, Death rates for tuberculous meningitis


per million population aged i-l~ years, 1931-61.


with a death rate of 600 per million, The rate 

fell steadily during the 1930’s, and by the outbreak of the warit had been reduced by76 percent; but even as recently as 1947 the rate 

was still 148 per million, Since then, however, 

the rate has fallen more rapidly and consistently. Deaths due to pertussis have not been 

completely eliminated, but in recent years the 

rate has been of the order of 2 per million. Immunization against whooping cough was 

introduced in the triple vaccine about 1950, 

and the use of this became widespread in1951. 

Thus, it may be said that 76 percent of the 

reduction in mortality had already taken place 

before an effective vaccine was introduced, but 

that the virtual elimination of the disease as 

a cause of mortality must be attributed to 

the preventive measures taken. 

Tuberculous meningitis was a common cause 

of death in the 1930’s, and although the mortality from this disease declined slowly during 

17 
---------

----- --------

the next decade, there was a recrudescence 

of the disease during the war (fig. 11). After 

the war the decline continued gradually until 

1952, when there was a precipitous fall; and by 

1961 the disease had almost been eliminated from 

this age group. Factors influencing mortality 

from tuberculous meningitis must have been social 

and medical care, improved case finding of known 

open contacts, isolation of adult cases, and 

extensive BCG i~munization of “at risk” cases 

which was introduced into the country in 1953. 

But this is clearly a disease where the introduction 

of specific chemotherapy after 1950 has transformed the scene and almost eliminated the condition entirely. 

The recent prominence of congenital malformations, especially congenital heart disease 

(fig. 12), as a cause of death among preschool 

30. 

2e-

,EATH 

~tTRE 

e 

. . 

7 

1931 S 33 43 47 51 55 5961 ;~$’~~ ‘3 43 47 51 55 S61 

Figure 12. Death rates for congenital heart d is­


ease per million population aged 1-14 years,


19?1-61.


children is due to two factors. Some infants 

who would otherwise have died in infancy are 

now able to survive the first year but are 

not able to cope with the more active life 

of the toddler. Although the actual mortality 

from this cause has increased little in these 

31 years, due to the complete ebb of the tide 

of infections, the rock of congenital diseases 

has become more prominent. It is not possible to decide whether there has been a rise 

FEMPLE -1 - 1 Zm 

Dkmuh 

?*Z ~%r 

Id ..-

%-:%. - ~%xzr 

‘--- ..-% 

6 bs.x 

~ !SS.64 _ 

~—
 S5-64 $4SZzT-­ “l- ‘m 

i- —’-=&3zd d m.s.33. 43.47, Y.s5. sw. lw. Ts.3.43. 47. s4.5. s.&. 

Y.,, 

Figure 13. Age-specific death rates for al 1 ma­


lignant diseases per million population, 1931-61.


18

in the incidence of such cases during this period 

as a national register of congenital defects would 

be required to prove this conclusively, but it seems 

probable that this effect has been minimal. 

Similarly, the relative importance of leukemia and other cancers (figs. 13 and 14) as 

a cause of death in 1961 is due to a very small 

increase in the absolute rate and a decline 

in other rates. The reason for this may be 

improved medical diagnostic ability, changes 

in the methods of classification, and a possible true rate of increase. Whether there has 

been a true increase in incidence of these 

diseases during the period under review is 

almost impossible to say, as there were changes 

in methods of classification and coding in 1940 

and in 1950 and hematological examinations 

have become much more frequent. 

Despite the very great increase in road 

traffic, deaths from road accidents in early 

childhood (fig. 15) are now fewer than they 

were 31 years ago, and there ‘has been no 

tendency for them to increase since 1951. To 

some extent this is due to improved accident 

services and blood transfusion, which have reduced the case fatality rates, but it is also 

due to the education of parents and children 

to take care on the roads. It is interesting 

to see that even at ages 1-4 years, boys are 

killed on the road with much greater frequency 

than girls. 

Other accidental deaths, a miscellaneous 

group, declined slowly during the period but 

was an important relative cause of death in 

1961, due to greater improvements in other 

death rates. 

School Child–5-14 Years 

The school child is a vigorous biological 

animal most resistant to the ravages of disease; but despite the low rates of mortality 

prevalent in 1931, these rates have been reduced by over 80 percent in the following 31 

4 

MALE “EMPLE MAW 

KM . 100 I 

1. to 4. 33394s 47515596! t93133394347515539 64 

YE.4R 

Figure 14, Death rates by age for leukemia per mill ion population, 1931-61. 

19 
Figure 15. Death rates by age for road accidents per million population, 1931-61. 

years, and once again it is apparent that the 1934. There was little improvement in this 

girls have benefited much more than the boys. rate for the next 5 to 6 years; but after the 

In 1931 the rates for boys and girls were introduction of free immunizationin 1940, school 

similar, but by 1961 the female rate was more children did not show an epidemic peak in 

than 30 percent lower than the male rate (fig. 6)., 1941 although this was apparent among preIn 1931 the major causes of death were school children. The rate fell very rapidly 

diphtheria, pneumonia, road accidents, tuber- indeed, and in 1957 no deaths from this disculous meningitis, and rheumatic heart dis- ease were recorded among the school chilease; in 1961 these had changed to road ac- dren. In recent years there have been a few 

cidents, leukemia, other malignant disease, con- outbreaks of the disease, with an occasional 

genital heart disease , and pneumonia. death attributed to it in social circumstances 

Diphtheria (fig. 8) has always been an im- which have been associated with failure of important cause of death among school children, munity, but it is considered that the disease 

from the time corynebacterium was recognized is virtually eradicated from this country. 

as a cause of the disease previously known Pneumonia and influenza as a cause of death 

as membranous croup. There had been some among school children declined during the 1930’s 

steady improvement, however, in mortality from and continued to decline fairly rapidly during 

the disease but this was arrested in the 1930’s. the war and the immediate postwar period (fig, 7). 

The disease appeared to be on the increase, It reached the low level of about 40 deaths 

reaching a peak of 350 deaths per million in per million children in 1950; since then the 

20 
mortality rate from this cause of death has 

fluctuated slightly and has shown no particular trend, 

Road accidents among school children have 

shown a considerable improvement over the 

period of 31 years (fig. 15). During the 1930’s, 

in spite of traffic increase there was a slow 

decline in these deaths; during the war years 

due to the blackout, the poor illuminations, 

and heavy military and industrial traffic there 

was a rise in mortality, but this rapidly declined during the years following the war and 

has continued to decline. There is a remarkable fact, however, that the male to female 

ratio is greater than 2, and that boys at this 

age are being killed twice as frequently as 

girls. 

The trends of deaths attributable to tuberCU1OUSmeningitis at school ages have shown 

exactly the same trends as in the case of the 

preschool child, although the rates for the school 

child have been lower than those for the toddler (fig. 11). There was very little change 

in the death rate until about 1947, when there 

was a small decline which became very much 

more pronounced in the early 1950’s with the 

introduction of effective treatment. There was 

a hesitation in the drop of the curve in 1956 

and 1957 which at the time was feared to be 

due to resistance to the main antituberculous 

drugs. Fortunately, however, this possible leveling off of the curve did not persist and the 

rate has continued to decline. 

Rheumatic heart disease like whooping cough 

is one of the few diseases for which the male 

to female mortality ratio has usually been less 

than 1. The rate declined slowly during the 

1930’s but improved rapidly during the war 

years and has continued to decline throughout 

the subsequent years. The rate has now fallen 

from about 80 per million children in 1931 

to less than 1 per million children in 1961, 

but even with this low rate there is still a 

slight predominance of females. 

Congenital heart disease on the other hand 

has increased from approximately 8 per million children in 1931 to approximately 26 per 

million in 1961 (fig, 12). Several factors may 

be involved—the first is refinement in diagnostic procedures and the second is the survival 

into school age of younger children who would 

previously have died in infancy. A third is 

statistical artifact due to changes in coding 

classifications. Figure 12 shows there were 

some most remarkable discontinuities in the 

coding system; and as these discontinuities appeared to affect the sexes differently, it is 

not possible to be quite certain what has been 

the effect of these statistical artifacts on the 

mortality from congenital heart disease. 

There has been a steady but quite slow 

increase in the rate of mortality from leukemia and other malignant diseases (figs. 13 

and 14), but once again it is not possible to 

determine whether this effect is due to improved diagnosis or to increased incidence, 

or whether children who had malignant disease at an earlier stage would have died of 

some other complaint. 

Adolescence and Early 20’s-15-24 Years 

This age range is a mixture both socially and physiologically; within it the individual passes out of the stresses of puberty to 

become a young adult. Indeed before the close 

of this decade many will accept the responsibilities of family life. fiere are undoubtedly differences in the mortality experienced 

at these various stages, and marriage appears 

to affect the risk of death; but in a general 

statistical survey of this type it is necessary to aggregate all young adults under one 

decade of age. 

It should also be remembered that this 

age group was one that was severely affected 

by the stresses of war and by the statistical artifacts introduced into the calculation of 

rates during the decade 1939-49. The mortality at 15-24 years of age was falling slightly 

during the 1930’s; it rose very steeply (largelY 

due to artifact during the war years) and then 

fell rapidly in the period 1945-55. Since 1955 

the male rate has risen slightly and the female rate has continued to fall, but this rate 

of fall has been slower than in the preceding 

10 years (fig. 6). 

In 1931 the main cause of death during 

this decade of life, far exceeding every other 

cause, was tuberculosis. Following behind this 

21 
captain of the men of death were rheumatic 

heart disease, road accidents, influenza and 

pneumonia, suicide in the case of males, and 

puerperal deaths in the case of females. In 1961 

the outstanding cause was road accidents which 

in the case of the males accounted for over 40 percent of the total mortality. Following a long way 

behind as causes of death were influenza and 

pneumonia, suicide, leukemia, and in the case of 

women puerperal causes. 

Mortality from respiratory tuberculosis (fig. 

16) was falling slowly during the 1930’s, and 

in fact this fall at this period was the reason for the general trend in deaths due to 

all causes. In the period 1940-45 “there was 

a sharp rise in the mortality among the males . which was almost certainly an artifact as unfit men remained in the civilian population; 

. 

DEATH


3ATE


PER


I@


0


i 

I 

I 15 . 1.s 

Isi. s. m 4s. 47. 51. 55. S.&. ts’’3l. %. 3. 43. 4?. 51. 55. s&, 

YEAR 

— 

however, there may also have been a natural 

increase in the disease because of wartime conditions. But with the return of peace in 1946, 

there was a sharp fall which has continued 

almost consistently until in 1961 the mortality from this disease in this age range was 

less than 2 per million persons compared 

with the rate of approximately 1,000 per million in 1931. There has been one interesting 

change in the effect on this age range; females 

remained more susceptible to the disease than 

the males, but the adolescent females do not 

continue to have a rate higher than those of 

women of the more advanced ages. This is 

probably due to a cohort effect, because the 

women who were 45 years of age in 1961 were 

themselves girls of 15 in 1931; and these women remain a- high risk group. In 1961 the mor­

“W FEMALE 

1000 

,/ 

~-%./ -...-+ \., %.65-74 

~> + 

“

75-64 :,’

.+” /s”

W.# 

.@. 564 >““”\.&/ 

\ 

~.% 

..-@$ \. 

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“ t 

DEATH


Wf


10s


10. IO


E 15


ml. s. 3?.45.4?. 51.55.S.@. s 31,s. 3. 43.47.51.5s,39.
bl. 

YEAR 

Figure 16. Death rates for respiratory tuberculosis per mi 11 ion population aged 1%34 years, 1931-61.


22 

5564 
tality from this disease increased in each decade of life from 15-55 years of age, whereas before the war the disease decreased in 

women with advancing age. 

Unfortunately, many of the gains which have 

been won by the improved mortality from tuberculosis have been lost on the roads of the 

country. Among males, mortality from road 

accidents (fig, 15) now accounts for about 42 

percent of all deaths at this age range; it’ 

is now approximately equal to the mortality 

from tuberculosis in 1939, and it continues 

to rise. These road accidents are predominantly a male phenomenon, the male to female ratio being of the order of 5. The motorcycle is a popular teenage recreation in this 

lgl !01 

19$1. ?s. 39. 43. 47. 51. 55. 59.61. 19$1.33. 39. 43. 47. 51. 55.59.61. 

YEAR 

country; and it is obviously a dangerous instrument, almost as lethal as the mycobacterium 

tuberculosis used to be a generation ago. 

Pneumonia and influenza (fig. 7) fell during 

the 1930’s, rose to a peak in 1940 and 1941 

due to wartime conditions, improved rapidly 

in the postwar period, but has not shown any 

general trend since 1950. In 1957, however, 

there was a large peak in mortality attributable to the influenza epidemic of that year 

which was especially severe on the young 

adolescent. 

Suicide (fig. 17) among young males has 

fluctuated during this period. There was a peak 

in the rate of 74 per million in 1933, at the 

depth of the industrial depression, which then 

\MALE I FEMALE


Figure 17. Death rates for suicide per mill ion population aged 15-84 years, 1931-61.


23 
declined and continued to decline throughout 

the war years and the postwar revival until 

a minimum rate of 37 per million was reached 

in 1951. During the 1950’s, however, the rate 

increased again reaching a secondary peak of 

56 per million in 1960. 

Deaths of young women due to puerperal 

causes (fig. 18) in the early 1930’s were approximately 140 per million; but in 1935 an 

improvement was discernible, which has continued with minor fluctuations. As the number 

of births to women in this age range has increased proportionately more than the general population during the period, this relative improvement is even greater than it appears. The reason why puerperal causes still 

account for one of the major causes of death 

is because of the remarkable improvement in 

all other causes. 

Young Adult-25-34 Years 

The human organism is fully developed 

at 25 years of age and from then onward there 

are very few deaths which can be attributable 

to congenital or developmental causes; yet the 

body has not aged sufficiently for degenerative 

causes to give rise to a considerable number of deaths, The general trend in mortality 

during the 31 years under review has been 

downward. During the first 4 or 5 years of 

the 1930’s mortality was constant, but a decline started before the beginning of the war 

in 1939. During the 1940’s the apparent mortality of adults 25-34 years of age was grossly 

distorted by the methods of Calculating mortality rates, by which only the unfit civilians 

remaining in the country were enumerated. In 

1946, however, the rate for both males and 

females was considerably lower than the corresponding rate for 1939, and this rate has 

continued to decline. During the later 1950’s, 

a marked divergence of the male and female 

rates became apparent. Since 1955 the male 

rate has hardly improved, whereas the female 

rate has continued a marked improvement, so 

that the male to female ratio has widened considerably, where in 1931 the male to female 

ratio was 1.06 and in 1961, 1.58 (fig 5). 

500 

FEMALE 

.t4, 

~. 

‘1 

1 ‘\. 

‘i /~“\\ 

“\. 

\ ~,q 

DEATH \ 

RATE “ JLh ‘1, 

PER ‘. I Io6 \. ! 

\* ‘1 

100 L 

\ 

\ 1. 1, 

-~J\ 

\ 

\-, “\. 

\* ‘,.\a 

“ 1 \-. \ 

‘~ ~25-34 

\. 

\QS@l 

20 15-24 . ..!!!!L 

i93L ~. 39. 43. 47. 51. 5.5. S.61. 

YEAR 

Figure 18. Death raies for compl ication of the pu­


erperium per mi 1Iion females aged 15-44 years!


1931-61.


In 1931, the main causes of death were 

respirator y tuberculosis, pneumonia and influenza, road accidents, rheumatic heart disease, 

suicide among males and childbearing among 

the women, By 1961, the causes of death were 

road accidents, suicide, coronary artery disease among men, rheumatic heart disease among 

women, pneumonia and influenza and deaths 

attributable to childbearing among women. 

Tuberculosis of the respiratory system (fig. 

16) declined from 1,030 per million population to 16 per million population in 1961, a 

reduction of nearly 99 percent. This decline 

started in the early 1930’s and continued until the outbreak of the war, when there was 

an artificial peak which reached a maximum 

in 1944; there was then a rapid decline dur-
ing the immediate postwar years which has 

continued without any hesitation until the pres ­

ent time—a dramatic demonstration of the ef ­

ficiency of treatment. 

Pneumonia and influenza (fig, 7) have shown 

a similar pattern; but the fall has not been 

quite so precipitous, so that in 1961 this group 

of diseases still remains among the five major causes. 

Road accidents (fig. 15) have been promoted from third to first cause of mortality 

among the adults in the age range 25-34 though 

surprisingly enough the rates of mortality have 

hardly changed at all. In the 1930’s the male 

mortality rate was slightly higher than 200 

per million, and in 1961 it was exactly 200 

per million. The rate 

shown little change; in 

most 33 per million, 

per million, As motor 

fivefold in this interval 

for females has also 

the 1930’s it was aland in 1961 it was 42 

traffic has increased 

and as adults of this 

age range are most exposed to the hazards 

of motor traffic, this is a remarkable phenomenon which should probably be attributed 

to increased care in driving, to improved engineering, and to public health education, as 

much as to medical care in saving the lives 

of those already injured. 

The study of the etiology of suicide (fig. 

17) is a most difficult but important probl:m, 

for suicide is now the second most important cause of mortality in the age range 25-34. 

In the early 1930’s deaths from suicide were 

about 150 per million males and about 75 per 

million females, reaching a peak in 1933 at 

the depth of the depression. During the war, 

despite the artifactual elevation of the total 

mortality rates, the suicide rate showed a considerable decline. This decline continued into 

the postwar years, reaching its lowest rate 

in 1950; but subsequently there has been a 

slow but quite steady rise in the mortality, 

and now suicides among males are over 100 

and among females about 50 per million population. Throughout the whole period, the male 

to female ratio has remained at about 2.0. 

There was a considerable decline during the 

national exhilaration of war and the reconstruction period following it, but in both the 

depression years of the 1930’s and the affluent years of the 1950’s suicides increased. 

This may be another demonstration of Durkheim’s 

hypothesis that the suicide rate is an expression of the failure of social cohesion in society. 

Heart disease was in the 1930’s one of 

the five major causes of death, and it still 

remains in this category (fig. 19). There has 

been a considerable shift in the type of heart 

disease occurring. In the 1930’s rheumatic heart 

disease was one of the major causes of death 

for both males and females, but this has now 

declined to about one-third of its original rate; 

whereas in the case of coronary artery disMALE WE 

loc#J 7 ‘-7


L/J yaooo~c 30,CC0 30-000 

,6s-74 

, b-— 

‘- J .- ,65-74 

$>_-+ , k.= 

10.CC.3 lo.cmo 

>G 

D~ulI 

P... 

106 nmm 

+wGi-z..f+ 

1.

,c@.33.39.43.47.	 s . Ss. %.ti. 1931.35.3.43.47. 51. 55.59.64. 

Y.., 

Figure 19. Death rates for al 1 cardiovascular


d iseases per mi 11 ion popul at ion aged 25-84


years, 1931-61.


25

.

ease there has been an increase both in the


male and female rates.


Deaths attributable to childbearing (fig. 18)


are still a cause for some concern. The rate


in 1934 was over 400 per 

as in 1961 it declined to 

and in the intervening 

of this age range had 

percent. Nevertheless, 

million women, where35 per million women; 

period births to women 

increased by nearly 50 

deaths still occur to 

women either in childbearing or in pregnancy, 

and constant vigilance is needed to ensure that 

all women are delivered in the best of circumstances. 

The Adult–35-44 Years 

The age range 35-44 years is one similar in pattern to the preceding age range of 

25-34 years, and it is difficult to make separate comment upon the major causes of death. 

The general tretid of mortality has been downward, and improvement started in the 1930’s; 

and although interrupted by the war, in 1946 

the mortality rate carried on the trend prevalent 

before the war. It has continued downward in 

the case of the females right throughout the 

following period of 15 years, but in the case 

of the males there has been a leveling off 

of the rate around 1955, with little advance 

in mortality since that time (fig. 6). 

The principal causes of death for both 

sexes in 1931 were tuberculosis, pneumonia 

and influenza, rheumatic heart disease, suicide, road accidents, and in the case of women 

childbearing. In 1961 the pattern was coronary 

artery disease, lung cancer, road accidents, 

suicide, and rheumatic heart disease for men, 

whereas in women there was a different grouping 

of causes of death—cancer of the breast being 

first, followed by rheumatic heart disease, cerebrovascular disease, suicide, and cancer of the 

cervix. 

The change in the total mortality at this 

age range may be attributed largely to the 

drop in the tuberculosis death rates for both 

sexes, which have fallen consistently and still 

continue to fall, Pneumonia and influenza (fig. 

7), which was also an important cause of death 

in the 1930’s, has been deposed as one of the 

major killers and now appears at the bottom 

of the list. Rheumatic heart disease (fig. 20) 

has also improved considerably, but the rate 

of improvement has been greatest among the 

men, whereas among the “women it still persists as a major cause of death. Women 45 

years of age in 1961 who die of rheumatic 

heart disease will usually have acquired their 

infection of acute rheumatism some 20 years 

before, consequently we can expect that this 

rate will continue to fall throughout the next 

decade. 

But the major reason male mortality has 

differed from female mortality at this age may 

be found in the causes attributable to coronary artery disease (fig. 21). In 1931 the death 

rates attributable to this cause were 60 per 

million males and 11 per million females; in 

1961 they were 477 for males and 65 for females. Although this means there has been 

a similar proportional increase for both sexes 

of 6 or 7 times above the original rate, the 

‘EMU 

\ 

“b,, 

““k\ 

‘“’\.L 

\ ,.. \ “...,, 

-x.” L ‘+ w,. +$: Id -’,,, k , 

,,,>., y%-” 

i - J“.+, 45.54 

f

100 -’ \... 

b/

3s-44 

7. ‘\, >,,.i

25-34 

.,.


is -24 

1

iu5! 555961 

K _-_2!! Y]

1 z 135 39 43 47 35. 39. 43. 47. 5!. 55. 59.61.

Figure 20. Death rates for rheumatic heart dis.


ease per mill ion population aged 15-81+ years,


1931-61.


26

-----

FEMALE 

CANCEROFBREAST CANCER OF CERVIX

..-JV 

V7------?3%’$ 

D&A;: 

PER 

10$ 

. 

10 

1931. 33. 3. 4s. 47, 5!. 55. s).u. 

YEAR 

Figure 21. Death rates for coronary artery dis. 

ease per million population aged 25-84 years, 

1931-61. 

absolute increase among males has been much 

greater nevertheless so that coronary artery 

disease now accounts for 20 percent of the 

mortality of men 35-44 years of age. Throughout the whole period deaths attributable to this 

cause in men have risen slowly but quite consistently; and the causes for this rise are, of 

course, the subject of numerous investigations. 

Deaths from suicide (fig. 17) were fourth 

in the order of mortality in the 1930’s and 

remained fourth in the 1960’s. The pattern 

seems to be similar to the pattern for suicides 

at !he younger ages; mortality declined from 

its peak in i934 to a low point in the early 

1950; since then ithas increased slowly. 

Cancers (fig. 13) begin to appear at this 

age range as one of the major causes of death, 

and cancer of the breast (fig. 22) looms as 

a major killer among women. In the whole 

period from 1931-61 the mortality from breast 

~ ~.%k /.-~5.74 low 

—--+%~~ 

>54 

“--- -.-v-... w 

75-s4 

)EATH 

yE~E 

~ ‘“ 64 I@ •->~ A---’ ~- “-%+.. 35-44 ~$y 

Km. 100, .-A, 

\ ~,.tia.: 3544 

‘\ 

‘.+ , 

v 

25-34 

pm 

A 25-34 

10 0 

034. =. 39. 43. 47. 51. s5. 9).6L ;9:;3S. 39. 43. 47. 51. 5. 5~61. 

Figure 22. Death rates for cancer of the breast 

and cervix per million females aged 25-84 

years, 1931-61. 

cancers has fluctuated closely, about 200 per 

million adult women; and no particular trend 

is discernible. But due to the great improvement in other causes of mortality, this means 

that cancer of the breast is now promoted 

from fifth cause of death in 1931 to first cause 

of death among women 35-44 years of age. 

Cancer of the cervix (fig, 22) is also an 

important cause of death, but in contrast with 

cancer of the breast, which is stationary, this 

is tending to increase. It was introduced as 

a separate category in the Statistical Classification in 1940, and deaths remained relatively constant at between 70 and 80 per million women until 1956 when the rate began 

to increase slowly, and it is now approximately 100. It is difficult to know whether this is 

due to a true increase in the incidence of 

the disease or whether it is due to improved 

case finding and certification. 

27 
Cancer of the lung (fig. 23) in men 35-44 climacteric and the onset of senescence. It 

years of age rose from an unimportant diag- may be divided into two decades, early middle 

nosis in 1931 to be the second leading cause life 45-54 years of age and late middle life 

of death in 1961. A great deal of work has 55-64 years of age. 

been done to analyze these figures to assess In early middle age male mortality has 

whether this is a true increase or whether declined from 11.4 per 1,000 in 1931-33 to 

it is an artifact of improved diagnosis; and 7.2 per 1,000 in 1959-61, a fall of 37 perthe general conclusion is that this is a true cent. The female. rate, however, declined from 

increase in the disease. 8.2 to 4.4 per 1,000, which is a fall of 46 percent (fig. 6). 

Early Middle Age–45-54 Years The male mortality rate remained high 

during the 1930’s, reaching a peak in 1940; 

Middle age is a stage of life which seems but then there was a rapid decline during the 

to recede as the individual himself becomes war and postwar years so that by 1950 there 

older so that here the term middle-aged is had been a decline of 34 percent. But in the 

used simply as an indication of that period following decade the improvement was relaof life which lies in the middle between the tively small. 

The female mortality, however, wak improving during the 1930’s and continued to fall 

even further during the 1940’s except for a 

peak in the bad winter of 1940, and in the postwar years it has continued to fall. 

In 1931 the major causes of death were 

tuberculosis, influenza and pneumonia, rheu­

(WI-E 65”74,,.’55.M EMALE matic heart disease, cerebrovascular disease, 55-64 ...-F with bronchitis among the men and cancer of 

J

/7/ the breast among the women. In 1961 these 

f“ J 

,.,..$,’- Looc had changed to coronary artery disease, cer­ ~ 

‘+-.,, 45.54 ebrovascular disease, influenza and pneumonia, {,4@ / and bronchitis, with cancer of the lung among 

the men and cancer of the breast among the 

women. 

f Even at this stage of life the fall in respirator y tuberculosis mortality (fig. 16) has 

been of great importance in the general pattern of the total mortality. Deaths due to tuberculosis among males and females were falling S1OW1y during the 1930’s, and they continued to fall in the 1940’s. There was a rapid 

decline in the 1950’s, reducing the number 

of deaths in the period of 31 years by over 

90 percent. The disease, however, has not yet 

Ic 

been eradicated from among the middle aged as Yd_!Y!sit has been among younger people, as deaths

+.. %. 43. i% il. 55. 59.61. 1 Ii=’. 2S 43. 47 S1. 55.59, 61 still occur to people with longstanding infec­ Y 

tions. But these rates are now so low that 

there is little opportunity for further improvement. . igure 23. Death rates for cancer of the resDi ratory system per mi 11 ion population aged 25-84 Pneumonia and influenza (fig. 7) when stated 

years, 1931-61. to be a cause of death in the elderly or mid28 
dle aged may sometimes be considered as a 

nonspecific diagnosis. Therefore the fall in mortality attributable to this cause may well be 

due to improved diagnostic ability rather than 

to chemotherapy, medical care, or better smial 

conditions, Nevertheless, whatever the cause, 

the rates have fallen by over 75 percent for 

both men and women 45-54 years of age, 

The fall in these deaths has been balanced by an increase due to coronary artery 

disease (fig. 21). In 1931 only 3 percent of 

all deaths among males were attributed to coronary artery disease, whereas in 1961 the proportion was at least 28 percent. In the case 

of women the mortality in 1931 had been less 

than 1 percent, and it rose by 1961 to 7 percent of all deaths among females. It is impossible to explain the etiology of this cause of 

death in a brief note; but this subject is examined later in further detail, where it is 

concluded that this trend is a real increase 

in a new disease and is not an artifact from 

diagnostic factors. 

Cerebrovascular disease (fig. 24) has remained fairly constant throughout the 31 years 

both among men and women, and there has 

been no particular trend throughout this period. 

This disease was subject to an artifactual change 

in the method of coding with the introduction 

of the Fifth Revision of the International Statistical Classification of Diseases, but this effect 

was not so great as to distort the pattern of 

the disease. The male to female ratio from this 

type of disease has also remained fairly constant between 0,8 and 1, 

Bronchitis as a cause of death appears 

to be typically an English complaint, and it 

becomes an important feature of the mortality tables in middle age. The diagnosis of this 

cause of death was affected by the Fifth Revision, but this does not seem to have been 

as severe in influencing diagnosis in middle 

age as it was in the later stages of life. Bronchitis behaves in a manner similar to that 

of other respiratory diseases in that it has 

epidemic peaks coinciding either with an influenza epidemic or with a winter in which 

the temperature falls consistently below zero 

degrees centigrade (O C.). But if allowances 

are made for these fluctuations, the mortality remains fairly constant throughout the period 

I-MALE 75-s4 FEMALE ~ 

b—’-” 

I.CCO lo.ocm 

_ L.-.* 

..-.” “&../\ -...-\._ 

_6~74 k-65-74 

Fiaure 24. Death rates for cerebrovascul ar d iseases per mi 1’1ion population aged 25-8! years, 

1931-61. 

of 31 years. The introduction of the broad 

spectrum antibiotics in the mid- 1950’s does 

not appear to have influenced the mortality 

from this disease. 

The two most common forms of cancer 

causing death in middle age are cancer of 

the lung among men and cancer of the breast 

among women. But whereas the male lung cancer rate (fig. 23) rose consistently throughout the 31 years, the female breast cancer 

rate (fig. 22) tended to remain constant. By 

1961 cancer of the breast had become the 

first cause of mortality among women and cancer of the lung the second most important 

cause among men. There is this important 

difference in the diseases, however, because 

the etiology of cancer of the lung is known, 

there is hope that we may be able to influence the mortality, whereas the etiology of cancer of the breast is unknown. 

29 
Late Middle Age–55-64 Years 

In late middle age the mortality trend has 

been somewhat similar to that of early middle 

age, but the rate of fall has not been quite 

as steep. The male mortality has declined from 

23.7 per 1,000 in 1931-33 to 21.7 per 1,000 in 

1959-61, a fall of only 8 percent; whereas the 

female rate has declined from 17.4 per 1,000 

to 10.7 per 1,000, a decline of 39 percent. It 

is especially at this pericd of life when the 

climacteric has passed and before senescence 

begins that the human female demonstrates her 

greater viability. Female mortality at these ages 

is less than one-half of that of the male, and 

this in itself implies a considerable difference 

in the expectation of life (fig. 6). 

The killing diseases in 1931 were cerebrovascular disease, rheumatic heart disease, influenza and pneumonia, cancer of the stomach, 

and tuberculosis. By 1961 these had become 

coronary artery disease, cerebrovascular disease, influenza and pneumonia, and bronchitis, 

with cancer of the lung among males and cancer 

of the breast among females. 

As in early middle age there has been 

a great change in mortality due to tuberculosis (fig. 16) in males and females. Mortalit y began to decline in the 1930’s and continued slowly in the 1940’s, becoming mor: 

rapid in the 1950’s so that deaths due to this 

disease have now decreased by over 75 percent in the 31-year period. 

Mortality due to pneumonia and influenza 

(fig. 7) follows a trend similar to that of the 

early middle aged although the pattern is not 

quite so marked. The mortality rate for this 

disease has declined over the 31- year period 

by over 55 percent, but, as in the previous age 

group, this fall may be largely due to improved 

diagnosis of other diseases. 

Coronary artery disease (fig. 21) has changed 

from a relatively unimportant cause of death in 

1931 .to the first cause of death in 1961. Deaths 

due to coronary artery disease in 1931 accounted 

for about 3 percent of all deaths among males 

and about 1 percent of all deaths among females. 

In 1961, however, coronary artery disease was 

responsible for about 27 percent of all deaths in 

males and 15 percent of all deaths in females. 

Cerebrovascular disease (fig. 24) has altered 

little during the 31 years for both males and females and no particular pattern has evolved during this time. The male to female ratio has remained fairly constant at abut 1.2. 

Bronchitis mortality among people 55-64 

years of age has also followed no particular trend, 

The mortality rate during the 31-year period has 

remained almost constant, except for a few peaks 

caused by epidemics. 

Cancer of the lung (fig. 23) among males has 

increased considerably from 1931 to 1961. In 

1931 only 2 percent of all deaths among males 

was attributed to cancer of the lung, whereas 

in 1961 the proportion was over 13 percent. The 

mortality rate rose constantly, and cancer of 

the lung is now the second major cause of death 

among males. 

Female mortality from cancer of the breast 

(fig. 22) has remained fairly constant throughout 

the period considered, but the disease itself is 

now the third most important cause of death 

among females. 

Retirement Age–65-74 Years 

By the middle of the seventh decade the pattern of the causes of death has become typical 

of old age. Neoplastic diseases continue to take 

an increasing toll of life; but they are surpassed 

in importance by the cardiovascular and respiratory diseases, especially coronary artery disease 

and bronchitis. 

Both male and female mortality rates declined during the early 1930’s, from a peak in 

1931 to a trough in 1938. The decline for males 

was of the order of 10 percent and that for females about 14 percent during these 7 years, In 

1940, however, there was a sharp rise back to 

the original rates due to the exceptional conditions of that year. During the remainder of the 

war years and immediately afterward, the mortality rate fell by over 20 percent; but since 1948 

the male rate rose slightly and the female rate 

fell slowly. As a consequence the male to female ratio was 1.3 in 1931 and 1.8 in 1961. 

The main causes of death in 1931 were cerebrovascular lesions, which are subsequently referred to as “strokes ,“ rheumatic heart disease, 

pneumonia and influenza, bronchitis, and cancer 

of the stomach. It is interesting to note that al30 
---------------------- ----------------------------

---------------------------- --------------------------

--------------------------

-------- -------- -------- --

--------------------------

--------------------------

-------- -------- -------- --

-------------------------- -------- -------- --

----------------------------

though the absolute level of mortality was different between the two sexes, the pattern of disease and the order of frequency were the same, 

In 1961 the main causes had changed only 

slightly to coronary artery disease, “strokes, ” 

bronchitis, pneumonia andinfluenza, cancer of the 

lung in men, and cancer of the breast in women. 

The mortality from “strokes” (fig. 24) in 

1931 was 6.4 per 1,000 males and 5.6 per 1,000 

females; in 1961 it was 6.6 for males and 5.6 

for females. Although there has been no apparent change in mortality; it should be remembered that there was a marked increase in the 

certification and coding for this cause of death 

with the introduction of the Fifth” Revision of the 

International Statistical Classification in 1940. 

If this sudden alteration in the rates over a period of 1 year is considered to be an artifact, then 

it appears that there was a reduction in mortality from “strokes” in the 1930’s; but that since 

1941 there has been little improvement in the 

rates. The only reason this cause of death has 

fallen from first place to second is because of 

the rise in deaths attributed to coronary artery 

disease. 

Rheumatic heart disease (fig. 20). was a classification included in the International List only 

with the SiMh Revision in 1950; in the preceding 

revisions there had been a classification for 

“chronic affections of the valves and endocar -

dium” of which the major subdivision was “mitral 

valve disease. ” At the time of the dual coding 

exercise in 1949, it was decided the great majority of these deaths were due to “rheumatic heart 

disease” but that some of them would have been 

nonspecific myocardial degeneration. It is not 

possible therefore to bridge adequately the 

gap between 1949 and 1950 in the statistical certification from this cause of death. But it is possible to consider the trends within each decade 

(tables H and J and fig. 20). 

There was, however, a marked decline of 

over 70 percent in the mortality from rheumatic heart disease between 1931 and 1949. 

In 1931 the rates per 1,000 were 3.96 males 

and 3.71 females, in 1949 they were 1.19 males 

and 1.10 females. In the period between 1950 

and 1961 there was also a considerable fall of 

about 40 percent in these rates. It is thus apparent despite difficulties arising from statistical 

artifacts to making valid comparisons, there has 

been a considerable reduction in the diagnosis of 

valvular or rheumatic heart disease as a cause 

of death at this age. 

Coronary artery disease (fig. 21) was introduced as a statistical classification in 1931, 

prior to which time it had been coded under angina pectoris. During the foliowing 31 years this 

cause of death has continued to rise for both 

sexes and all ages as shown in table 1?and figure 21. 

In England and Wales there has been a rise 

in 31 years in deaths attributed to coronary 

artery disease or to angina pectoris of between 

sevenfold and eightfold; and this rise has been 

similar in both sexes. 

Table G. Ratio of male to female death rates for all causes, by age and specified ,, years: England and Wales 

Age 1961 1951 1931 

Under 1 year--= 1.26 1,31 1.29 1,30 

1-4 years 1$30 1.14 1,12 1.14 

5-9 ears 1.45 1.41 1.21 1.15 

10-11 years 1.60 1.54 1.21 0.99 

15-24 years 2.19 1.41 1.45 1.08 

25-34 years 1.58 1.24 1,63 1.(S6 

35-44 years 1.38 1.28 1,50 1.28 

45-54 years 1.63 1.62 1.52 1.40 

55-64 years 2.06 1,87 1.63 1,36 

65-74 years 1.76 1.59 1.40 1.32 

75-84 yeara . ------- 1,42 1.31 1,33 1.21 

85+ years 1.13 1.24 1.07 1.16 

31 
----------------

Table H. Death rates for rheumatic heart 

sex, for specified 

45-54


years 

Male Female 

1961----------------- 0.18 0.28 

1951----------------- 0.23 0.36 

1949----------------- 0.29 0.38 

1941----------------- 0.46 0.46 

1939----------------- 0.49 0.46 

1931----------------- 0.63 0.65 

Percent change, 

1961/31------------- 0.29 0.43 

Table J. Death rates for all cardiovascular 

by sex for specified 

4,5-54


years 

Year 

Male Female 

1961----------------- 2.66 0.90 

1951” 2.30 1.10 

1949----------------- 1.87 0.94 

1941----------------- 1.84 1.14 

1939----------------- 2.23 1.29 

1931----------------- 1.83 1.37 

Percent change, 

1961/31------------- 1.5 0.66 

disease per 1,000 population 45-84 years, by 

years: England and Wales 

55-64 65-74 75-84


years years years 

I


Male Female Male Female Male Female 

Rate per 1,000 population 

0.27 0.41 0.37 0.56 0.46 0.72 

0.41 0.53 :.;; 0.88 1.15 1.37 

0.63 0.59 1.10 1.90 1.99 

0,91 0.77 1:83 1.64 3.13 3.02 

1.04 0.87 2.16 1.98 ;.;; 3.92 

1.59 1.42 3.96 3.71 e 7.48 

0.17 0.29 0.09 0.15 0.06 0.10 

diseases per 1,000 population 45-84 years, 

years: England and Wales 

55-64 65-74 “ 75-84


years years years 

Male Female Male Female Male Female 

Rate per 1,000 population 

8.04 3.13 20.7 11.9 51.5 38.4 

7.62 3,68 22.5 14.2 60,4 ;$: 

6.46 3.11 17.8 11.8 46.2 

5.70 3.33 16.3 11.9 50.9 43:0 

6.87 4.04 19.3 14.1 59.7 50.4 

5.33 4.11 17.2 14.1 47.0 44.0 

1.5 0.75 1.20 0.84 1.10 0.87 

In contrast to coronary artery disease all 

cardiovascular diseases have shown different 

trends according to sex (table J and fig. 19), 

Ifall such diseases are considered together, 

the mortality for males has increased at65-74 

years of age by 21 percent in 31 years although 

the rate during the last 10years has’beenrelatively constant, The mortality for females has 

fallen by 16 percent in the 31years and the rate 

has continued to fall during the last 10 years. 

If we were to consider these statistics alone, it 

would suggest that some cardiovascular diseases 

that had a relatively high incidence amongwomen 

have been replaced by anotherdisease thataffects 

men more severly than women. Thus itisprobable that the increase in coronary artery disease 

and the fall in rheumatic heart disease is not 

mainly an artifact due to changes in diagnostic 

fashion orstatistical coding but it is a real trend 

with one disease declining and the other rising. 

32

.

Mortality due to pneumonia and influenza 

(fig, 7) has shown a decline for both sexes; but 

deaths due to these causes tend to fluctuate from 

year to year according to the weather or the 

epidemicity of influenza itself, with typical peaks 

in 1933, 1937, 1940, 1943, 1951, and 1957. There 

appears to have been a general improvement by 

both sexes between the early 1930’s and the end 

of the war, but in the postwar era little improvement has been detected, The relative effects of 

the introduction of therapy and improved social 

condition cannot now be assessed accurately. 

Bronchitis as a cause of death was severely 

influenced by the introduction of the Fifth Revision when according to the revised coding instructions the mortality attributed to this cause 

more than doubled. Hence it is not possible to 

discuss the changes in these deaths as a continuous function over 31 years, but each decade should 

be considered separately. Between 1931 and 1939, 

according to the Fourth Revision, deaths from 

bronchitis were declining quite rapidly in both 

men and women. The rate for men was 3.3 per 

1,000 in 1931 and 1.8 in 1939. For women the 

rate fell from 2.7 in 1931 to 1.1 in 1939. The year 

1940 was an exceptionally bad one for bronchitis 

due to the special climatic conditions as well as 

to the change in code. Since 1941 the bronchitis 

death rate among men remained relatively constant at about 4.5 per 1,000, except for epidemic 

peaks, until about 1954. Since this date there has 

been a definite rise in the general level of the 

death rate so that in 1961 the rate was 5:5 per 

1,000. Among women mortality from bronchitis 

since 1941 has shown a constant decline with 

small epidemic peaks, arid in 1961 it had fallen 

to 1.2 per 1,000. 

All neoplastic diseases (fig. 13) among men 

remained constant from 1931 until approximately 

1954 when there was a steady rise in the total 

rate, from 10.5 in 1931 to 11.7 in 1961; but among 

women there has been a steady but small decline 

throughout the whole period— in 1931 the female 

cancer rate was 7.9 and in 1961 it was 6.1, a fall 

of 23 percent in 31 years. 

The pattern of cancers, however, has changed. 

Among men stomach cancers (fig. 25) have declined by 25 percent and respiratory cancers (fig. 

23) have increased sevenfold. For women stomach cancers have fallen by 42 percent and breast 

cancers have fallen by 13 percent, and cancer of 

(w-E 

-L’”——— 75-84 

-’--- -./+- -.... %-= 

&74 

1C90 b--- -.., -.,-. 

, 

.

‘-&..._% lax 

55-64 

“--’+.. D&ATTzH 

PER 

I@ 45-54 

/-.,&,.”~”\.L- 100 $... .....* 100 

‘.wii/.<, 

35-44 

10 

6 ?s. 39. 43. 47. 5!. 53. 59.6I. I< 

Y1 

‘EhmLE 

-’~~ 75-84 ‘---\ ., 

.-/-- .\ 

‘- -,,, 

65:;4 

-’- ..%. 

.\ 

“-”v, 

“-’..-.. 

5564 

*-W 

-K 45.54 

S-5. ?s. 43. 47. 51. 5. 59.63 i 

Figure 25. Death rates for cancer of the stomach


per mi 11 ion population aged 25-84 years, 193[-61.


the cervix uteri has declined little and that mostly 

during the latter 1950’s. 

Old Age–75-84 Years 

I 

Until 1942 the Registrar Gen&al did not 

tabulate separately persons over 80 years of age, 

and, consequently, prior to this datq it has been 

necessary to include into the old age group all 

persons over 75; subsequent to that d~te only the 

decade 75-84 is considered (fig. 6). 

Above the age of 75 cardiovascular and respiratory diseases are the most prominent causes 

of death. 

. The main causes of death in 1931 are similar to those at 65-74 years of age and are the 

same for both sexes: “stroke, ” bronchitis, pneumonia and influenza, rheumatic heart disease, and 

all cancers, with cancer of the stomach prominent 

in both sexes. 

33

In 1961 these hadchanged to’’stroke’’, coronary artery disease, pneumonia and influenza, 

bronchitis, and all cancers, with cancer of the lung 

as the most important site among men and cancers of the stomach and of the breast among 

women. 

At this age the mortality attributed to 

“strokes” declined during the 1930’s, but then 

there was a discontinuity due to the change in 

coding introduced by the Fifth Revision. Since 

1942 the trend appears to have been upward for 

both sexes. 

Mortality from the cardiovascular diseases 

(fig. 19) has shown trends similar to t@ose discussed in detail above. Deaths due to all cardiovascular diseases have increased for men and 

decreased for women. Rheumatic heart disease 

has declined as a cause of death, but coronary 

artery disease has more than compensated for 

this decline. 

Mortality from all the respiratory diseases 

(fig. 26) seemed to improve from 1931 until about 

1948; since then the rate among men, especially 

for pneumonia, has increased but the rate among 

women has continued to fall a little, although the 

epidemicity of respiratory diseases makes it 

most difficult to detect trends accurately. 

Deaths from malignant neoplasms (fig. 13) 

among men have increased, especially from cancer of the lung, whereas among women neoplastic deaths have declined, especially from cancer of the stomach. 

Senescence–85 + Years 

Over the age of 85 considerable difficulties 

arise in interpreting any trends in mortality. 

Declaration of the age of the deceased upon the 

death certificate is not accurate, anc.1certification 

by the doctors is not so careful, while multiple 

causes of death due to general degenerative diseases give rise to many problems in classification. 

AS a consequence no discussion on individual 

causes of death at “this age is given. 

Total mortality at this age improved slightly 

during the 1930’s, continued to improve during the 

war years, and has remained constant (fig. 6). 

The improvement during the war years (except for 1940) was probably a real one and was 

also detectable among persons 75-84 years of 

age. It is interesting to speculate why in England 

75-84 ff’vi

5S-64

19.% 2.5394347 s155s964 was5394347st5559ti


1 

t-w

a-l , ‘--l 

2S-34 3 J.. .


Iw. s.s. a.m. sl. ss. s.a. 1%4. s.32.43. 47.51 .55.59.’$.


1 101


193.s.3.43. 47.5 !.s6.S’.6. 193.35. 3.43. 47.31 .55. *A.


r..r 

Figure 26. Age-specific death races for al 1 respiratory diseases per million population, 1931-61. 

34

and Wales old age should have benefited from the 

shortages and sufferings of the war years. This 

effect may be due to improved nutrition and better 

social care; communal kitchens were organized in 

many areas during the war to economize the food, 

and all people in the area could have at least one 

cooked meal a day at a low cost. It is probable 

that for the elderly who frequently live alone 

this was an improvement both in their nutrition 

and in their welfare as it brought them into 

closer contact with the community so that when 

they fell ill medical provision could be made for 

them more easily. 

MALE TO FEMALE MORTALITY 

RATIO 

One feature of the mortality rates throughout 

the whole period 1931-61 is the widening of the 

gap between the sexes. This has occurred at 

every age from 1 to 84, and it has occurred for 

almost every disease which has been considered; 

there are some factors in modern society which 

are inimical to the survival of the male which 

are beneficial to the female. 

Figure 5 and table F show. that even in 1931 

the male was at a disadvantage compared with 

the female at all ages except 10-14 years; but 

by 1961 at all ages from 1-84 years the male was 

suffering a death rate at least 30 percent higher 

than the female rate, and in some age groups 

more than double. Figure 27 analyzes these 

ratios in detail for each age group and for years 

between 1931 and 1961. 

In childhood between 1 and 14 years of age, 

the death rate for boys in 1931 was approximately 

10 percent higher than for girls, and much of this 

difference was due to a higher death rate for accidents and respiratory diseases. By 1961, the gap 

between the two sexes had widened to over 40 percent, largely due to accidentd both at home and on 

the road. In the case of respiratory diseases it is 

apparent that despite modern therapy boys still 

fare worse than girls, and even in malignant diseases there is a marked disadvantage to the male. 

During adolescence and early adult life 15-34 

years of age, the male disadvantage in 1931 was 

only of the order of 6 to 8 percent. This was due 

partly to deaths attributed to childbearing, but 

mainly due to incidence of respiratory tuberculosis and rheumatic heart disease which were 

particularly fatal to young women at this time. 

2.5-

r’15-24 

i“; 

1.5. 

\ 

I 

19313335373? 4143ye: 47495153555? S961 

2.* 

Maid 

Fmn.1. 

Ratio of Death Rata 

1.5 

\ 

I 

O.% 

?931 33 35 37 39 41 43 45 47 49 51 53 S5 57 59 61 

Year 

Figure 27. Age-specific ratio of male mortality


to female mortality, 1931-61.


35

Almost all of the other diseases in this age group 

were higher among men. The picture altered 

completely in 1961; males 15-24 years of age 

now have a mortality rate more than double that 

of women. Although the absolute male rate has 

improved during the 31 years, it is the greater 

improvement among the females which is so 

dramatic. Almost all of this difference in sex 

mortality during adolescence can be attributed to 

deaths from violence, especially to deaths from 

road accidents which are five times as frequent, 

and from suicide which are twice as frequent. 

During early adult life, 25-34 years of age, 

in 1961 males have a mortality rate 60 percent 

higher than their wives or sisters. Most of this 

difference can be assigned to four causes of 

death—road accidents, where the male rate is five 

times that of the female; suicide, where it is 

twice as high; coronary artery disease, where it 

is eight times as high; and cancer of the lung, 

where it is three times as high. 

In middle life, 35-64 years of age, the male 

death rate in 1931 was approximately 35 percent 

higher than the female rate, but by 1961 the relative difference between the two ‘sexes had widened 

to approximately 60 percent, and this gap was 

especially wide at 55-64 years of age when the 

male rate was double that of the female. The 

causes for this gap in 1931 were respiratory 

diseases, tuberculosis, road accidents, and suicide; in 1961 the relative increase in the male 

rate was due to coronary artery disease, cancer 

of the lung, road accidents, and suicide. In the 

case of both coronary artery disease and of lung 

cancer the male death rates were at least four 

times higher than the female rates, and in the 

case of road accidents and suicide it was approximately twice as high. 

For elderly persons, 65-84 years of age, the 

male death rate in 1931 was about 25 percent 

higher than the female rate, whereas in 1961 

it was 60 percent higher. In 1931 the main contributors to this excess were tuberculosis, respiratory diseases, all cancers, and suicide; in 

1961 the male killers were coronary artery disease, which was twice as high, bronchitis four 

times as high, and lung cancer seven times as 

high. 

At the advanced ages, over 85 years, the 

male to female ratio has remained relatively constant at approximately 13 percent to the disadvantage of the male. This ratio of the relative 

difference between males and females is of fundamental importance and offers opportunities for 

public health administrators and epidemiologists 

to speculate on the reasons why this should have 

occurred and to investigate whether it would be 

possible to reduce male mortality. If mortality 

of males had improved at a rate similar to that 

of females, there would be a saving of approximately 20 percent of male deaths. 

When we consider why the excess of male 

deaths has continued to increase, it is clear that 

the causes are the same at most ages—road accidents, violence, suicide, bronchitis, lung cancer, 

and coronary artery disease. Why should the 

male have an excess of suicides and accidents 

at all ages when he has so many other opportunities 

of killing himself? Is this symptomatic that many 

of the other predominantly male diseases are 

also expressions of a “deathwish”? Bronchitis 

and lung cancer could certainly be decreased by 

reducing cigarette consumption and controlling 

urban air pollution; coronary artery disease 

could probably be decreased if men would reduce 

their weight and take more exercise. 

Suicide and road accidents are, however, two 

problems which have proved very intractable and 

may be symptomatic of the whole problem. Modern society has not the will to take the steps that 

are known to he effective. 

DISEASE-SPECIFIC MORTALITY 

In the following section it is proposed to 

discuss the trends of mortality within disease 

groups. 

Infectious Diseases 

Because of coding and classification conventions, influenza and pneumonia are excluded 

from this group of diseases and will be considered 

in detail under the respiratory diseases. 

Major advances in the last 31 years have 

been made in the conquest of these diseases (fig. 

28), and there have been three lines of attack--ape. 

cific chemotherapy, immunization programs, and 

advances in the social environment, As in any 

warfare, it is impossible to determine to what 

extent the ultimate victory was due to any spe. 

cific ally, and after the battle all that can be done 

36 
-----

3000 MALE 3c300 

FEMALE 

1 I 

\ 2C0 .,,

65-74 

S-64 

I00 1.....”100 ,.,,,,,\ 

lv3135s94247515559f4 191t35343.95555is 

2.Lxx3i 1 

‘“~ 

IW35294247515S 5964 J9335 3943051 55s9a 

v.., 

Figure 28. Age-specific death rates for all infectious diseases per million population, 1931-61. 

is to indicate what sections of the battlefield were 

under attack from which army when abulgeappearedin the line. 

The extent of the victory is clear. In 1931 

there were 51,441 deaths attributedto infectious 

diseases, 35,818 of them due to tuberculosis; 

and there were also 47,982 deaths due to influenza and pneumonia. In 1961 there were 5,639 

deaths due to infectious diseases, 3,334 from 

tuberculosis; and the number of influenza and 

pneumonia deaths had fallen to36 ,377. 

In 1931 the battle against the enteric fevers 

or the socially communicative diseaseswasover, 

with only cleaning up operations to be completed; 

but the personally communicative diseases were 

still a serious force. In childhood scarlet fever, 

which had been such a virulent disease in the 

earlier part of the century, had lost its effectiveness for no apparent reason; but diphtheria, 

measles, and whooping cough were each taking 

a heavy toll and each was to yield to a different 

attack. 

Deaths from diphtheria (fig. 8) continued to 

increase during the 1930’s despite attempts by 

certain lo:al authorities and isolated general 

practitibn;rs to encourage the use of immunization. Only with the threat of war and the possibility of a pandemic in the shelters and evacuation areas was the responsibility for the immunization program accepted by the Government and 

free immunization was successfully carried out 

by the local school and health authorities. There 

was an epidemic in 1941 when fortunately many 

school children were immune, and the brunt of 

the attack was borne by the preschool children 

who had not yet been fully immunized. This was 

the last push by the corynebacterium, and by 1949 

the mortality had fallen by 98 percent; and by 1959 

no deaths from this cause occurred in this country. 

Victory had been achieved by general immunity. 

But between 1922, when the Ministry of Health 

in its circular No. 68/Meal first gave instructions 

on the Schick methcd of active immunization, and 

1940 over 49,000 children had died from a disease that was preventable. 

Whooping cough (fig. 10) was not defeated so 

dramatically. There was a slow improvement during the 1930’s and the rate of fall increased with 

the introduction of sulfonamides. There was a 

sharp epidemic peak in 1941, but then the rate 

of fall continued throughout the 1940’s. A vaccine 

37 
was introduced in 1950 which accelerated the 

improvement, but unfortunately the disease still 

causes an occasional death. This victory was 

an allied one between chemotherapy, immunization, and improved social conditions. 

Measles (fig. 9) remains a dangerous disease 

in childhood; there was a peak in the mortality 

in 1934, and since then every epidemic peak (except 1961) has been lower than the preceding peak. 

Most of the deaths from measles are the result 

of complications either of pneumonia or encephalitis; chemotherapy has controlled the pneumonic 

complications and hospital care is usually successful in the management of encephalitis. No 

specific chemotherapy nor any vaccine was available for this disease by 1961. So in this case the 

success is largely due either to a loss of virulence 

by the virus, or to medical success in the management of complications, or to improved social 

conditions. 

Tuberculosis (figs. 11 and 16) is clearly a 

disease that has been defeated by specific chemotherapy. There had been small but definite advances during the 1930’s partly due to improved 

social conditions but also as a result of sanatorium 

care, collapse therapy and isolation of contacts, 

and identification of infectious cases by tuberculin testing. But the rate of progress was very 

slow, and in the older age groups mortality 

was rising. It was a particular distressing feature of the mortality that the groups most affected 

were women in early reproductive life, 15-24 

years of age, and men in early middle life, 45-54 

years of age. During the war years this advance 

continued despite unfavorable conditions. 

In late 1946 streptomycin was first heard of 

in this country, and when the first supplies became available in 1947 the Medical Research 

Council immediately organized a controlled trial 

in a select number of hospitals which was so 

successful that supplies became available for use 

in other hospitals in late 1947 and early 1948. 

The effect, especially among young women, was 

dramatic; their mortality fell by 90 percent in 

the next 5 years and had fallen by 99 percent 

within 10 years. The reduction in the older age 

groups was not quite so sharp but was nevertheless very satisfactory. There was some hesitation 

in the rate of improvement in 1953-54, probably 

due to development of a resistance to therapy; 

but fortunately new drugs became available and 

the advance continued. This complete victory 

was largely due to chemotherapy. 

Neoplastic Diseases 

Throughout the 31 years there has been a 

small but constant rise in death rates attributed 

to neoplasms among men and a small decline 

among women (fig. 13). There has been no important change in the classification of these diseases during this period, and the coding changes 

of 1940 do not appear to have affected seriously 

neoplastic diseases. 

Diagnostic changes have, of course, been 

considerable; and the advances in surger y, radiotherapy, and even chemotherapy have been important. Even today it is realized that many neoplasms are not diagnosed until post-mortem examination and that many others could be detected 

at an earlier stage. It is difficult to say therefore 

whether there has been an increase in the incidence 

of neoplastic disease accompanied by improved 

survival rates which have resulted in a constant 

mortality or whether the total incidence has been 

level and therapy has been relatively ineffective. 

When specific sites are examined, however, 

it is possible to make some positive statements 

about trends. Three neoplasms” account for almost half the total deaths—cancer of the stomach, 

cancer of the lung and bronchus, and cancer of 

the female breast. The trends for each of these 

sites have been different. 

Cancer of the stomach (fig. 25) at all ages 

below 75 and for both sexes has declined as a 

cause of death throughout the period. It is only 

possible to speculate on the reasons for this. 

Stomach cancer has always been a disease associated with poverty and malnutrition. In England and Wales there is a steep social class gradient in the mortality, and it is highest in the industrial areas of the North and in Wales. It is 

exceptionally high in parts of rural Wales. As 

prosperity has increased and nutrition improved 

the incidence of the disease has declined. Although extensive palliative surgery is performed 

for this disease, it seems improbable that improved treatment has affected mortality during 

this period. Therefore, it is concluded that this 

38 
is a disease of declining incidence, declining 

mortality, and of doubtful etiology. 

hfortalitj from cancer of the female breast 

(fig. 22) has remained constant during the whole 

period, and the pattern of the disease is the 

same in 1961 as it was in 1931. There have been 

no advances in diagnosis, very little advance in 

therapy, and no decline in the survival rates. AS 

other causes of death among women are so low, 

cancer of the breast becomes the most important 

cause of death in middle-aged women, 45-54 

years of age. This is a disease of constant incidence, constant mortality, and of unknown etiology. 

Cancer of the cervix (fig. 22) was classified 

separately in 1940 and since then the mortality 

has increased slightly. Diagnostic facilities have 

improved, and although cytology has not been 

available on a national basis, surgery and radiotherapy have both improved. It would appear that 

this is a disease with an increase in diagnosis 

which may be a real increase in incidence but 

with little change in survival. It is, however, a 

disease curable by early detection. 

Cancer of the respiratory system (fig. 23) 

has increased at all ages and in both sexes during 

the 31-year period, and almost all of this increase 

is cancer of the lung and bronchus. It is over 14 

years since papers were published indicating 

cigarette smoking as an important cause of this 

disease, and it is 3 years since the Surgeon 

General and 2 years since the Royal College of 

Physicians declared the case proved; but mortality continues at a rate of 23,000 per year and 

its cause is unchecked. It is interesting to note 

that among men 25-54 years of age the mortality 

from this disease has not risen during the last 

5 years, and it is possible that an equilibrium 

between the etiological agent and the disease has 

been reached. This is a disease of increasing 

incidence and increasing mortality with a known 

preventable cause. 

There are many reasons why leukemia (fig. 

14) has shown an apparent increase at almost 

all ~ges since 1931. The total number of deaths 

attributed to leukemia and aleukemia in 1931 

was 1,272, in 1961 it was 2,645. The effect of 

this increase on the total death rate was negligible but the reasons are difficult to determine. 

There has been increased interest in the disease 

with improved hematological laboratories and 

an awareness by doctors that many of the older 

patients formerly believed to be suffering from 

wasting diseases are really cases of chronic 

lymphatic leukemia. Acute leukemia in childhood 

has also increased, and again it is impossible 

to state whether this is due to an artifact or is 

a real increase. Leukemia is therefore a malignant disease with increasing mortality for reasons 

unknown. 

Cardiovascular Diseases 

Although there have been no extensive 

changes in the coding and classification of infectious and neoplastic diseases, this is not 

true for the cardiovascular diseases. This group 

of diseases has been especially affected by changes 

in nomenclature, methods of diagnosis, classification, and coding instructions. This is so much 

so that it is difficult to trace a continuous thread 

through the whole 31- year period. 

As seen in table C, the alteration from the 

Fourth to the Fifth Revision of the International 

List in 1939-40 caused a large shift in coding 

from arteriosclerosis to cerebrovascular disease 

and from m yocardial degeneration to bronchitis. 

The extent of these changes were different for 

different age groups. Table C indicates that when 

the Fifth Revision was replaced by the Sixth in 

1949-50, there was a smaller shift back again 

from respiratory diseases to the heart diseases, 

and within the cardiovascular system there was 

a large increase in hypertension at the expense 

of arteriosclerosis and nephritic disease. The 

sharp rises and falls between 1939 and 1940 

and between 1949 and 1950, which are seen in figures 19-21, 24, and 26, are largely due to artifacts 

of this kind. 

There has been a large increase over 31 

years in deaths attributed to the vascular system 

including vascular lesions of the central nervous 

system (fig. 19). In 1931 there were 151,000 

deaths, or 28 percent of the total, whereas in 

1961 they had risen to 282,000, or 51 percent of 

the total. 

But the importance of this rise must be overemphasized, it is largely due to two factors—the 

aging of the population and the relative decline 

of other diseases. If the age-specific death rates 

39 
---------- ---

are compared in figures 19 and 24, it is clear 

that there have been no startling rises in the 

age-specific mortality from all vascular diseases, 

and among women there have been some falls. 

Table J summarizes some of the death rates 

for the cardiovascular diseases in 10-year-age 

groups from 45-84 years, and figure 19 shows 

the rates for ages 25-84 years. There was a rise 

in mortality from all cardiovascular diseases between 1930 and 1939 for all men over 45 years of 

age and women over 65 years, but this rise was 

artificially interrupted by the change in coding 

methods introduced in 1940. During the war the 

rates continued to rise slowly, but there was a 

sharp upturn in the years 1947-49. Since 1950, 

however, over the age of 65 there has been a 

decline for both males and females, whereas 

under the age of 65 there has been a rise in the 

male rate and a decline in the female rate which 

has produced the widening gap in the male to 

female ratio which was noted previously. Over 

the whole period 1931-61 the male rate between 

ages 45 and 64 years rose by about 50 percent, 

whereas the female rate fell by 30 percent. Between ages 65 and 84 years the male rate rose 

about 15 percent and the female rate fell 15 

percent. 

Cerebrovascular disease (fig. 24 and table K) 

declined slowly during the 1930’s especially at 

ages over 65 years. In 1940 with the Fifth ReTable K. Death rates for all cerebrovascular 

vision there was a sharp increase due to the 

shift of deaths formerly attributed to arteriosclerosis; since then there has been very little 

change in mortality. 

This disease which caused 77,000 deaths in 

1961 has remained constant in its sex and age 

pattern for 20 years, the only disease other than 

cancer of the breast which has done so. Only at 

ages 75.84 years is there any suggestion that 

there may have been a minor increase in the 

mortality rate. 

In contrast rheumatic heart disease (fig. 20) 

has shown a marked decline in both sexes and 

at all ages. In 1961 there were only 7,000 deaths 

attributed to rheumatic valvular disease. The 

fall from 1931-61 at the younger ages 15-24 

years has exceeded 90 percent, in middle age 

the fall has been less steep, but in old age once 

again the improvement has been greater than 90 

percent. Both sexes have benefited by similar 

amounts. Although there were changes in the 

coding systems which affected this group of 

diseases, these changes did not seriously interrupt the trends (table H). 

It may be safely deduced that there has been 

a real fall in the mortality from rheumatic heart 

disease, and that effective treatment of early 

rheumatic carditis in the acute stage will further 

reduce the rates in middle and advanced ages in 

the future. 

diseases per 1,000 population 45-84 years, 

by sex for specified years: England and Wales 

45-54 55-64 65-74 75-84 

years years years years 

Year 

Male Female Male Female Male Female Male Female 

Rate per 1,000 population 

1961 ----------------- 0.44 0.46 1.85 1.44 5.57 5.58 19.14 17.79 

1951 ----------------- 0.49 0.57 2.04 1.95 7.30 6.45 19.47 18.40 

1949 ----------------- 0.46 0.54 1,92 1.82 6.55 6.11 16.14 16.23 

1941 ----------------- 0.49 0.62 2.09 2.02 6.46 6.14 17.41 15.75 

1939 ----------------- 0.48 0.51 1.85 1.75 5.58 5.02 13.75 12.63 

1931 ----------------- 0.44 0.52 1.80 1.63 6.44 5.58 16.29 15.32 

P~~:~$lchange, 

1.00 0.88 1.02 1.00 1.18 1.16 

* 

40 
-----------------

--------- --------

� 

The picture for coronary artery disease (fig. 

21 and table L), however, is entirely different. 

Coronary artery disease was a term introduced 

to the International Statistical Classification in 

1931 when the total number of deaths attributed 

to this cause together with angina was 6,628; 

since then they have continued to rise until 1961 

when these causes were responsible for 95,000 

deaths, 

The changes in coding in 1940 caused a 

small apparent drop at all ages which was counterbalanced by an increase in 1950, the net result 

being that coding cannot account for the rise in 

the disease, 

The contrast with the fall in rheumatic heart 

disease might suggest that there may have been 

a gradual shift in diagnosis by younger doctors 

from rheumatic heart disease to coronary artery 

disease. To some extent this may be true but 

close inspection of figures 20 and 21 and tables 

H and L show that the fall in rheumatic heart 

disease has been especially marked among young 

women, whereas the rise in coronary artery disease has been prominent among middle-aged men. 

The absolute fall in rheumatic heart disease in 

the 31- year period has only been of the order of 

20,000 deaths, whereas the rise in coronary 

artery disease has been 89,000 deaths. This 

would all suggest that there has been a true and 

absolute rise in deaths attributed to coronary 

artery disease. 

Respiratory Diseases 

The Sixth Revision in 1949-50 included influenza with the respiratory diseases rather than 

with the infectious diseases as studies had shown 

that the age and sex pattern of deaths from influenza in nonepidemic years was similar to that 

of pneumonia. Even in epidemic years an increase in influenza deaths was always accompanied by a peak in pneumonia deaths. In this 

report influenza deaths from 1931 onward have 

been included in all respiratory diseases and 

have been excluded from the infectious diseases. 

Coding changes with the Fifth Revision in 

1939-40 were severe, and many deaths which had 

formerly been attributed to the cardiovascular 

system were now assigned to the respiratory 

system, especially to bronchitis. This was largely 

due to the change in coding instructions which 

now allowed the coding clerks to take cognizance 

of the doctor’s statement of the underlying cause 

of death rather than to compel them to allocate 

an arbitrary priority to certain causes when there 

were multiple causes of death given in a certificate. 

Figure 26 shows that there was a marked 

discontinuity between 1939 and 1940. Some of 

this was due to these coding differences but part 

of this difference was a real one due to the special 

conditions of that year, 

Table L. Death rates for 

sex 

coronary artery disease per 1,000 population

for specified years: England and Wales 

45-84 years, by 

45-54 55-64 65-74 75-84 

years years years years 

Year 

Male Female Male Female Male Female Male Female 

Rate per 1,000 population 

1961 ----------------- 1951 ----------------- 1949 ----------------- ;;;; -

2,04 

1.44 

1,15 

0.55 

0.68 

0.33 

0.26 

0.22 

0.12 

0.13 

6.04 

4.39 

3.56 

1.51 

1.99 

1.63 

1,25 

1,05 

0.51 

0.59 

1;. ’22 5.94 

4.43 

7:27 3.42 

3.45 1.55 

3.93 1.73 

22.63 

15.19 

1:;:; 

5.82 

13,14 

8.76 

6.04 

2.78 

3.30 

1931 ----------------- 0.27 0.05 0.78 0.23 1.78 0.71 2.31 1.26 

Percent change, 

1961j31------------- 7,6 6.6 7.7 7.1 7.4 8.4 9.8 10.4 

41 
-- ----

-----

-----

-------

------

There appears to be only two major influences that cause a marked fluctuation in the 

total mortality rate of an individual year in England and Wales, and these are either a severe 

cold winter o“r an influenza epidemic. A cold 

spell in England in which the temperature falls 

below O°C. for a period of a month is rare but 

this occurred in 1929 and 1940; and in each of 

these years there was a considerable increase in 

total mortality, and most of the excess mortality 

occurred in the winter quarter January to March. 

Influenza epidemics, on the other hand, may 

occur at any time of the “year and tend to be 

cyclical. 

Epidemics which had an appreciable effect 

on total mortality occurred in 1933, 1937, 1943, 

1951, and 1957. 

The trend of mortality during the last 31 

years from all respiratory diseases has been a 

decline for both sexes and at all ages. 

The decline at the younger ages has been 

very marked, and at ages under 2.5 years, the 

reduction is of the order of 80 percent of mortality. Much of this improvement may be attributed to improved therapy; but it is interesting to 

note that the trend was already well established 

in the early 1930’s, and there was no alteration 

in the rate of improvement (except for 1940) 

after the introduction of the sulfonamides subsequent to 1937, or of penicillin after 1944, or of 

tetracycline after 1950. At these ages the rate 

continued to fall until 1956. In 1957 there was a 

peak due to the influenza epidemic of that year 

which especially affected the younger population, 

and subsequent to that outbreak the long-term 

trend has completely altered and now appears 

to be constant. 

At ages between 45 and 54 years there have 

been falls of the order of 60 percent over 31 

years in the respiratory mortality, and once 

again the introduction of the antibiotics does not 

appear to have modified the trend; but this has 

been altered after the epidemic of 1957. 

Violent ‘Deaths 

Violent deaths in 1931 accounted for only 

21,578 deaths and in 1961 for 23,314. Within the 

various categories of violence, the pattern of the 

causes of death remained constant as is shown 

by the total number of deaths occurring in 1931 

and 1961. 

ca”seofdea

Total-- 21,578 100 23,314 100 

Suicide 5,147 24 5,200 22 

Homicide 190 1 255 1 

Motor vehicle 

traffic accidents 5,818 27 6,544 28 

A:::::ntal 

5,632 26 5,376 23 

All other 

violent 

deaths 4,791 22 5,939 25 

Within this constant pattern, however, mere 

have been important changes in the age-specific 

mortality (fig. 29). All violent deaths at ages 1-14 

years remained fairly constant from 1930-39, rose 

sharply in 1940, and then declined rapidly until 

1954; since then they have been fairly constant. 

At ages 15-24 years, however, there was a constant rate between 1930 and 1939 and a sharp rise 

in 1940 with a fall which persisted only until 1949; 

since then there has been a sharp and continuing 

rise in both sexes. In adult and middle age there 

was the same fall in the later 1940’s and a small 

rise during the 1950’s; this pattern was repeated 

in the older ages. 

Suicide, however, has had an interesting 

pattern (fig. 17). The suicide rate for most ages 

increased between 1930 and 1933, but then it 

started to fall and this fall was increased during 

the war years. Suicide unlike most other causes 

of death did not show the sharp peak in 1940 

and reached a trough in the period 1942-44; 

this pattern being most clearly demonstrated by 

the age groups 45-64 years in both sexes. 

In the postwar years there was a rise in the 

suicide rate at most ages until approximately 

1950 when a divergence appeared. In the last 

decade the female suicide rate has continued to 

rise at all ages, but the male rate has remained 

constant over the age of 45 years and has only 

risen at ages under 45 years. Despite this 

42 
.

10.0001 MALE 

10.000 

FEwLE 

D-* ..-..: \ Mt. 

n, 

I@ ,\I 

,.+.., ‘L< ‘V’7544 

Looo k 7-

IoOl 

1,nn 

ml%n4247s15252 a1231 sw4347545swt4 

la ‘& %29424724%*U lw%39424i E45s2u 

2.000 

. 

“1 

I-4 ~ 

“1 

i. lb\ 

. 

I 

I..., 15-24/’ 

X2 “\ ) 

-v $+, ,,., 10 ,, L__3_JL 1932s39434751ss 59a 15@43S 39434751 5S 5961 

Y.,* 

Figure 29. Age-specific death rates for all vio­


lent deaths per million population, 1931-61.


divergence, however, it remains true that at 

all ages the male suicide rate is greater than 

the female. 

Deaths due to homicide.in England and Wales 

have usually averaged about 200 per annum; but 

since 1956 there was a slight increase, and the 

255 in 1961 was a maximum for the 31-year 

period. 

Motor vehicle traffic accidentshave been very 

remarkable; the number of vehicles registeredin 

1931 was 2.0 million and in 1961 this had risen 

to 9.2 million, but in contrast the number of deaths 

had remained almost constant. The age pattern 

had altered, however. The rates for children had 

fallen slowly during the 1930’s, rose in 1940 

and 1941, but have continued to fall ever since. 

In absolute contrast with this there has been a 

sharp rise in the mortality at ages 15-24 years, 

the male mortality in 1948 was 150 per million and 

in i961 it was 418. The female rates, however, 

rose from 20 td 79, an increase to both sexes 

of approximately 3 times. At all ages above 2.5 

the trends of mortality from road accidents have 

been simi~ar, a small decline from 1930-38, a 

peak from 193%41, a fall from 1942-48, and a 

subsequent rise, which approximately doubled the ,. moriahty rates in i3 years. 

Deatlis from falls have not been tabulated 

in detail in ihik study. They are largely a phenomenon of women over age 65, and the age-specific 

rates have fallen slowly probably as a consequence 

of the introduction of antibiotics. 

CAbJLATED AGE TRENDS 

The age-specific death rates for the period 

1950-61 have been analyzed mathematically in 

order to determine whether the trends have altered duting this period. This analysis was confined to the period 1950-61 because the population 

used for calculating mortality rates was changed 

in 1950 from the civilian to the total population 

thus affecting many rates. This res~”iction of the 

mathematical analysis should not unduly affect 

the conclusions, as by 1950 the country had recovered from the experience of the ‘war years and 

the fn~rtality at all ages under 75 was continuing 

to decline. 

The method used in this analysis was to calculate the logarithm of the sex- and age-specific 

death rates an@to fit these figures with a series 

43

------

------ ---------

--------- -------

-------

-------

-------

-------

-------

-------

-------

------- ---------

------

------ ---------

--------- -------

-------

-------

-------

-------

-------

-------

-------

------- ---------

of orthogonal polynomials using the year as the 

independent variable with 1950 being the base 

year. Standard statistical tests were then applied 

to determine what was the lowest degree of polynomial to give a significant fit to the data. The 

orthogonal polynomials were then reconverted to 

the standard form as given in the equation 

where Y = logarithm of death rate (1) 

X = (Year - 1950) 

The equations may be interpreted as follows: b,is the logarithm of the expected death 

rate in 1950, ignoring small annual fluctuations, 

1950 being the year in which X= O. 

bl is the main trend in mortality and is the 

amount by which the logarithm of the death rate 

is changing each year. If a logarithm is changing by a constant amount, this implies that the 

death rate itself is altering by a constant percentage; bl therefore is the annual percentage 

change in the mortality. 

bz modifies bl and because it is a function of 

X2 it does so by an increasing amount each year; 

if b2 is of the same sign as blitacts as an accelerator to the rate of change, whereas if it is 

Table M. Analysis of the trend of morta li$y, by sex and age: England and Wales, 

1950-61 

Age Mean level in 1950 Trend Damping factor Turning date 

b. bl ,b2 bl12b2


~ 

All ages +1.094 Before 1950 

Under 1 year +1.539 -.023 +.0008 After 1961 

1-4 years -m.179 -.042 +.0024 1959 

5-9 years

10-14 years 

-0.139 -.052 

-0.240 -.033 

+.0035 

+.0016 

1957 

1960 

15-19 years -0.015 -.023 +.0021 1955 

20-24 years +0.151 -.027 +.0017 1958 

25-34 years +0.229 -.036 +.0018 1960 

35-44 years

45-54 years 

+0.473 -.017 

+0.918 -.006 

+.0008 1960 

After 1961 

55-64 years +1.,359 -.002 After 1961 

65-74 years -1.733 Before 1950 

75-84 years +2.10 Before 1950 

85+ years +2.403 Before 1950 

Female 

All ages +1.039 Before 1950 

Under 1 year 

1-4 years 

+1. 427 ~ � ::; 

-.025 

-.043 

-I-.OO1O 

+.0021 

Aftg6;961 

5-9 years

10-14 years -0:395 

-.050 

-.031 

+.0030 

+.0011 

1958 

After 1961 

15-19 years

20-24 years 

-0.128 

+0.021 

-.074 

-.072 

+.0044 

+.0039 

1958 

1960 

25-34 years +0. 150 -.044 +.0017 After 1961 

35-44 years +0. 360 -.012 - After 1961 

45-54 years +0.728 -.016 +.0008 1960 

55-64 years +1.107 -.014 +.0006 1961 

65-74 years +1.538 -.006 After 1961 

75-84 years +1.983 -.005 After 1961 

85+ years +2.338 Before 1950 

44 
of the opposite sign it acts as a damper and may 

in fact destroy the main trend altogether. 

b~ suggests a complete alteration in trend, 

and as it is a function of X3 may rapidly become 

dominant; but fortunately in no instance was any 

b~ factor statistically significant in the period 

1950-61. 

Table M and figure 30 give the results of 

these calculations. 

At every age b, for males was higher than 

for females, and the difference between these two 

factors within one age group is a measure of the 

ratio of the male to the female rates in 1950. 

They suggest a pattern exactly the same as in 

figure 4 and table G. The difference is greatest 

in the age group 55-64 years. 

At all ages below 65 in the males and below 

85 in the females b ~was negative. This means 

that at these ages the main trend in mortality 

was downward. The actual values of bl fluctuate 

a little between age groups, but in almost every 

case the rate of change of females was greater 

than the rate for males even though their basic 

rate in 1950 was already lower than the male 

rate; furthermore this rate of improvement among 

women continued to a higher age group than 

for men. 

In every instance where bz was statistically 

significant it was positive and opposite in sign 

to bl; hence it is always acting as a dampening 

factor to decrease the rate of fall in the mortality 

and never as an accelerator. 

It is possible to calculate from these-equations when the dampening effect of b2 overrides 

the main trend of bl; at this point of time the 

mortality would be at a minimum and the subsequent trend would be upward. This can be calculated from the equations (2) and (3).. 

When dy/dx=O (2) 

Then x= bl/2b2 (3) 

This has been done in the right-hand column 

of table M, where it will be seen that in the great 

majority of age groups the turning point had already been reached prior to the end of 1961. It 

is not necessary therefore to extrapolate the data 

beyond the decade analyzed to estimate when the 

main trends of mortality were likely to change, 

as they had already done so. 

MALE 

) es. 

‘1=m. 

C-74 

4s’54 

o 

1=

I 

I 

k

,4 

*9 

O.M 

FEMALE 

%2.4 c+ 

7-

sk 

4c- 6$.X 

30 . 

,-

ALL AGZS 

,? - K-u 

7. 

en s-~ 

4-

3-

S-u 2-

!0 I 

I 

. 

5.9 

to. u

‘k


Fiaure . 30. Estimated trends in the death rate, b’ .


age and sex, 1950-61.


Unless, therefore, some new factor intervenes which was not present during this decade, 

the age-specific mortality rates are not likely to 

show further improvement in the near future. 

. DISCUSSION 

The purposes of a retrospective survey of 

mortality are twofold: first to examine the actual 

effects on mortality of certain economic, social, 

medical, and administrative changes as a guide 

45

for action in the future and, second, to estimate 

probable future trends. 

In this study it has proved very difficult to 

disentangle the various factors influencing survival over a prolonged period that covers economic 

depression, war, and therapeutic revolution, but 

some general conclusions may be drawn. 

It seems probable that the 90 years of constant improvement in mortality which started in 

the early 1870’s has almost come to an end so 

that in the future most age-specific rates are 

more likely to remain constant or to increase 

rather than to decrease. 

In this country it is almost certain that the 

change in the general pattern of mortality by 

age and sex is not due to an artifact. Conceivably 

several statistical factors could influence. the 

mortality rates; there could be improved registration of death, there could be underestimation 

of the total population, or there may be a decreasing tendency to overstate the ages of the 

deceased. 

Only three censuses were taken during this 

period, in 1931, 1951, and 1961, but a national 

register of the whole population was established 

in 1939 which was used as a basis for food rationing and proof. of identity during the war and 

postwar periods, and this did not suggest that 

there was any serious underestimation of the 

population. Similarly there are current registers 

for social security and for the national health 

services, none of which indicate any serious 

deficiencies in the census estimates of population. 

In fact, the final figures for the census of 1961 

agreed very closely with the Registrar General’s 

precensal estimates. 

Death registration has been established 

throughout the country for 125 years; and cooperation among doctors, coroners, funeral directors, and cemetery superintendents has been 

perfectly efficient so that there is almost no 

possibility of the disposal of a body without legal 

registration. There is no evidence of inadequate 

registration of deaths at any time in the last 31 

years. 

It is difficult to determine whether there 

has been a change in the ‘stated age at death. It 

is not necessary to produce the birth certificate 

when registering a death, and no investigation has 

been made into the accuracy of stated ages. If 

previously stated ages had been overestimated and 

if during the period of study these had become 

more accurate, this would have the effect of apparently increasing the age-specific rates at all 

ages. An old age pension has been available for 

over 50 years in this country, and to collect this 

pension a birth certificate or other adequate proof 

of age has to be produced. There has been no 

recent change in this policy, thus the majority 

of elderly people know when they become eligible 

for the pension, consequently it seems improbable 

that there has been any reason why stated ages 

of deceased persons as declared by informants 

should have declined. 

Thus it is certain that the halt in the decline 

of most age-specific death rates during the last 

decade in England and Wales is a true one. The 

reasons for this halt, however, are more dif ­

ficult to determine. When the causes of death 

are examined, there are many artifacts of diagnosis and coding which may affect the diseasespecific rates; but making full allowances for all 

possibilities a clear pattern emerges. Infectious 

diseases have declined by over 90 percent, respiratory diseases have declined by nearly 50 

percent, neoplastic diseases and violent deaths 

have not altered greatly, and vascular diseases 

have increased slowly. The balance between these 

various trends has altered considerably, and now 

the sheer weight of numbers have permitted the 

slow inexorable increase in vascular deaths to 

tip the scales in favor of an absolute increase 

in mortality. 

Within each disease group, however, there 

are considerable variations of the pattern. In 

some cases a specific disease may have decreased only to be replaced by another disease 

of the same system, and so even within the groups 

of diseases an uneasy balance is maintained 

which may or may not be an equilibrium. 

Acute infectious diseases as agents of death 

have almost lost their former importance. Scarlet 

fever, diphtheria, pertussis, and measles have all 

declined by 99 percent, but each for a different 

reason—scarlet fever, presumably due to a loss 

of virulence by the streptococcus, diphtheria due 

to prophylaxis, pertussis possibly due to therapy, 

and measles for a variety of possible reasons. 

Fortunately these diseases have not been replaced 

by a worse devil as may well have happened if 

46 
poliomyelitis had not been conquered or infectious 

hepatitis had become more virulent. 

Tuberculosis has been the one disease that 

has influenced the trend of total mortality for 

many years, and in the decade following 1950 

it was mainly the dramatic fall in these deaths 

due to effective chemotherapy which tended to obscure the slow rise in other types of mortality; 

but now these deaths account for less than 1 percent of all mortality. Even the complete conquest 

of this disease would have little effect on total 

mortality. 

Although the total neoplastic death rate has 

remained relatively constant, there has been an 

interesting contrast between the three most important sites of cancer. Cancer of the ‘stomach 

has declined, cancer of the breast has remained 

constant, and cancer of the. lung has increased 

steadily, while almost all other cancers have declined. The net result of these changes is an equilibrium but this appears to be entirely fortuitous 

and may not persist. If the female deaths from 

respiratory cancer continue to follow the pattern 

of male mortality with a 20-year lag between 

them as they appear to have done in recent years, 

then this possible increase would certainly upset 

the balance and cause a rise in the total neoplastic death rate. If, however, vigorous and effective action were taken” to reduce cigarette 

smoking, then within 5 years the mortality from 

respiratory cancers would decline very rapidly 

and the total picture of neoplastic disease would 

be completely altered, leaving cancer of the breast 

as the most significant site. 

Respiratory diseases have declined in total 

largely due to the fall in pneumonia deaths. This 

may be partly an artifact as pneumonia is frequently the terminal stage of many other diseases; 

and if diagnosis of these other causes had improved, then pneumonia would have declined. As 

a consequence it is difficuIt to decide whether 

this is a real improvement or not. The failure 

of the rate to be influenced by the introduction 

of the various antibiotics would suggest that 

there was some underlying trend which was ot 

even greater importance than the therapeutic revolution that has taken place,, and this may well 

have been the great improvements in diagnostic 

facilities, Influenza as an epidemic disease shows 

no sign of a real decline in mortality; the outbreaks in 1951 and in 19S7 were quite as serious 

as many previous episodes, but as an endemic 

diagnosis there is evidence that it is slowly disappearing from the death certificates. 

Bronchitis is a disease that has been severely influenced by diagnostic and statistical 

artifacts so that it is almost impossible to determine the true trend, but it is probable that at ages 

over 55 years there has been a recent increase 

in this cause of death. 

Violent deaths are a relatively unimportant 

cause of total mortality, being only about 5 percent of all deaths. Suicides have fallen and risen 

again, road accidents have done the same and are 

now rising rapidly, other accidental deaths have 

fluctuated so that the whole group of deaths have 

remained almost constant. 

Vascular diseases now dominate the whole 

trend of mortality as this one group of diseases 

accounts for 51 percent of total deaths, but due 

to several changes in, coding and rapid advances 

in diagnostic techniques it is almost impossible 

to be precise concerning specific trends. Within 

the group it seems clear that there has been 

little change in cerebrovascular disease, that 

rheumatic heart disease has declined, and that 

coronary artery disease has increased. It seems 

to be fortuitous that the scales are overweighted 

by the increase in coronary artery disease, but 

unfortunately this one disease now accounts for 

23 percent of male mortality; and its incidence 

continues to increase especially among middleaged men. It is this rise that has halted agespecific mortality rates and has altered the whole 

prospect of the future trends in mortality. 

In England and Wales the average age of the 

population is still increasing so that if there are 

no prospects of improvement in mortality at 

specific ages, then the crude mortality will rise 

in the future and may rise by as much as 10 

percent in the next 10 years unless major changes 

are made in the prevention and cure of coronary 

artery disease. Such changes in the prevention 

and cure of disease in the past have taken many 

years before they influence the major trend of 

total mortality. 

It is possible to modify a disease process 

in a community at various stages. An environment conducive to the disease may be eliminated; 

this is the typical condition of a socially com -

47 
municative disease such as the enteric fevers or 

malaria, where the environment itself is modified. There was no such disease in this study. 

Alternatively the population may be taught 

to avoid particular hazards in the environment 

even though these hazards remain; such a case 

is the instruction of children in road safety which 

seems to have been so successful in this country 

in recent years. 

Frequently with infectious diseases it is possible to offer some form of immunity to that section of the population most exposed to a particular risk; the classic example of this is vaccination, but in the period under review diphtheria is 

an excellent demonstration of the effectiveness 

of this technique. 

If it is not possible to remove a hazard nor 

to immunize the population against a disease, the 

introduction of effective therapy to prevent active 

cases of the disease from becoming fatal may 

both reduce the mortality and ultimately the incidence of the disease; tuberculosis since 1947 is 

an excellent illustration of this. 

Finally if it is not possible to cure a disease, 

it may be possible to avert a fatal result as with 

insulin treatment of diabetes. 

What are the prospects of any major advances 

being made in any of these fields in the future? 

The Clean Air Act of 1956 produced some 

excellent results in modifying the environment 

and may ultimately reduce some of the bronchitis 

mortality. 

The Government may take measures to control cigarette smoking either by taxation or by 

legislation and possibly the population may be 

convinced of the scientific evidence concerning 

smoking. If so, this would decrease mortality 

from bronchitis, lung cancer, and possibly from 

coronary artery disease. 

There is no major cause of death that could 

be influenced by immunization, but a revolution 

is just possible within the next decade in the 

management of coronary artery and hypertensive 

diseases. Such a breakthrough, however, cannot be 

predicted, and if it came would have a dramatic 

effect similar to the introduction of the antituberculous drugs. 

Maintenance therapy is a field in which there 

is a great deal of research going ahead, with 

anticoagulants in vascular diseases and chemotherapy in the chronic respiratory diseases, but 

advances in these fields are unlikely to alter the 

main trends in mortality. 

Thus except for the reduction in cigarette 

smoking there is no major advance in medicine 

or public health in prospect that is likely to alter 

the main trend in mortality which has failed to 

advance in the last few years. The present halt 

in the reduction is likely to be a lengthy one. 

SUMMARY AND CONCLUSIONS 

A review has been made of mortality in England and Wales from 1931 to 1961 anaIyzing the 

data by sex, age, and cause of death. 

The general trend of mortality during this 

period, when allowance is made for changes in 

the age of the population, has been downward; the 

standardized mortality ratio based upon 1950-52 

as 100 has fallen from 142 in 1931 to 92 in 1961. 

But due to the fortuitous balance between increasing age of the population and decreasing 

age-specific death rates, the crude mortality 

has remained ahnost constant. 

The rate of improvement has been greatest 

in childhood between the ages of 1 and 4, where 

the mortality rates have fallen to less than 12 

percent of the rates prevailing in 1931. 

There has been only a small improvement 

in the male mortality above age 55 years. 

At all ages not only is the female mortality 

lower than that of the male, but at all ages between 1 and 84 the female rates have improved 

more than the male rates. 

The greatest improvements were found in the 

infectious diseases especially diphtheria, measles, and whooping cough. 

Deaths due to tuberculosis have fallen by 

approximately 90 percent in the 31-year period, 

and this fall has been greatest at the younger 

ages, where tuberculosis has almost disappeared 

as a cause of death. 

Neoplastic deaths have shown a small but 

constant rise in men and a small decline among 

women. Lung cancer has increased, leukemia 

has increased, breast cancer remains constant, 

and stomach cancer has fallen. 

All vascular diseases have increased considerably from 28 percent’ of all deaths in 1931 

to 52 percent in 1961. Cerebrovascular deaths 

48 
have remained constant, rheumatic heart disease 

has declined steeply, and coronary artery disease 

has increased. 

Respiratory diseases have fallen, especially 

at younger ages; pneumonia has declined; bronchitis has fluctuated and may have been affected 

by coding changes; in epidemic years influenza 

remains a serious hazard. 

Deaths due to violence remain relatively constant, but road accidents are now increasing. 

There is clear evidence that the rate of 

improvement at most ages has been dampened 

and even arrested at some period between 1955 

and 1961; and there is little probability y that 

rates will improve in the next few years and the 

crude mortality rate will probably increase. 

‘The reason for this recent halt in improvement is the lack of balance between the increase 

in vascular mortality, especially deaths attributed to coronary artery disease, and the diminishing improvements in infectious and respiratory 

diseases. 

The best prospect to reverse this trend would 

be to determine why males have failed to match 

the improvement in female mortality and to remedy any environmental or social conditions that 

affect men rather than women. 

In particular a reduction in smoking liabits 

would probably result in a reduction of deaths 

due to lung cancer, bronchitis, and possibly 

vascular diseases. 

000 

49 

* U. S. GOVERNMENT PRINTING OFFICE: 1965 0-789-937 
OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS 

Public Health Service Publication No. 1000 

series 1.	 Programs and collection procedures. —Reports which describe the general programs of the National 

Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and 

other material necessary for understanding the data. 

Reports number 1-4 

SeVies 2.	 Qata evaluation and methods reseavch.— Studies of new statistical methaiology including: experimental 

tests of new survey methcds, studies of vital statistics collection methods, new analytical techniques, 

objective evaluations of reliability of collected data, contributions to statistical theory. 

Reports number 1-11 

Series 3.	 Analytical studies. —Reports presenting analytical or interpretive studies based on vital and health statistics, carrying the analysis further than the expository types of reports in the other series. 

Reports number 1-4 

Series 4. Documents and committee reports.— Final reports of major committees concerned with vital and health 

statistics, and documents such as recommended model vital registration laws and revised birth and 

death certificates. 

Reports number 1 and 2 

Scvies 10.	 Data Fyom the Health InteYview Survey. —Statistics cm illness, accidental injuries, disability, use of 

hospital, medical, dental, and other services, and other health-related topics, based on data collected in 

a continuing national household interview survey. 

Reports number 1-23 

Series 11.	 Data From the Health Examination Suwey.-Statistics based on the direct examination, testing, and 

measurement of national samples of the population, including the medically defined prevalence of specific diseases, and distributions of the population with respect to various physical and physiological 

measurements. 

Reports number 1-12 

Suyies 12. Data Fvom the Health RecoYds Survey. —Statistics from records of hospital discharges and statistics 

relating to the health characteristics of persons in institutions, and on hospital, medical, nursing, and 

personal care received, based on national samples of establishments providing these services and 

samples of the residents or patients. 

Reports number 1 and 2 

Series W.	 Data on mortality. —Various statistics on mortality other than as included in annual or monthly reportaspecial analyses by cause of death, age, and other demographic variables, also geographic and time 

series analyses. 

No reports to date 

Scvies 21,	 Data on natatity, man’iage, and divoyce. —Various statistics on natality, marriage, and alvorce other 

than as included in annual or monthly reports —special analyses by demographic variables, also geographic and time series analyses, studies of fertility. 

Reports number 1-6 

Se vies 2.?. Data From the National Natality and MoYtality Su?weys. —Statistics on characteristics of births and 

deaths not available from the vital records, based on sample surveys stemming from these records, 

including such topics as mortality by socioeconomic class, medical experience in the last year of life, 

characteri~stics of pregnancy, etc. 

Reports number 1 

For a list of titles of reports published in these series, write to:	 National Center for Health Statistics 

U.S. Public Health Service 

Washington, D.C. 20201